Search

Aim Non-expert training in rheumatic heart disease (RHD) detection is a valuable strategy in resource-limited settings. Here we present an innovative handheld ultrasound application featuring views of correct probe position, imaging protocol and echocardiographic loops of RHD pathology versus normal, accessible during real-time scanning. Methods This prospective study was implemented into a pre-existing school health screening programme at an elementary school in Koror, Palau. Six learners with no prior ultrasound experience were taught a simplified screening protocol in which a mitral regurgitation jet ≥1.5 cm and/or presence of aortic insufficiency were considered a positive screen. All consented children underwent echocardiographic screening by experts with standard portable echocardiography. All positive cases and 25% of negative cases were referred for handheld scans by learners. Results A total of 26 (4.1%) children were diagnosed with borderline or definite RHD. Mean sensitivity and specificity compared to expert RHD diagnosis over all learners was 71% (standard deviation (SD) 11.3) and 92% (SD 4.9), respectively. For the three highest scanning learners, mean sensitivity was 88% (SD 4.9) and mean specificity was 90% (SD 5.7). For all definite RHD cases, sensitivity was 100% for all but one learner, who achieved sensitivity of 60%. The novel application was used in 229 of 624 (36%) of all handheld scans and 50 of 112 (45%) of expert-diagnosed positive scans, with protocol and reference features most frequently used. Utilisation of the novel application overall decreased per day of scanning per learner. Conclusion Adjunctive handheld ultrasound technology may help ease non-experts into RHD screening.

Background Coronary artery aneurysms (CAAs) may occur after Kawasaki disease (KD) and lead to important morbidity and mortality. As CAA in patients with KD are rare and heterogeneous lesions, prognostication and risk stratification are difficult. We sought to derive the cumulative risk and associated factors for cardiovascular complications in patients with CAAs after KD. Methods and Results A 34‐institution international registry of 1651 patients with KD who had CAAs (maximum CAA Z score ≥2.5) was used. Time‐to‐event analyses were performed using the Kaplan–Meier method and Cox proportional hazard models for risk factor analysis. In patients with CAA Z scores ≥10, the cumulative incidence of luminal narrowing (>50% of lumen diameter), coronary artery thrombosis, and composite major adverse cardiovascular complications at 10 years was 20±3%, 18±2%, and 14±2%, respectively. No complications were observed in patients with a CAA Z score Z score and a greater number of coronary artery branches affected were associated with increased risk of all types of complications. At 10 years, normalization of luminal diameter was noted in 99±4% of patients with small (2.5≤ Z Z Z ≥10). CAAs in the left anterior descending and circumflex coronary artery branches were more likely to normalize. Risk factor analysis of coronary artery branch level outcomes was performed with a total of 893 affected branches with Z score ≥10 in 440 patients. In multivariable regression models, hazards of luminal narrowing and thrombosis were higher for patients with CAAs of the right coronary artery and left anterior descending branches, those with CAAs that had complex architecture (other than isolated aneurysms), and those with CAAs with Z scores ≥20. Conclusions For patients with CAA after KD, medium‐term risk of complications is confined to those with maximum CAA Z scores ≥10. Further risk stratification and close follow‐up, including advanced imaging, in patients with large CAAs is warranted.

Objective To evaluate practice variation in pharmacologic management in the International Kawasaki Disease Registry (IKDR). Study design Practice variation in intravenous immunoglobulin (IVIG) therapy, anti-inflammatory agents, statins, beta-blockers, antiplatelet therapy, and anticoagulation was described. Results We included 1627 patients from 30 IKDR centers with maximum coronary artery aneurysm (CAA) z scores 2.5-4.99 in 848, 5.0-9.99 in 349, and ≥10.0 (large/giant) in 430 patients. All centers reported IVIG and acetylsalicylic acid (ASA) as primary therapy and use of additional IVIG or steroids as needed. In 23 out of 30 centers, (77%) infliximab was also used; 11 of these 23 centers reported using it in 20% of patients. Nonsteroidal anti-inflammatory agents were used in >10% of patients in only nine centers. Beta-blocker (8.8%, all patients) and abciximab (3.6%, all patients) were mainly prescribed in patients with large/giant CAAs. Statins (2.7%, all patients) were mostly used in one center and only in patients with large/giant CAAs. ASA was the primary antiplatelet modality for 99% of patients, used in all centers. Clopidogrel (18%, all patients) was used in 24 centers, 11 of which used it in >50% of their patients with large/giant CAAs. Conclusions In the IKDR, IVIG and ASA therapy as primary therapy is universal with common use of a second dose of IVIG for persistent fever. There is practice variation among centers for adjunctive therapies and anticoagulation strategies, likely reflecting ongoing knowledge gaps. Randomized controlled trials nested in a high-quality collaborative registry may be an efficient strategy to reduce practice variation.

Objective To reduce the frequency of non-ICU arrests through the implementation of an intramural collaborative focused on patient deterioration. Design Prospective quality improvement project. Setting Single-center, free-standing, tertiary children's hospital. Patients All patients admitted to acute care units. Interventions The Late Rescue Collaborative was formed in 2014 to monitor compliance with hospital escalation protocols and evaluate episodes of patient deterioration. The collaborative is a multidisciplinary team of physicians, nurses, and respiratory care providers. Three monthly meetings occur: 1) individual acute care unit-based meetings to evaluate trends and performance; 2) hospital-wide multidisciplinary whole group meetings to review hospital trends in deterioration and share lessons learned; and 3) steering committee to determine areas of focus. Based on these three meetings, unit- and hospital-based interventions have been put in place to improve recognition of deterioration and promote early rescue. Measurements and main results Rates of rapid response team activations, unplanned transfers, and non-ICU arrest are reported. Non-ICU arrest rates fell from a baseline of 0.31 per 1,000 non-ICU patient days to a new centerline of 0.11 and sustained for 36 months. Days between non-ICU arrests increased from a baseline of 15.5 days in year 2014 to a new centerline of 61.5 days and sustained for 37 months. Mortality following non-ICU arrests fell from four in 2014 and 2015 to zero in years 2016-2018. Conclusion The Late Rescue Collaborative is an effective tool to improve patient safety by reducing non-ICU arrests.

Background Patient transitions create vulnerability for care teams. Failures in the handoff process result in communication errors and knowledge gaps, mainly when the handoff occurs between resident and expert-level subspecialty clinicians. The authors set out to develop a standardized handoff using resident comfort as a proxy for implementation. The primary measurable aim of this study was to increase the percentage of pediatric residents who self-reported comfort in assuming care of patients transitioned from the cardiac intensive care unit to the cardiology acute care unit. Methods Investigators surveyed residents at a 323-bed pediatric hospital on their handoff experiences. The study team performed a Failure Mode Effect Analysis and created a key driver diagram. Interventions included a transfer checklist and algorithm, a huddle between care teams, and education surrounding the transfer process. Results Residents completed a survey before (n = 74) or after (n = 23) intervention. The percentage of residents who reported feeling "always" or "very often" prepared to care for patients at the time of transfer increased from 15% to 83%. The percentage of residents who reported that they "always" or "very often" had concerns about floor appropriateness decreased from 23% to 4%. Conclusions The authors designed a transfer process to improve communication, resident-level education, and psychological safety among team members to ensure safe, thorough handoffs between providers with different levels of training. Although we cannot definitively conclude that resident comfort improved due to a small "n" postintervention, we offer a description outlining process changes, barriers to implementation, and lessons learned.

Adult patient series have shown hand-held echocardiography (echo) units (HHE) to be accurate for rapid diagnosis and triage. This is the first study to evaluate the ability of HHE to inform decision making in outpatient pediatric cardiology. New pediatric cardiology patients in outpatient clinics staffed by six pediatric cardiologists (experience 1-17 years) were prospectively enrolled if an echocardiogram (echo) was ordered during their initial visit. After history and physical examination and before a standard echo, the cardiologists performed a bedside HHE examination (GE Vscan 1.7-3.8 MHz), documented findings, and made a clinical decision. Diagnoses and decisions based on HHE were compared with final management after the standard echo. The study enrolled 101 subjects (ages 9 days to 19 years). The cardiologists considered HHE imaging adequate for decision making for 80 of the 101 subjects. For 77 of the 80 subjects with acceptable HHE imaging (68/68 normal and 9/12 abnormal standard echoes), the HHE-based primary diagnoses and decisions agreed with the final management. The sensitivity of HHE was 75 % (95 % confidence interval [CI] 43-94 %) and the positive predictive value 100 % (95 % CI 66-100 %) for pediatric heart disease. The agreement between standard echocardiography and HHE imaging was substantial (κ = 0.82). Excluding one of the least experienced cardiologists, HHE provided the basis for correct cardiac diagnoses and management for all the subjects with acceptable HHE imaging (58/58 normal and 9/9 abnormal echoes). In outpatient pediatric cardiology, HHE has potential as a tool to complement physical examination. Further investigation is needed to evaluate how value improves with clinical experience.

Renal artery stenosis (RAS) accounts for 10 % of cases of systemic hypertension in children. Initial management involves anti-hypertensive therapy. Percutaneous interventions are documented for the treatment of RAS in the adult population. In children, case reports suggest benefit.This is a retrospective analysis of consecutive patients referred for catheterization for RAS between 2002 and 2010 at a single institution. Recorded variables included: age, weight, systemic blood pressure, minimal luminal diameter, interventional devices, antihypertensive medications, contrast volume, and complications.Twelve patients (median age 8.2, IQR 6-12.4 years); median weight 42.8 kg, IQR: 25-47.4 kg) were referred for renal artery catheterization and underwent percutaneous intervention. Overall, minimal luminal diameter (MLD) increased by 1.2 ± 0.9 mm for all patients (p 0.05) and by 1.3 ± 0.9 mm for post-renal transplant patients (p 0.05). Only stent angioplasty patients demonstrated significant improved blood pressure (p 0.05). One patient had stent thrombosis requiring re-intervention with repeat balloon angioplasty.This retrospective analysis suggests that percutaneous intervention might play a role in the management of RAS, with an improvement in MLD in children with RAS. Transcatheter intervention is technically feasible with low morbidity. A prospective, longitudinal study is warranted to compare standard medical therapy with percutaneous interventions.

To design a deflectable guiding catheter that omits long metallic components yet preserves mechanical properties to facilitate therapeutic interventional MRI procedures.The catheter shaft incorporated Kevlar braiding. A 180° deflection was attained with a 5-cm nitinol slotted tube, a nitinol spring, and a Kevlar pull string. We tested three designs: passive, passive incorporating an inductively coupled coil, and active receiver. We characterized mechanical properties, MRI properties, RF induced heating, and in vivo performance in swine.Torque and tip deflection force were satisfactory. Representative procedures included hepatic and azygos vein access, laser cardiac septostomy, and atrial septal defect crossing. Visualization was best in the active configuration, delineating profile and tip orientation. The passive configuration could be used in tandem with an active guidewire to overcome its limited conspicuity. There was no RF-induced heating in all configurations under expected use conditions in vitro and in vivo.Kevlar and short nitinol component substitutions preserved mechanical properties. The active design offered the best visibility and usability but reintroduced metal conductors. We describe versatile deflectable guiding catheters with a 0.057" lumen for interventional MRI catheterization. Implementations are feasible using active, inductive, and passive visualization strategies to suit application requirements.

To develop an approach to vascular access under magnetic resonance imaging (MRI), as a component of comprehensive MRI-guided cardiovascular catheterization and intervention.We attempted jugular vein access in healthy pigs as a model of "difficult" vascular access. Procedures were performed under real-time MRI guidance using reduced field of view imaging. We developed an "active" MRI antenna-needle having an open-lumen, distinct tip appearance and indicators of depth and trajectory in order to enhance MRI visibility during the procedure. We compared performance of the active needle against an unmodified commercial passively visualized needle, measured by procedure success among operators with different levels of experience.MRI-guided central vein access was feasible using both the active needle and the unmodified passive needle. The active needle required less time (88 vs. 244 sec, P = 0.022) and fewer needle passes (4.5 vs. 9.1, P = 0.028), irrespective of operator experience.MRI-guided access to central veins is feasible in our animal model. When image guidance is necessary for vascular access, performing this component under MRI will allow wholly MRI-guided catheterization procedures that do not require adjunctive imaging facilities such as x-ray or ultrasound. The active needle design showed enhanced visibility, as expected. These capabilities may permit more complex catheter-based cardiovascular interventional procedures enabled by enhanced image guidance.

The prevalence of ductal aneurysms is approximately 8.8% [2]. Ductal aneurysms are associated with serious complications, which makes accurate diagnosis prudent. Diagnosis is traditionally made by echocardiography, however, additional imaging modalities are sometimes required for a definitive diagnosis. Our patient, D.C., is a full-term newborn male who was transferred from an outside hospital to our Neonatal Intensive Care Unit secondary to respiratory failure and dysmorphism. His physical examination was significant for hypertelorism and low-set ears. He had increased precordial activity and a 3/6 holosystolic murmur heard throughout the precordium. An echocardiogram was performed on day of life 5, which showed a primum atrial septal defect (ASD) with left-to-right shunt, a secundum ASD with left-to-right shunt, and atrioventricular canaltype ventricular septal defect with no physiologic shunt secondary to atrioventricular valve tissue filling the defect. At that time echocardiography demonstrated significant left pulmonary artery stenosis. A follow-up echocardiogram was performed to further evaluate the caliber of the left pulmonary artery. A 1.6 9 1.8-cm cystic mass was noted anterior to and to the left of the main pulmonary artery/left pulmonary artery junction. There appeared to be a connection via a small communication to the main pulmonary artery (Fig. 1). A CT angiogram was performed, which showed a well-circumscribed contrast-filled structure measuring 1.7 9 1.4 9 1.2 cm arising from the anterior aspect of the proximal portion of the descending thoracic aorta, located anterolateral to the left main pulmonary artery branch, most consistent with a pseudoaneurysm. However, the exact anatomy was still difficult to precisely delineate. Therefore, we used three-dimensional reconstruction of the CT angiogram to show the aneurysm in connection with the ductus arteriosus and to demonstrate compression of the left pulmonary artery by the aneurysm (Fig. 2). Ductal aneurysms are rare and are more frequently associated with patients who have had surgical ligation of the ductus arteriosus or in association with connective tissue disorders [1]. One study demonstrated a prevalence of 8.8% in all newborn infants [2]. Ductal aneurysms usually are asymptomatic and incidentally discovered on routine echocardiographic evaluation or diagnosed by fetal echocardiogram. Although rare, ductal aneurysms are associated with serious complications, which include thromboembolism, infection, rupture, and death [3]. The conventional method to identify ductal aneurysm anatomy is by two-dimensional echocardiogram with color Doppler. However, some patients require additional imaging with CT angiography or MRI to further define the anatomy [1]. In our patient, the connection between the aneurysm and the artery was difficult to isolate on two-dimensional echocardiogram and CT angiogram. Therefore, three-dimensional reconstruction of the CT angiogram was necessary to make the exact diagnosis. Additionally, the three-dimensional reconstruction replicated the exact area of aneurysmal connection to the pulmonary artery. Three-dimensional CT has been described more often in the adult literature for diagnosis of aneurysms. The most common use is as a diagnostic tool for circle of Willis aneurysms. However, three-dimensional CT angiography has been used to diagnose aortic aneurysms in the adult population. In pediatrics, three-dimensional CT angiography Deneen Heath and Russell Cross contributed equally to this work.