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Virtual reality (VR) as a distraction tool decreases anxiety and fear in children undergoing procedures, but its use has not been studied during transthoracic echocardiograms (TTEs). We hypothesized that VR in children undergoing pre-intervention TTEs decreases anxiety and fear and increases TTE study comprehensiveness and diagnostic accuracy when compared with standard distractors (television, mobile devices). Patients (6-18 years old) scheduled for pre-intervention TTEs at Lucile Packard Children's Hospital in 2021 and 2022 were prospectively enrolled and randomized to VR and non-VR groups. Patients completed pre- and post-TTE surveys using the Children's Anxiety Meter-State (CAM-S) and Children's Fear Scale (CFS). Patients, parents, and sonographers completed post-TTE experience surveys. TTEs were reviewed by pediatric cardiologists for study comprehensiveness and compared with electronic medical records for diagnostic accuracy. Among 67 enrolled patients, 6 declined VR, 31 randomized to the VR group, and 30 to the non-VR group. Anxiety (average CAM-S difference 0.78 ± 1.80, p = 0.0012) and fear (average CFS difference 0.36 ± 0.74, p = 0.0005) decreased in both groups. There was no difference between groups in the change in anxiety and fear pre- and post-TTE (p = 0.96-1.00). TTE study comprehensiveness and diagnostic accuracy were high in both groups. Procedure time (time in the echocardiography room) was less for the VR group (48.4 ± 18.1 min) than the non-VR group (58.8 ± 24.4 min), but without a statistically significant difference (p = 0.075). VR is similar to standard distractors and may decrease procedure time. Patients, parents, and sonographers rated the VR experience highly and encouraged its use with future procedures.
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OBJECTIVE: To compare the appropriateness and diagnostic yield of initial outpatient transthoracic echocardiography (TTE) between a community pediatric cardiology practice and an academic children's hospital. STUDY DESIGN: Initial outpatient pediatric TTE ordered by pediatric cardiologists between January and March 2014 at a community practice (Packard Children's Health Alliance [PCHA]; n = 238) and an academic tertiary center (Lucile Packard Children's Hospital [LPCH]; n = 76) were evaluated based on appropriate use criteria (AUC) released in December 2014. Multivariate logistic regression was used to identify predictors of "rarely appropriate" indications and abnormal TTE findings. RESULTS: Of 314 TTEs, 165 (52.5%) were classified as "appropriate," 40 (12.7%) were classified as "may be appropriate," 100 (31.9%) were classified as "rarely appropriate," and 9 (2.9%) were unclassifiable. The proportion of abnormal findings did not differ between the 2 practice settings (5.3% for LPCH vs 7.6% for PCHA; P = .61). TTEs performed at PCHA were significantly more likely to be "rarely appropriate" (OR, 2.57; 95% CI, 1.28-5.15; P = .008). Children aged <1 year (OR, 1.90; 95% CI, 1.03-3.50; P = .04) and ordering providers with <10 years since the completion of their fellowship (OR, 2.15; 95% CI, 1.20-3.87; P = .01) were associated with "rarely appropriate" indications. "Appropriate" TTEs were associated with abnormal findings (OR, 8.69; 95% CI, 1.77-42.68; P = .008). CONCLUSION: The community practice was independently associated with greater inappropriate ordering of initial outpatient pediatric TTEs compared with the academic practice. The assessment of practice patterns following AUC release should account for physician and practice-related factors that could influence differences in TTE ordering patterns.
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Centros Médicos Acadêmicos/estatística & dados numéricos , Centros Comunitários de Saúde/estatística & dados numéricos , Ecocardiografia/normas , Procedimentos Desnecessários/estatística & dados numéricos , Adolescente , Doenças Cardiovasculares/diagnóstico por imagem , Criança , Pré-Escolar , Ecocardiografia/estatística & dados numéricos , Feminino , Fidelidade a Diretrizes , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Lactente , Masculino , Padrões de Prática Médica/estatística & dados numéricos , Estudos RetrospectivosRESUMO
The levoatrial cardinal vein (LACV), first described in 1926, acts as a decompressing vessel for pulmonary venous return in cases of severe left-sided obstruction with an intact or significantly restrictive atrial septum. The LACV and the persistent left superior vena cava (LSVC) are thought to share similar embryologic origins. To challenge this notion, we present a unique case of a neonate with hypoplastic left heart syndrome, cor triatriatum, and a decompressing LACV in the presence of bilateral superior venae cavae.
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Coração Triatriado/diagnóstico por imagem , Síndrome do Coração Esquerdo Hipoplásico/diagnóstico por imagem , Veias/anormalidades , Veias/diagnóstico por imagem , Veia Cava Superior/anormalidades , Veia Cava Superior/diagnóstico por imagem , Anormalidades Múltiplas/diagnóstico por imagem , Diagnóstico Diferencial , Ecocardiografia/métodos , Humanos , Ultrassonografia Pré-Natal/métodosRESUMO
BACKGROUND: The complexity of congenital heart disease has been primarily stratified on the basis of surgical technical difficulty, specific diagnoses, and associated outcomes. We report on the refinement and validation of a pediatric echocardiography complexity (PEC) score. METHODS AND RESULTS: The American College of Cardiology Quality Network assembled a panel from 12 centers to refine a previously published PEC score developed in a single institution. The panel refined complexity categories and included study modifiers to account for complexity related to performance of the echocardiogram. Each center submitted data using the PEC scoring tool on 15 consecutive inpatient and outpatient echocardiograms. Univariate and multivariate analyses were performed to assess for independent predictors of longer study duration. Among the 174 echocardiograms analyzed, 68.9% had underlying congenital heart disease; 44.8% were outpatient; 34.5% were performed in an intensive care setting; 61.5% were follow-up; 46.6% were initial or preoperative; and 9.8% were sedated. All studies had an assigned PEC score. In univariate analysis, longer study duration was associated with several patient and study variables (age <2 years, PEC 4 or 5, initial study, preoperative study, junior or trainee scanner, and need for additional imaging). In multivariable analysis, a higher PEC score of 4 or 5 was independently associated with longer study duration after controlling for study variables and center variation. CONCLUSIONS: The PEC scoring tool is feasible and applicable in a variety of clinical settings and can be used for correlation with diagnostic errors, allocation of resources, and assessment of physician and sonographer effort in performing, interpreting, and training in pediatric echocardiography.
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Cardiopatias Congênitas , Melhoria de Qualidade , Criança , Humanos , Pré-Escolar , Consenso , Cardiopatias Congênitas/diagnóstico por imagem , Cardiopatias Congênitas/cirurgia , Erros de Diagnóstico , EcocardiografiaRESUMO
BACKGROUND: Fetal echocardiography is a major diagnostic imaging modality for prenatal detection of critical congenital heart disease. Diagnostic accuracy is essential for appropriate planning of delivery and neonatal care. The relationship between study comprehensiveness and diagnostic error is not well understood. The aim of this study was to test the hypothesis that high fetal echocardiographic study comprehensiveness would be associated with low diagnostic error. Diagnostic errors were defined as discordant fetal and postnatal diagnoses and were further characterized by potential causes, contributors, and clinical significance. METHODS: Fetal echocardiographic examinations performed at Lucile Packard Children's Hospital in which fetuses with critical congenital heart disease were anticipated to require postnatal surgical or catheter intervention in the first year of life were identified using the fetal cardiology program database. For this cohort, initial fetal echocardiographic images were reviewed and given a fetal echocardiography comprehensiveness score (FECS). Fetal diagnoses obtained from initial fetal echocardiographic images and reports were compared with postnatal diagnoses confirmed by transthoracic echocardiography and other imaging studies and/or surgery to determine diagnostic error. The relationship between FECS and diagnostic error was evaluated using multivariable logistic regression. RESULTS: Of the 304 initial fetal echocardiographic studies, diagnostic error (discrepant diagnosis, false negative, or false positive) occurred in 92 cases (30.3%). FECS was not associated with diagnostic error, but low FECS (≤80% complete) was associated with false negatives and procedural/conditional (P < .001) and technical (P = .005) contributors compared with high FECS (>80% complete). Cognitive factors made up the largest proportion of contributors to error. CONCLUSIONS: The comprehensiveness of fetal echocardiographic studies was not related to diagnostic error. The most common contributors to error were cognitive factors. Echocardiography laboratories can work to mitigate preventable cognitive error through quality improvement initiatives.
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Cardiologia , Cardiopatias Congênitas , Criança , Ecocardiografia/métodos , Feminino , Coração Fetal/diagnóstico por imagem , Feto , Cardiopatias Congênitas/diagnóstico por imagem , Humanos , Recém-Nascido , Gravidez , Diagnóstico Pré-Natal/métodos , Ultrassonografia Pré-Natal/métodosRESUMO
Transthoracic echocardiography (TTE) is an essential tool for diagnosis and management of congenital heart disease. Pediatric echocardiography presents unique challenges including complex anatomy, variable patient cooperation and provider expertise. Diagnostic errors inevitably occur. We designed a collaborative and stepwise quality improvement (QI) process to address diagnostic errors within our laboratory. We retrospectively reviewed medical records to identify diagnostic TTE errors in 100 consecutive cardiac surgery patients ≤ 5 years old (July 2020-January 2021). We identified 18 diagnostic errors. Most errors had minor impact (14/18), and 13 were preventable or possibly preventable. We presented these results to our sonographers and faculty and requested input on preventing and managing diagnostic errors. Our root cause analysis based on their responses yielded 7 areas for improvement (imaging, reporting, systems, time, environment, people, QI processes). Our faculty and sonographers chose QI processes and imaging as initial areas for intervention. We defined our SMART goal as a 10% reduction in diagnostic errors. We implemented interventions focused on QI processes. On initial follow up in May 2022, we identified 7 errors in 70 patients (44% reduction in error rate). Utilizing a stepwise and team-based approach, we successfully developed QI initiatives in our echocardiography laboratory. This approach can serve as a model for a collaborative QI process in other institutions.
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Primary care providers often are asked to perform the preparticipation physical exam and cardiac screening of pediatric athletes. It can be challenging to evaluate which athletes may require further cardiac evaluation and specialist referral based on a focused history and physical. There is considerable controversy surrounding mass electrocardiogram (ECG) screening of athletes in the United States. The ECG is one of several diagnostic tests used by pediatric cardiologists in the evaluation of underlying heart disease in young athletes. This article reviews cardiac conditions associated with sudden death, discusses pertinent findings on history and physical, and provides clinically relevant information for practitioners who are deciding which patients to refer for detailed cardiac evaluation.
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Atletas , Morte Súbita Cardíaca/prevenção & controle , Programas de Rastreamento , Anamnese , Cardiomegalia/etiologia , Cardiomegalia/fisiopatologia , Criança , Morte Súbita Cardíaca/etiologia , Dispneia , Eletrocardiografia , Humanos , Resistência Física/fisiologia , Exame Físico , Guias de Prática Clínica como Assunto , Atenção Primária à Saúde , Medicina Esportiva , SíncopeRESUMO
DTI indices have been associated with cellular rejection in adult heart transplant recipients, but their predictive value in pediatric recipients is unknown. The purpose of this study was to evaluate DTI measures in the detection of cellular and AMR in pediatric heart transplant recipients. One hundred and forty-eight pediatric heart transplant recipients who had 267 cardiac catheterization procedures with EMB, echocardiogram with DTI, and BNP level performed on the same day were included in the study. For the mitral and tricuspid valves, the ratios (E/E') between the early diastolic inflow velocity by pulsed Doppler (E, m/s) and the early diastolic annular velocity by DTI (E', m/s) were obtained and compared between subjects with and without rejection. Of the 148 recipients, 30 subjects had a total of 37 episodes of rejection: 10 cellular (>or=1B), 17 AMR, and 10 biopsy-negative clinical rejection. Mitral and tricuspid valve E/E' ratios were significantly higher in rejectors than in non-rejectors (5.5 +/- 1.3 vs. 4.4 +/- 1.4, p < 0.001 and 4.9 +/- 2.1 vs. 4.1 +/- 1.5, p < 0.01, respectively). By multivariate linear regression, mitral valve E/E' was an independent predictor of rejection. Mitral and tricuspid valve E/E' <5.0 had 93% and 89% NPV, respectively, for rejection. Mitral and tricuspid valve E/E' ratios <5.0 may be useful non-invasive screening measures to exclude rejection in pediatric heart transplant recipients.
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Rejeição de Enxerto/diagnóstico por imagem , Rejeição de Enxerto/imunologia , Adolescente , Formação de Anticorpos , Criança , Feminino , Transplante de Coração/efeitos adversos , Transplante de Coração/imunologia , Humanos , Imunidade Celular , Masculino , Valor Preditivo dos Testes , Estudos Retrospectivos , Ultrassonografia DopplerRESUMO
BACKGROUND: Accreditation through the Intersocietal Accreditation Commission (IAC) is believed but not proven to increase quality in imaging. The goal of this study was to use quality metrics to evaluate the impact of accreditation on quality in pediatric echocardiography. METHODS: This is a retrospective study comparing quality metrics in 236 pediatric transthoracic echocardiograms in patients with congenital heart disease from (1) California Pacific Medical Center (CPMC), a community hospital, before and after IAC accreditation, and (2) the IAC-accredited Lucile Packard Children's Hospital (LPCH), an academic children's referral center, during equivalent eras. Consecutive patients who required cardiac intervention were matched between sites based on age, complexity, and time period. Two raters independently evaluated echocardiograms for image quality and study comprehensiveness. A third rater reviewed echocardiogram reports and medical charts for report completeness and diagnostic accuracy. Diagnostic error characterization was performed by consensus among the three raters. Report completeness was an IAC tool approved for maintenance of certification. The remaining quality metrics were developed by the American College of Cardiology Adult Congenital Pediatric Cardiology Quality Metrics Working Group initiative. RESULTS: At each site, 74 echocardiograms in the era before CPMC accreditation and 44 echocardiograms in the era after CPMC accreditation were included. There was no significant difference in image quality and diagnostic accuracy at CPMC before and after accreditation. Study comprehensiveness and report completeness improved at CPMC after accreditation (P < .001). CONCLUSIONS: Accreditation through the IAC leads to increased study comprehensiveness and report completeness. Image quality and diagnostic accuracy did not differ significantly before and after IAC accreditation. We recommend further studies to assess the effects of accreditation on quality in echocardiography and patient outcomes.
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Acreditação/normas , Cardiologia/educação , Competência Clínica/normas , Ecocardiografia/normas , Cardiopatias Congênitas/diagnóstico , Melhoria de Qualidade , Humanos , Estudos Retrospectivos , Sociedades Médicas , Estados UnidosRESUMO
OBJECTIVE: As part of the American College of Cardiology Adult Congenital and Pediatric Cardiology Section effort to develop quality metrics (QMs) for ambulatory pediatric practice, the chest pain subcommittee aimed to develop QMs for evaluation of chest pain. DESIGN: A group of 8 pediatric cardiologists formulated candidate QMs in the areas of history, physical examination, and testing. Consensus candidate QMs were submitted to an expert panel for scoring by the RAND-UCLA modified Delphi process. Recommended QMs were then available for open comments from all members. PATIENTS: These QMs are intended for use in patients 5-18 years old, referred for initial evaluation of chest pain in an ambulatory pediatric cardiology clinic, with no known history of pediatric or congenital heart disease. RESULTS: A total of 10 candidate QMs were submitted; 2 were rejected by the expert panel, and 5 were removed after the open comment period. The 3 approved QMs included: (1) documentation of family history of cardiomyopathy, early coronary artery disease or sudden death, (2) performance of electrocardiogram in all patients, and (3) performance of an echocardiogram to evaluate coronary arteries in patients with exertional chest pain. CONCLUSIONS: Despite practice variation and limited prospective data, 3 QMs were approved, with measurable data points which may be extracted from the medical record. However, further prospective studies are necessary to define practice guidelines and to develop appropriate use criteria in this population.
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Assistência Ambulatorial/organização & administração , Cardiologia/normas , Técnicas de Diagnóstico Cardiovascular/normas , Cardiopatias Congênitas/diagnóstico , Pediatria/normas , Criança , Humanos , Estudos Prospectivos , Estados UnidosRESUMO
OBJECTIVE: Pleural effusions after the Fontan operation contribute significantly to morbidity and prolonged hospitalization. This study investigates the association between selected preoperative, operative, and postoperative variables and persistent pleural effusions after the extracardiac Fontan procedure. METHODS: We conducted a retrospective study of extracardiac Fontan procedures. The variables analyzed as potential risk factors included age and weight at the time of the operation, anatomic diagnosis, preoperative oxygen saturation, mean pulmonary artery pressure, ventricular end-diastolic pressure, presence of an accessory source of pulmonary blood flow, presence of significant aortopulmonary collateral vessels, presence of fenestration, cardiopulmonary bypass time, conduit size, postoperative pulmonary artery pressure, use of angiotensin-converting enzyme inhibitors, and presence of postoperative infection. The outcome measures evaluated were duration and volume of chest tube drainage after surgical intervention. RESULTS: From June 1997 to August 2002, 100 consecutive patients underwent the extracardiac Fontan procedure. The median age at operation was 3.1 years. The median duration of chest tube drainage was 10 days, and the median volume of drainage was 14.7 mL.kg(-1).d(-1). As determined by means of multivariate analysis, significant risk factors for pleural effusions lasting more than 2 weeks were lower preoperative oxygen saturation (P =.011) and the presence of postoperative infections (P =.003). Significant risk factors for pleural effusions draining at more than 20 mL.kg(-1).d(-1) were lower preoperative oxygen saturation (P =.005), smaller conduit size (P =.04), and longer duration of cardiopulmonary bypass (P =.004). CONCLUSIONS: Lower preoperative oxygen saturation, presence of postoperative infection, smaller conduit size, and longer duration of cardiopulmonary bypass were associated with persistent pleural effusions after the extracardiac Fontan procedure. Modifications of some of these risk factors might influence the duration and volume of pleural drainage after surgical intervention.
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Técnica de Fontan/efeitos adversos , Técnica de Fontan/métodos , Cardiopatias Congênitas/cirurgia , Derrame Pleural/epidemiologia , Adolescente , Criança , Pré-Escolar , Terapia Combinada , Drenagem/métodos , Feminino , Cardiopatias Congênitas/diagnóstico , Humanos , Masculino , Derrame Pleural/etiologia , Derrame Pleural/terapia , Complicações Pós-Operatórias/epidemiologia , Prevalência , Probabilidade , Prognóstico , Recidiva , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Somatostatina/uso terapêutico , Resultado do TratamentoRESUMO
One- half of women in the United States do not meet the weekly dose of physical activity recommended by the Centers for Disease Control. Many women could benefit tremendously if they were to adopt a more active lifestyle. Health benefits from exercise include lowering the risk for cardiovascular disease, slowing the rate of bone loss in osteoporosis, and improving mood during pregnancy. In this article, we review the health benefits that women may gain from physical activity and the recommendations for physical activity for adults in the United States. We offer evidence supporting use of the exercise prescription, discuss how to write an exercise prescription, and how to tailor the exercise prescription for women with particular medical problems.
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BACKGROUND: This study aimed to obtain hemodynamic measurements of nesiritide in children with dilated cardiomyopathy. METHODS: A prospective, randomized, double-blinded, placebo-controlled pilot study was conducted in the pediatric intensive care unit at the University of California, Los Angeles. All subjects younger than 21 years admitted to the pediatric intensive care unit with a diagnosis of dilated cardiomyopathy and submitted to cardiac catheterization were randomized to receive either nesiritide or placebo. Right heart catheterization with Swan-Ganz catheter placement was performed. Nesiritide was infused over 24 h. Hemodynamic data were obtained before, during, and after the 24-h nesiritide infusion. The measures obtained included pulmonary capillary wedge pressure (PCWP), central venous pressure, mean pulmonary arterial pressure (MPAP), systolic arterial blood pressure (SBP), cardiac index, and systemic vascular resistance. RESULTS: The study included 20 children: 9 randomized to nesiritide and 11 to placebo. At 24 h, the mean decreases in PCWP, MPAP, and SBP were significantly greater for nesiritide than for placebo: PCWP (-5.3 vs. 1.2 mmHg; p = 0.02), MPAP (-8.0 vs. 0.4 mmHg; p = 0.006), SBP (-7.9 vs. 2.6 mmHg; p = 0.04). CONCLUSIONS: Nesiritide significantly decreases PCWP, MPAP, and SBP in children with dilated cardiomyopathy.
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Cardiomiopatia Dilatada/tratamento farmacológico , Cateterismo de Swan-Ganz , Hemodinâmica/efeitos dos fármacos , Natriuréticos/uso terapêutico , Peptídeo Natriurético Encefálico/uso terapêutico , Adolescente , Adulto , Pressão Sanguínea/efeitos dos fármacos , California , Criança , Pré-Escolar , Método Duplo-Cego , Feminino , Indicadores Básicos de Saúde , Ventrículos do Coração , Humanos , Lactente , Recém-Nascido , Los Angeles , Masculino , Estudos Prospectivos , Sístole/efeitos dos fármacos , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE: The aim of this study is to report our experience using the Amplatzer Duct Occluder (ADO) for occlusion of significant coronary artery fistulae (CAF). BACKGROUND: Transcatheter closure of CAF with coils is well described. Use of newer devices may offer advantages such as improved control of device placement, use of a single instead of multiple devices, and high rates of occlusion. METHODS: A retrospective review of all patients catheterized for CAF from July 2002 through August 2005 was performed. RESULTS: Thirteen patients with CAF underwent cardiac catheterization, of which a total of 6 patients had ADO placement in CAF (age, 21 days to 56 years; median age, 4.3 years and weight, 3.8 kg to 74.6 kg; median weight, 13.3 kg). An arteriovenous wire loop was used to advance a long sheath antegrade to deploy the ADO in the CAF. Immediate and short-term outcomes (follow-up, 3 months to 14 months; median follow-up, 8.5 months) demonstrated complete CAF occlusion in 5 patients and minimal residual shunt in 1 patient (who had resolution of right atrial and right ventricular enlargement). On follow-up clinical evaluation, all 6 patients had absence of fistula-related murmurs, and 2 previously symptomatic patients had resolution of congestive heart failure symptoms. Early complications included transient palpitations and atrial arrhythmia in the 2 oldest patients (52 and 56 years old). CONCLUSIONS: Use of the ADO is applicable for transcatheter closure of significant CAF. Advantages of using the ADO include the antegrade approach, use of a single device, and effective CAF occlusion.
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Anomalias dos Vasos Coronários/cirurgia , Próteses e Implantes , Fístula Vascular/cirurgia , Cateterismo Cardíaco , Criança , Angiografia Coronária , Embolização Terapêutica , Humanos , Lactente , Recém-Nascido , Pessoa de Meia-Idade , Desenho de PróteseRESUMO
OBJECTIVE: To increase awareness of congenital disorders of glycosylation (CDG), we report the features of patients with a variety of clinical presentations ranging from mild hypotonia and strabismus to severe neurologic impairment. STUDY DESIGN: Nine North American patients with CDG type I and different ethnic origins were studied. RESULTS: All patients had transferrin isoelectric focusing studies with a type 1 sialotransferrin pattern. Molecular analysis showed the previously described R141H, V231M, and T237M PMM2 mutations in four patients as well as 3 rare mutations (DeltaC389, L104V, and IVS1 -1 G-->A) in the PMM2 gene in two Asian patients. CONCLUSIONS: The clinical features of these patients with diverse ethnic backgrounds confirm the variable course of CDG type I. Screening for CDG should be considered in children with relatively mild neurologic impairment, especially if they have suggestive findings such as cerebellar hypoplasia and abnormal fat distribution.