The Appalachia Mind Health Initiative (AMHI): a pragmatic randomized clinical trial of adjunctive internet-based cognitive behavior therapy for treating major depressive disorder among primary care patients.

BACKGROUND: Major depressive disorder (MDD) is a leading cause of disease morbidity. Combined treatment with antidepressant medication (ADM) plus psychotherapy yields a much higher MDD remission rate than ADM only. But 77% of US MDD patients are nonetheless treated with ADM only despite strong patient preferences for psychotherapy. This mismatch is due at least in part to a combination of cost considerations and limited availability of psychotherapists, although stigma and reluctance of PCPs to refer patients for psychotherapy are also involved. Internet-based cognitive behaviorial therapy (i-CBT) addresses all of these problems. METHODS: Enrolled patients (n = 3360) will be those who are beginning ADM-only treatment of MDD in primary care facilities throughout West Virginia, one of the poorest and most rural states in the country. Participating treatment providers and study staff at West Virginia University School of Medicine (WVU) will recruit patients and, after obtaining informed consent, administer a baseline self-report questionnaire (SRQ) and then randomize patients to 1 of 3 treatment arms with equal allocation: ADM only, ADM + self-guided i-CBT, and ADM + guided i-CBT. Follow-up SRQs will be administered 2, 4, 8, 13, 16, 26, 39, and 52 weeks after randomization. The trial has two primary objectives: to evaluate aggregate comparative treatment effects across the 3 arms and to estimate heterogeneity of treatment effects (HTE). The primary outcome will be episode remission based on a modified version of the patient-centered Remission from Depression Questionnaire (RDQ). The sample was powered to detect predictors of HTE that would increase the proportional remission rate by 20% by optimally assigning individuals as opposed to randomly assigning them into three treatment groups of equal size. Aggregate comparative treatment effects will be estimated using intent-to-treat analysis methods. Cumulative inverse probability weights will be used to deal with loss to follow-up. A wide range of self-report predictors of MDD heterogeneity of treatment effects based on previous studies will be included in the baseline SRQ. A state-of-the-art ensemble machine learning method will be used to estimate HTE. DISCUSSION: The study is innovative in using a rich baseline assessment and in having a sample large enough to carry out a well-powered analysis of heterogeneity of treatment effects. We anticipate finding that self-guided and guided i-CBT will both improve outcomes compared to ADM only. We also anticipate finding that the comparative advantages of adding i-CBT to ADM will vary significantly across patients. We hope to develop a stable individualized treatment rule that will allow patients and treatment providers to improve aggregate treatment outcomes by deciding collaboratively when ADM treatment should be augmented with i-CBT. TRIAL REGISTRATION: ClinicalTrials.gov NCT04120285 . Registered on October 19, 2019.

Automated external defibrillators in West Virginia schools.

INTRODUCTION: Sudden death, particularly when occurring in children and adolescents, is a traumatic event not only for the victim's family, but for the entire community. It has been shown that school-based automated external defibrillator (AED) programs provide a high survival rate for both students and nonstudents who suffer sudden cardiac arrest (SCA) on school grounds. The use of AEDs is becoming increasingly more common in schools in the United States. In West Virginia middle and high schools, we analyzed the prevalence and use of AEDs, barriers to obtaining a device, and cases of sudden death on school grounds. METHODS: A mailed survey distributed to West Virginia high schools and middle schools collected general demographic data, AED data, and occurrences of sudden death on school grounds. Schools reporting a death were contacted to obtain details regarding the event. For schools with a device, the number of AEDs, length of possession, reasons for and means of obtaining the AED, personnel trained to operate the AED and the number of device uses were determined. For schools without an AED, barriers to and interest in obtaining a device were determined. RESULTS: Two hundred and twenty-five of 312 surveys (72%) were returned. One hundred and fifty-two schools (68%) currently have at least one AED and 73 schools (32%) do not have an AED. Public high schools had the highest prevalence of AEDs (76%) compared to public middle schools (62%) and private schools (67%). Sixty-nine percent of schools obtained their devices by donations or grants and 32% obtained them using school funds. Barriers to obtaining a device included cost (82%), lack of trained personnel (45%), unfamiliarity with AED (22%), and liability issues (19%). There were a total of 23 deaths on school premises reported by 20 schools. There was one reported occurrence of an AED being used to save a life. CONCLUSION: Over two thirds of West Virginia middle schools and high schools currently have at least one AED on their premises. An AED is an effective way of preventing death following sudden cardiac arrest, and has saved at least one life in a West Virginia school. While most schools without AEDs cite cost as the main deterrent, the majority of schools with a device received them via donation or grant. We submit that a number of sudden deaths on West Virginia school grounds could possibly have been averted by use of an AED.

Ventricular tachycardia in infants with structurally normal heart: a benign disorder.

We evaluated the presentation, treatment, and outcome of infants who present with ventricular tachycardia in the first year of life. Seventy-six infants were admitted to our institution with a diagnosis of ventricular tachycardia between January, 1987 and May, 2006. Forty-five infants were excluded from the study because of additional confounding diagnoses including accelerated idioventricular rhythm, Wolff-Parkinson-White syndrome, supraventricular tachycardia with aberrancy, long QT syndrome, cardiac rhabdomyoma, myocarditis, congenital lesions, or incomplete data. The remaining 31 included infants who had a median age at presentation of 1 day, with a range from 1 to 255 days, and a mean ventricular tachycardia rate of 213 beats per minute, with a range from 171 to 280, at presentation. The infants were treated chronically with propranolol (38.7%), amiodarone (12.9%), mexiletine (3.2%), propranolol and mexiletine (9.7%), or propranolol and procainamide (6.5%). The median duration of treatment was 13 months, with a range from 3 to 105 months. Ventricular tachycardia resolved spontaneously in all infants. No patient died, or received catheter ablation or device therapy. Median age at last ventricular tachycardia was 59 days, with a range from 1 to 836 days. Mean follow-up was 45 months, with a range from 5 to 164 months, with a mean ventricular tachycardia-free period of 40 months. Infants with asymptomatic ventricular tachycardia, a structurally normal heart, and no additional electrophysiological diagnosis all had spontaneous resolution of tachycardia. Furthermore, log-rank analysis of the time to ventricular tachycardia resolution showed no difference between children who received chronic outpatient anti-arrhythmic treatment and those who had no such therapy. While indications for therapy cannot be determined from this study, lack of symptoms or myocardial dysfunction suggests that therapy may not be necessary.

Tricuspid atresia and tetralogy of Fallot in an infant of a diabetic mother.

An infant of a diabetic mother with a prenatal diagnosis of tetralogy of Fallot and tricuspid atresia is presented. To the best of the authors' knowledge, this is the first report of such an association.

Outcome of high-risk neonates with congenital complete heart block paced in the first 24 hours after birth.

OBJECTIVE: Risk factors for poor outcome with congenital complete heart block include prematurity, low birth weight, hydrops, low ventricular rates, and congenital heart disease. In this group, medical therapy is often ineffective, pacing is technically challenging, and mortality exceeds 80%. The purpose of this study is to assess outcomes of patients with congenital complete heart block who were paced in the first 24 hours after birth owing to the presence of known risk factors. METHODS: We performed a retrospective review of patients with congenital complete heart block paced in the first 24 hours after birth at our institution between November 1, 1995, and July 31, 2007. RESULTS: Thirteen patients were identified, 4 of whom had heterotaxy syndrome. Eleven patients had temporary epicardial pacing wires placed; 2 received permanent pacemakers as the initial mode of pacing. There were 7 deaths (54% mortality) at a mean age of 19.9 +/- 19 days. Among 7 patients with structural heart disease, there was 1 survivor. Among 6 patients with structurally normal hearts, there were 5 survivors (P = .025). Patients with temporary wires who survived to permanent pacemaker implantation (6/11) used their temporary leads for 33.8 +/- 18.3 days. CONCLUSIONS: In the severely affected fetus with congenital complete heart block and significant structural heart disease, outcomes remain poor; however, neonates with congenital complete heart block and structurally normal hearts who are monitored antenatally and delivered in a planned fashion at an institution capable of early pacing can have favorable outcomes. The use of temporary pacing wires is an option in the management of these patients.

Substrate characterization of ventricular tachycardia in a porcine model of tetralogy of Fallot using noncontact mapping.

BACKGROUND: Ventricular tachycardia (VT) in patients following tetralogy of Fallot (TOF) repair is challenging to map because of the presence of scar, patch material, and hemodynamic residua of surgery. This study investigates whether noncontact mapping can identify the arrhythmia substrate in a porcine model that involves a right ventricular outflow tract (RVOT) patch and either chronic volume or pressure load on the right ventricle. METHODS: Nine infant pigs (3-5 kg) underwent surgery involving an RVOT patch and creation of pulmonary insufficiency (PI, n = 4) or pulmonary stenosis (PS, n = 5). After a mean of 4.2 months, pigs underwent invasive electrophysiology studies (EPS) with noncontact mapping (Ensite, St. Jude Medical, St. Paul, MN USA) of the right ventricle. Automated, unipolar voltage maps (VM) were constructed during sinus rhythm. Threshold for substrate was set at -0.5 mV and incrementally adjusted to higher values until a contiguous region of low voltage was delineated. Programmed stimulation was performed to induce VT. VT activation was correlated to location of VM defined substrate. Three control pigs underwent EPS and VM. RESULTS: Free-wall RVOT substrate was identified in each of the model animals, correlating to location of the patch. The mean voltage threshold was -1.1 mV. VT was induced in 6/9 animals. Diastolic activation approximated the inferior or lateral border of the substrate in all animals. No RVOT substrate was identified in the control pigs. CONCLUSION: Automated voltage mapping of sinus beats identifies substrate for VT in a porcine model of TOF. Consistent diastolic activation of the substrate border was found during VT. Targeting this area may be useful in the ablation of VT after repair of TOF.

Subcutaneous array with active can implantable cardioverter defibrillator configuration: a follow-up study.

BACKGROUND: Novel nontransvenous implantable cardioverter defibrillator (ICD) configurations are sometimes required for small children and children with complex congenital heart disease at risk for sudden death. Mid- to long-term follow-up of these nontraditional implant techniques is not well known. We assessed the mid-term performance of a subcutaneous lead technique used in our practice. METHODS: Between July 2002 and November 2003, 4 patients (age 2.1-8.5 years, weight 13-33.3 kg, height 90-126.7 cm) received an ICD with a single-finger (n = 3) or 2-finger (n = 1) subcutaneous array with an active abdominal can and epicardial pace/sense lead. The subcutaneous tunnel was created via a subxiphoid incision using a tunneling tool within a sheath along the seventh intercostal space and extended posterior to the spine. Diagnoses included long QT syndrome (n = 2), idiopathic ventricular fibrillation (n = 1), and idiopathic dilated cardiomyopathy (n = 1). Implantable cardioverter defibrillator indications included syncope (n = 2) and cardiac arrest (n = 2). RESULTS: Mean follow-up was 22.3 +/- 13.9 months. During follow-up, 1 patient underwent heart transplantation and the other 3 patients underwent generator replacement secondary to a manufacturer's advisory. There was 1 appropriate and successful shock for ventricular fibrillation. This patient experienced a second episode of ventricular fibrillation that the ICD discharge failed to terminate. The arrhythmia spontaneously resolved. There were no inappropriate shocks. There was 1 instance of false detection of ventricular fibrillation because of intermittent T wave oversensing but therapy was not administered. There were no infections, lead fractures, or other complications during follow-up. CONCLUSION: This novel nontransvenous ICD configuration can be used safely in a select group of pediatric patients and allows for the applicability of this life-saving technology to small children at high risk for sudden cardiac death.

The pharmacokinetics of esmolol in pediatric subjects with supraventricular arrhythmias.

Esmolol is often used in the acute management of children with arrhythmias and/or hypertension; however, pharmacokinetic studies of the drug in children have been limited. The objective of this study was to determine the pharmacokinetics of esmolol in children with a history of supraventricular arrhythmias (SVT) who were scheduled for diagnostic electrophysiology study or a catheter ablation procedure. Subjects were stratified into two age groups: 2-11 and 12-16 years. After an episode of stimulated or spontaneous SVT, esmolol was administered intravenously as a 1,000 microg/kg bolus followed by continuous infusion at 300 microg/kg/min. Blood samples were collected before, at 5, 10 and 15 min after the loading dose, and 3, 6, 9, 12, 15 and 20 min after the end of the infusion. Plasma concentration of esmolol was quantitated by a specific LC/MS assay. Pharmacokinetic data were available for 25 subjects. Arterial esmolol concentrations were approximately five times greater than venous concentrations. Esmolol had an extremely short distribution half-life (0.6 min), a rapid terminal elimination half-life (6.9 min), and a rapid clearance (119 +/- 51 mL/min/kg) which was not related to subject age or weight. Seventeen of the subjects (63%) converted to normal sinus rhythm in an average of 2 min (range 0-5 min). The pharmacokinetics of esmolol and its efficacy in terminating SVT in children is similar to that observed in adults.

The adult with congenital heart disease.

There are approximately 800,000 adult survivors of congenital heart disease in the U.S., and this number continues to increase on an annual basis. It was only 50 years ago that the first intracardiac repair of a congenital heart defect was performed. Survival into adulthood has only been realistic in the last three decades. This has created a new patient population with a number of challenges such as the impact of adult onset diseases on their underlying cardiac pathology, cognitive, physical, and psychosocial development, as well as issues related to reproduction, employment and health insurance. Possibly the most significant obstacle is identifying healthcare professionals who can provide long-term care. This manuscript reviews the challenges and recommendations for the care of these patients.

Heart rate variability following neonatal heart surgery for complex congenital heart disease.

BACKGROUND: Altered cardiac autonomic control may play a role in the morbidity and mortality suffered by neonates who undergo surgery for complex congenital heart disease (CHD). The purpose of this study was to evaluate cardiac autonomic activity, as measured by spectral indices of heart rate variability (HRV), prior to and early after infant surgery for CHD and attempt to correlate HRV indices with clinical outcome. In addition, we assessed the hypothesis that single-ventricle physiology and surgical interruption of the great arteries negatively affects HRV. METHODS: Sixty neonates prospectively wore 24-hour Holter monitors at three time points: before and early after CHD surgery, and at 3- to 6-month follow-up. Standard spectral indices of HRV were measured. RESULTS: In the early postoperative time point, patients with single-ventricle physiology had lower low-frequency power (LF) compared to patients with two ventricles (P=0.040). Surgical interruption of the great arteries did not affect HRV in this cohort. For the entire cohort, LF (P=0.004) and high-frequency power (HF) (P<0.001) increased over the three time points, while LF/HF (P=0.119) did not significantly change. In the multivariable linear regression model, significant predictors of longer postoperative hospital stay included longer total support time (P=or<0.001), longer duration of inotrope support (P=0.012), elevated mean heart rate at postoperative time point (P=0.002), and lower LF/HF ratio at the postoperative time point (P=0.014). CONCLUSION: Patients with single-ventricle physiology have a significant physiologic reduction in LF in the early postoperative period compared to patients with two ventricles. Diminished cardiac autonomic control is associated with longer hospitalization following neonatal cardiac surgery.

Induction of atrial fibrillation after the routine use of adenosine.

We report a case of atrial fibrillation induction after the use of adenosine for the termination of supraventricular tachycardia in the emergency department. Atrial fibrillation is not an uncommon side effect of adenosine administration. Hemodynamic collapse may occur if an antegrade-conducting accessory pathway allows for a rapid ventricular response. Therefore, we would recommend that the use of adenosine be limited to situations in which there is appropriate electrocardiographic monitoring and emergency resuscitative capabilities.

The roles of chronic pressure and volume overload states in induction of arrhythmias: an animal model of physiologic sequelae after repair of tetralogy of Fallot.

OBJECTIVE: Sudden death occurs in as many as 8% of patients after repair of tetralogy of Fallot and has been attributed to arrhythmias. The purpose of this study was to establish an animal model to evaluate the individual contribution of different physiologic sequelae after tetralogy of Fallot repair in the development of late-onset arrhythmias. METHODS: Forty-nine piglets were divided into 5 groups: (1) pulmonary artery band; (2) pulmonary valvotomy; (3) pulmonary artery band plus pulmonary valvotomy; (4) infundibular scar; and (5) age-matched control animals. Baseline and follow-up electrocardiograms were obtained and recorded, as well as changes in QRS duration. A total of 45 animals underwent hemodynamic evaluation and programmed electrical stimulation at 5.6 months postoperatively. RESULTS: Sustained ventricular tachyarrhythmias (ventricular tachycardia/ventricular fibrillation) were induced in 31.1%, and atrial arrhythmias were induced in 33.3%. The pulmonary valvotomy group was 30 times more likely to evidence arrhythmias than control animals for sustained ventricular tachycardia/ventricular fibrillation, as well as atrial arrhythmias (P = .01). The pulmonary artery band group was 15 times more likely to evidence atrial arrhythmias than control animals (P = .02). Prolonged QRS duration was predictive of inducibility of both atrial arrhythmias (P < .01) and sustained ventricular tachycardia/ventricular fibrillation (P = .01). Mean right atrial (P = .01) and capillary wedge (P = .01) pressures predicted atrial arrhythmia inducibility. Right ventricular end-diastolic pressure predicted atrial arrhythmia (P= .01) and sustained ventricular tachycardia/ventricular fibrillation inducibility (P = .05). Right ventricular systolic pressure did not predict inducibility of either atrial arrhythmias (P = .10) or sustained ventricular tachycardia/ventricular fibrillation (P = .94). CONCLUSIONS: Chronic right ventricular volume overload resulted in an increased incidence of inducible ventricular and atrial arrhythmias.

Slow pathway modification for atrioventricular nodal reentrant tachycardia.

The change in the "refractory window" was assessed as a possible indicator of successful slow pathway modification in 26 pediatric patients with persistent dual-atrioventricular node physiology. The "refractory window" was defined as the difference between the fast and slow pathway effective refractory periods. A significant decrease in the refractory window (p <0.001) after successful slow pathway modification was found.

Postpericardiotomy syndrome after permanent pacemaker implantation in children and young adults.

BACKGROUND: Postpericardiotomy syndrome (PPS) occurs in 10% to 50% of pediatric patients after cardiac surgery. The incidence and outcome of PPS after permanent pacemaker implantation in children is not described. METHODS: A retrospective analysis was performed of all pediatric patients who underwent isolated placement of a pacemaker between January 1984 and December 2002. Patients who underwent congenital heart surgery at the time of pacemaker implantation were excluded. PPS was diagnosed on the basis of clinical symptoms with echocardiographic confirmation of a pericardial effusion. RESULTS: Four hundred and forty-three pacemakers (237 epicardial, 206 transvenous) were implanted in 370 patients (median age 10 years, range 2 months to 24 years). Eight (2%) episodes of PPS (6 epicardial, 2 transvenous) occurred in 7 patients. The median time from implantation to PPS was 12.5 days (range 8 to 22 days). Six (75%) episodes followed primary pacemaker implantation, two occurred after subsequent lead revision. Three patients were initially treated with medical therapy (1 nonsteroidal agents, 2 steroids), and 1 required subsequent pericardiocentesis. Five patients underwent initial pericardiocentesis followed by medication. One patient had echocardiographic recurrence of a pericardial effusion 3 weeks after a nonsteroidal taper, with resolution after nonsteroidal agents were reinitiated. One patient required a pericardial window for a persistent effusion. No pacemaker was explanted. CONCLUSIONS: PPS occurred in 2% of children undergoing isolated pacemaker implantation of both epicardial and transvenous systems. PPS is usually managed successfully with medical therapy. Patients with medical treatment failure were successfully treated with pericardiocentesis or the surgical creation of a pericardial window.

Efficacy of prophylactic epicardial pacing leads in children and young adults.

BACKGROUND: Epicardial pacemakers are often required in children and young adults who cannot undergo a transvenous system because of patient size, vascular barriers, or significant residual intracardiac shunts. Prophylactic epicardial pacing leads, placed at the time of concomitant congenital heart surgery, may reduce a late thoracotomy or sternotomy. The efficacy of prophylactic epicardial leads in the pediatric population is unknown. METHODS: A retrospective review of the cardiovascular surgery and pacemaker databases at The Children's Hospital of Philadelphia identified all patients less than or equal to 21 years of age, who underwent placement of an epicardial pacing lead between January 1, 1990 and December 31, 2002. Prophylactic epicardial pacing leads placed at the time of a concomitant congenital heart procedure were compared to standard epicardial leads that were connected to a simultaneous programable generator. Pacing and sensing threshold data were obtained in prophylactic epicardial leads at the time of lead retrieval and 6 month follow-up and compared to standard epicardial pacing leads. RESULTS: Twenty-two (13 ventricular, 9 atrial) prophylactic epicardial pacing leads were retrieved in 13 patients at a median of 252 days (7 days to 3.98 years) from the time of initial implant and compared to 256 (164 ventricular, 92 atrial) standard epicardial leads placed in 142 patients. Nineteen (86%) prophylactic epicardial leads had acceptable pacing and sensing thresholds at lead retrieval. Only 1 patient with atrial and ventricular leads had poor pacing and sensing at retrieval and required a redo-sternotomy for placement of new atrial and ventricular epicardial pacing leads. For the remaining atrial (n = 7) and ventricular (n = 12) prophylactic epicardial leads, there was no significant difference in pacing (atrial, 1.59 +/- 1.1 microJ; ventricular, 1.98 +/- 1.9 microJ) or sensing (atrial, 3.6 +/- 1.8 mV; ventricular, 13.8 +/- 4.4 mV) compared to standard pacing (atrial, 2.1 +/- 1.8 microJ; ventricular, 1.9 +/- 3.4 microJ) and sensing (atrial, 3.3 +/- 1.7 mV; ventricular, 11.3 +/- 5.3 mV) epicardial leads. Six-month follow-up pacing and sensing thresholds were not significantly different between the prophylactic and standard epicardial pacing leads. CONCLUSIONS: Prophylactic epicardial pacing leads can be successfully placed and retrieved in a subset of children and young adults who will likely require pacing at a later date. Prophylactic leads have comparable pacing and sensing qualities at lead retrieval and short-term follow-up compared to standard epicardial leads. Consideration for prophylactic epicardial pacing leads will likely reduce the need for a late thoracotomy or sternotomy.

Capture management efficacy in children and young adults with endocardial and unipolar epicardial systems.

AIMS: This prospective study characterized performance of the Kappa 700 Ventricular Capture Management trade mark (VCM) system for monitoring ventricular pacing threshold and adapting outputs in both endocardial and unipolar epicardial pacing systems in children and young adults. VCM bears cautionary labelling against use with epicardial leads since they have not been demonstrated appropriate for use with VCM. METHODS AND RESULTS: VCM was programmed in "Monitor Only" mode. Ventricular pacemaker thresholds were measured daily using VCM for a minimum of 2 months. Potential device longevities at nominal outputs (3.5 V, 1.0 ms) and at VCM-recommended outputs were compared. Thirty patients (median age 14.4 years (1-27 years); 15 epicardial/15 endocardial) completed the study. During the daily measurements, consistent undersensed evoked response occurred in 2 patients (Medtronic epicardial leads 4965). For the other 28 patients, programming VCM in "Adaptive" mode from implant would provide an additional 6.8 months (0-19 months) of battery life. CONCLUSION: Although not an IDE (Investigation Device Exemption) study, this study showed acceptable VCM performance in "Monitor Only" mode in 13/15 patients with unipolar epicardial leads. A 2-month "Monitor Only" observation period helps screen patients who might not benefit from VCM. VCM may provide substantial energy savings and extended battery life for children and young adults.

Postoperative junctional ectopic tachycardia in children: incidence, risk factors, and treatment.

BACKGROUND: Junctional ectopic tachycardia (JET) occurs commonly after pediatric cardiac operation. The cause of JET is thought to be the result of an injury to the conduction system during the procedure and may be perpetuated by hemodynamic disturbances or postoperative electrolyte disturbances, namely hypomagnesemia. The purpose of this study was to determine perioperative risk factors for the development of JET. METHODS: Telemetry for each patient admitted to the cardiac intensive care unit from December 1997 through November 1998 for postoperative cardiac surgical care was examined daily for postoperative JET. A nested case-cohort analysis of 33 patients who experienced JET from 594 consecutively monitored patients who underwent cardiac operation was performed. Univariate and multivariate analyses were conducted to determine factors associated with the occurrence of JET. RESULTS: The age range of patients with JET was 1 day to 10.5 years (median, 1.8 months). Univariate analysis revealed that dopamine or milrinone use postoperatively, longer cardiopulmonary bypass times, and younger age were associated with JET. Multivariate modeling elicited that dopamine use postoperatively (odds ratio, 6.2; p = 0.01) and age less than 6 months (odds ratio, 4.0; p = 0.02) were associated with JET. Only 13 (39%) of the patients with JET received therapeutic interventions. CONCLUSIONS: Junctional ectopic tachycardia occurred in 33 (5.6%) of 594 patients who underwent cardiac operation during the study period. Postoperative dopamine use and younger age were associated with JET. It may be speculated that dopamine should be discontinued in the presence of postoperative JET.