Bridging the Cardiac Needs of a Large, Underserved Immigrant and Resettled Refugee Population.

OBJECTIVE: To describe a monthly outreach pediatric cardiology clinic established to better understand the cardiac needs of immigrant/resettled refugee children. STUDY DESIGN: Data obtained between 2014 and 2017 from a monthly pediatric cardiology clinic at a Federally Qualified Health Center were analyzed using descriptive statistics. RESULTS: A total of 366 patients (222 male, 61%) were evaluated. Indications for referral included murmur (242, 66%), nonexertional symptoms (31, 9%), exertional symptoms (16, 4%), history of cardiac surgery/transcatheter interventions (15, 4%), previous diagnosis of heart conditions without intervention (13, 4%), arrhythmia/bradycardia (13, 4%), and others (36, 10%). Echocardiograms were performed on 136 patients (67 were abnormal, 49%). The most common final diagnoses include innocent murmur in 201 (55%), simple congenital heart disease in 61 (16%), complex congenital heart disease in 3 (1%), and acquired heart disease in 3 (1%). A total of 15 patients (4%) were ultimately determined to require surgical or cardiac catherization as an intervention. Patients have been followed for a median of 0.7 years (range 0-3.3 years). CONCLUSIONS: Rates of abnormal echocardiograms suggest a greater likelihood of congenital or acquired heart disease at time of initial consultation compared with nonimmigrant/refugee populations. The most common indication for referral to the outreach pediatric cardiology clinic was a murmur. Collaborative efforts between physicians and support services are essential in assisting this vulnerable population access pediatric subspecialty care.

Radiopathologic correlation of a tricuspid valve papillary fibroelastoma detected in an infant.

Papillary fibroelastomas are benign primary cardiac tumors that usually arise from the valve apparatus and are rare in the pediatric population. Involvement of the tricuspid valve is even less common with only a few cases reported in the literature. Cardiac magnetic resonance imaging is a valuable examination that aids in differentiating a tumor from a thrombus. We present the case of an 11-month-old girl referred by her pediatrician to investigate a murmur noted since birth. To our knowledge, this is the first report of a pathologically proven papillary fibroelastoma arising from the tricuspid valve characterized by magnetic resonance imaging in an infant.

Accessory Mitral Valve Leaflet Causing Severe Left Ventricular Outflow Tract Obstruction in a Preterm Neonate with a Partial Atrioventricular Septal Defect.

Atrioventricular septal defects represent a class of congenital cardiac malformations that vary in presentation and management strategy depending upon the severity of the particular lesions present. We present the case of a premature neonate who had a partial atrioventricular septal defect and an accessory mitral (or left atrioventricular) valve leaflet. The latter caused severe left ventricular outflow tract obstruction and severely depressed left ventricular function. We found only one other report of this atrioventricular valve abnormality in association with atrioventricular septal defect. To our knowledge, our patient (at a body weight of 1,800 g) is the smallest to survive corrective surgery of an accessory mitral valve leaflet with severe left ventricular outflow tract obstruction. In addition to our patient's case, we discuss the relevant medical literature.

Percutaneous closure of a prosthetic pulmonary paravalvular leak.

Paravalvular leak following prosthetic valve surgery has the potential to cause serious complications such as hemolysis and congestive heart failure. Successful percutaneous closures of prosthetic mitral and aortic paravalvular leaks have been performed as an alternative to reoperation. This case represents the first known report of successful percutaneous closure of a prosthetic pulmonary paravalvular leak in an adult patient with a history of congenital heart disease using two muscular ventricular septal defect occluder devices.

Femoral vein homograft for neoaortic reconstruction in the Norwood stage 1 operation: a follow-up study.

OBJECTIVE: The aim of this study was to analyze our experience with the cryopreserved femoral vein homograft in comparison with standard biomaterials for neoaortic reconstruction in the Norwood stage 1 operation. METHODS: All patients who underwent the Norwood operation from September 2004 to April 2011 were analyzed retrospectively (n = 107). Patients were grouped into group A (cryopreserved femoral vein homograft; n = 72) or group B (other; n = 35). Intergroup comparisons and dimensional analyses of all available angiograms were performed. Two surgical techniques, "standard homograft cuff" and "homograft tube," were compared. RESULTS: Multivariable Cox regression analysis revealed use of biomaterial other than femoral vein (P = .01; hazard ratio, 3.0; 95% confidence interval [CI], 1.4-6.4), weight less than 2.5 kg at the time of stage 1 (P = .01; hazard ratio, 3.7; 95% CI, 1.7-7.8), and need for extracorporeal membrane oxygenator support after stage 1 (P < .001; hazard ratio, 13.8; 95% CI, 5.9-31.9) as significant independent predictors of overall mortality. Improved late survival at 48 months was seen with the femoral vein homograft compared with other biomaterials when a "homograft tube with end-to-side ascending aortic reimplantation technique" was used (group A [75%] vs group B [44%]; P = .03). With the use of the "homograft cuff technique," survival was similar for femoral vein homografts and other biomaterials (group A [67%] vs group B [61%]; P = .85). Similar neoaortic coarctation rates were seen in both groups (A: 25/59 [42%] vs B: 12/26 [46%]; P = .81). A progressive increase in the diameter of the neoaorta was seen over time in both groups with both technical modifications (tube grafts pre-stage 2 vs pre-stage 3: group A [10.61 mm ± 1.93 vs 13.74 mm ± 3.16] [P < .001] and group B [13.93 mm ± 6.71 vs 17.38 mm ± 5.92] [P = .049]); cuff repair pre-stage 2 to pre-stage 3: group A [13.98 mm ± 2.13 vs 19.09 mm ± 4.18] [P = .002] and group B [16.06 mm ± 3.05 vs 19.73 mm ± 2.93] [P < .001]). The neoaortic Z-scores were generous with the use of homograft cuffs and modest when homograft tubes were used and maintained in range over the follow-up time. CONCLUSIONS: Survivals are improved with the use of femoral vein homograft for neoaortic reconstruction for Norwood stage 1 operation, especially when used as a homograft tube with end-to-side aortic reimplantation. Femoral vein homografts have similar recoarctation rates compared with standard biomaterials. Progressive growth/dilation of the neoaorta in proportion to somatic growth is seen with femoral vein tube grafts.

Sterile inflammation associated with transradial catheterization and hydrophilic sheaths.

In 1999, we noted the development of inflammation and/or abscesses at the site of radial access in a group of patients. Over a 3-year period, we noted this inflammation in 33 patients out of 2,038 (1.6%) who had catheterization via the radial approach. The radial abscesses occurred in 30 patients out of 1,063 (2.8%) in whom we could confirm the use of a hydrophilic-coated sheath, but in no patient for whom we can document that an uncoated sheath was used. No infectious agent could be implicated, and the time course for the development of the abscess, typically 2 to 3 weeks, seemed long for a bacterial infection. Later patients had biopsies, and granulomatous reactions were seen in most. Additionally, a few of the biopsies showed an amorphous extravascular substance consistent with the catheter coating. All patients had good long-term outcomes.