Application and Utility of iPads in Pediatric Tele-echocardiography.

BACKGROUND: Telemedicine is used with increasing frequency to improve patient care in remote areas. The interpretation of medical imaging on iPad(®) (Apple, Cupertino, CA) tablets has been reported to be accurate. There are no studies on the use of iPads for interpretation of pediatric echocardiograms. We compared the quality of echo images, diagnostic accuracy, and review time using three different modalities: remote access on an iPad Air (iPad), remote access via a computer (Remote), and direct access on a computer linked through Ethernet to the server, the "gold standard" (Direct). MATERIALS AND METHODS: Fifty consecutive archived pediatric echocardiograms were interpreted using the three modalities. Studies were analyzed blindly by three pediatric cardiologists; review time, diagnostic accuracy, and image quality were documented. Diagnostic accuracy was assessed by comparing the study diagnoses with the official diagnosis in the patient's chart. Discrepancies between diagnoses were graded as major (more than one grade difference) or minor (one grade difference in severity of lesion). RESULTS: There were no significant differences in accuracy among the three modalities. There was one major discrepancy (size of patent ductus arteriosus); all others were minor, hemodynamically insignificant. Image quality ratings were better for iPad than Remote; Direct had the highest ratings. Review times (mean [standard deviation] minutes) were longest for iPad (5.89 [3.87]) and then Remote (4.72 [2.69]), with Direct having the shortest times (3.52 [1.42]) (p < 0.0001). CONCLUSIONS: Pediatric echocardiograms can be interpreted using convenient, portable devices while preserving accuracy and quality with slightly longer review times (1-2 min). These findings are important in the current era of increasing need for mobile health.

Remote diagnosis of congenital heart disease in southern Arizona: comparison between tele-echocardiography and videotapes.

OBJECTIVE: We report our experience with tele-echocardiography and echocardiograms recorded digitally or on videotape (recorded-echos) at The University of Arizona from August 2006 to December 2010 and compare their quality and diagnostic accuracy. MATERIALS AND METHODS: Tele-echocardiograms (tele-echos) were transmitted from the Yuma Regional Medical Center to The University of Arizona via a T-1 and aT-3 line at a bandwidth of 768 kilobits per second. Recorded-echos were shipped for interpretation to The University of Arizona by overnight mail. Diagnostic accuracy was assessed by comparing tele- and recorded-echos with electrocardiograms performed by a pediatric cardiologist (PedsCard-echos). RESULTS: Three hundred forty-six tele-echos in 260 patients and 455 recorded-echos in 406 patients were performed (median age, 6 and 8 days, respectively). Indications included possible congenital heart disease (CHD), patent ductus arteriosus (PDA), and persistent pulmonary hypertension of the newborn. Diagnostic categories included complex CHD, non-critical disease, PDA, and other. PedsCard-echos were available for 27% of the tele-echo and 30% of the recorded-echo patients. Comparisons between tele- and PedsCard-echo yielded no discrepancies in 12 (23%), expected resolution of condition in 26 (49%), and minor in 14 (26%). One (2%) major discrepancy was detected. Comparisons between recorded- and PedsCard-echo showed no discrepancies in 28 (40%), expected resolution of condition in 14 (20%), and minor discrepancies in 28 (40%) patients. No significant difference with respect to discrepancies was detected between tele- and recorded-echos. There was significant (p<0.01) improvement in tele- and recorded-echo study quality by 2010. CONCLUSIONS: (1) Tele-echocardiography can be performed successfully with excellent accuracy. (2) The quality of tele- and recorded-echo studies improved toward the end of the analysis period. (3) Although initially tele-echo studies were more accurate than recorded-echo studies, there was no difference between these two types of studies by the fourth year of the study. (4) Both tele- and recorded-echos were indispensible in the remote diagnosis of CHD.

Successful thrombolysis of acute left atrial thrombi in two pediatric patients following interventional cardiac catheterization.

Acute left atrial intracardiac thrombi require aggressive therapy due to the risk of embolization and cerebrovascular accidents. Current treatment includes the use of high-dose recombinant tissue plasminogen activator (rTPA), which is associated with significant bleeding complications. We report the successful treatment of two pediatric patients with acute left atrial thrombi following interventional cardiac catheterizations using low-dose rTPA. Echocardiography was used to document the presence of the thrombi and monitor treatment with rTPA infusion at 0.03 mg/kg/hour and heparin. Both patients experienced complete resolution of left atrial thrombi without hemodynamically significant side effects. Low-dose (0.03 mg/kg/hour) rTPA with heparin is an acceptable and safe alternative to high-dose rTPA infusion for intracardiac thrombi in children.

Alcohol- and Caffeine-Induced Changes in Mitral Valve Echo Morphology and Auscultation in Healthy Females.

Mitral valve prolapse (MVP) is a common cardiac valve abnormality that affects women more frequently than men. We have shown that mild dehydration induces echocardiographic signs of MVP in healthy females more frequently than in males. The present study investigated whether ethanol and caffeine, two commonly used substances, will induce changes in mitral leaflet morphology in normal subjects and whether these changes are gender dependent. Ten healthy volunteers were examined after ingesting 0.95 g/kg ethanol at breath ethanol values of 0.025% +/- 0.005%, 0.050% +/- 0.005%, and 0.075% (peak) +/- 0.005%, and at decreasing ethanol levels of 0.050% +/- 0.005% and 0.025% +/- 0.005%. Twelve healthy subjects were studied at 1.5, 3, and 4.5 hours after ingesting 5 mg/kg body weight of caffeine in a randomized, double-blind, crossover manner. A significant increase in mitral valve shape index (MVSI) on apical four-chamber view was documented in females following ethanol ingestion at all ethanol levels. These changes were accompanied by auscultatory findings characteristic of MVP. Decreased systemic vascular resistance, and afterload and increased heart rate, also occurred after ethanol ingestion. A significant increase in MVSI occurred on parasternal long axis in females at peak caffeine level; auscultatory findings characteristic of MVP also were documented. MVSI increased slightly on apical four-chamber view in males; however, no male subject developed auscultatory MVP. Body mass index was significantly lower in females (20.8 +/- 0.7 kg/m(2)) versus males (23.7 +/- 0.3 kg/m(2), P < 0.05). All subjects lost weight after caffeine intake; afterload and contractility also were increased. This study documents that ethanol and caffeine, at concentrations similar to those present in social intake, induced significant echo changes in mitral leaflet morphology and auscultation suggestive of MVP in healthy females. These results suggest that in addition to apparent hydration state, recent ethanol or caffeine intake should be taken into consideration before making the diagnosis of MVP.

Left ventricular assist device support as a bridge to recovery in young children.

OBJECTIVE: Left ventricular assist device (LVAD) experience and follow-up data in children are limited. We report the deployment and successful weaning from LVAD in young children with severe heart failure (HF). DESIGN: From 2004--2009, 13 children suffering from HF were placed on LVAD. All presented with a dilated left ventricle (LV) with severely reduced contractility, secondary to myocarditis, atrial arrhythmia or idiopathic HF. This study reports their outcomes and longitudinal follow-up. RESULTS: Of 13 young children with HF (ages 1 month--6 years; mean 19.2 months) placed on LVAD: eight weaned to recovery and successful hospital discharge, one was transplanted and four died. Echo follow-up in the weaned patients (mean age 22.1 months) revealed significant improvements from pre-LVAD measurements: LV end-diastolic dimension (LVED) mean z-score decreased from +4.8 to +0.95 (P < .001); fractional shortening (FS %) improved from a mean of 9.3% to 33% (P < .001); and the degree of mitral regurgitation (MR) significantly improved (P < .05). Time to LVAD deployment from HF diagnosis was more likely to be less than 30 days in the successfully weaned patients (100%) than patients who died or were transplanted (20%); P = .007. CONCLUSIONS: LVAD support can be utilized as a bridge to recovery in young children with HF. Following LVAD weaning, children sustain improvements in LV size, function and degree of MR. LVAD deployment less than 30 days from HF diagnosis improves the likelihood of successful weaning and illustrates that children with acute etiologies of HF are more likely to achieve recovery.

Are all ventricular septal defects created equal?

The authors report the occurrence of infective endocarditis in a 32-year-old man with a ventricular septal defect and a left ventricular-to-right-atrial shunt who adhered to the revised 2007 American Heart Association guidelines for infective endocarditis. The patient had received antibiotic prophylaxis prior to multiple previous dental procedures. At a recent dental evaluation for fillings, he was informed that he no longer needed prophylaxis. Fatigue and fevers developed 1 week later, and he was treated with an oral course of ciprofloxacin. The symptoms recurred, and blood cultures grew Streptococcus viridans. A 7-mm vegetative mass was seen on the septal leaflet of the tricuspid valve during transesophageal echocardiography. This report raises the concern that patients with ventricular septal defects and left ventricular-to-right-atrial shunts are at higher risk for endocarditis and may require antibiotic prophylaxis.

Look before you close: atrial septal defect with undiagnosed partial anomalous pulmonary venous return.

The growing and continued success of percutaneous closure of atrial defects is related to its high benefit-to-risk ratio in appropriately selected patients. The following case illustrates a previously undocumented danger, namely, the potential for incomplete correction. A thorough transesophageal examination performed at the time of the planned atrial defect closure suggested the presence of a partial anomalous pulmonary vein insertion, which was then appropriately documented and the incomplete closure was averted.