Limited Relationship Between Echocardiographic Measures and Electrocardiographic Markers of Left Ventricular Size in Healthy Children.

Pediatric ECG standards have been defined without echocardiographic confirmation of normal anatomy. The Pediatric Heart Network Normal Echocardiogram Z-score Project provides a racially diverse group of healthy children with normal echocardiograms. We hypothesized that ECG and echocardiographic measures of left ventricular (LV) dimensions are sufficiently correlated in healthy children to imply a clinically meaningful relationship. This was a secondary analysis of a previously described cohort including 2170 digital ECGs. The relationship between 6 ECG measures associated with LV size were analyzed with LV Mass (LVMass-z) and left ventricular end-diastolic volume (LVEDV-z) along with 11 additional parameters. Pearson or Spearman correlations were calculated for the 78 ECG-echocardiographic pairs with regression analyses assessing the variance in ECG measures explained by variation in LV dimensions and demographic variables. ECG/echocardiographic measurement correlations were significant and concordant in 41/78 (53%), though many were significant and discordant (13/78). Of the 6 ECG parameters, 5 correlated in the clinically predicted direction for LV Mass-z and LVEDV-z. Even when statistically significant, correlations were weak (0.05-0.24). R2 was higher for demographic variables than for echocardiographic measures or body surface area in all pairs, but remained weak (R2 ≤ 0.17). In a large cohort of healthy children, there was a positive association between echocardiographic measures of LV size and ECG measures of LVH. These correlations were weak and dependent on factors other than echocardiographic or patient derived variables. Thus, our data support deemphasizing the use of solitary, traditional measurement-based ECG markers traditionally thought to be characteristic of LVH as standalone indications for further cardiac evaluation of LVH in children and adolescents.

Impact of Obesity on Ventriculo-Arterial Interaction in Patients After Coarctation of Aorta repair.

Survival of patients after repair of coarctation of Aorta (CoA) has improved significantly over the decades, but patients have decreased life expectancy as compared to the general population. This has been attributed to increased hypertension, cerebrovascular disease, and coronary artery disease. There has also been an increasing concern of overweight and obesity in patients with adult congenital heart disease. While there have been studies looking at the impact of long-term hypertension on myocardial performance and outcomes in this population, this study aims to assess the impact of obesity in these patients on their myocardial performance. Ventriculo-arterial coupling is used as a measure of myocardial performance which reflects the interaction between cardiac contractility and arterial elastance. Patients after CoA repair are known to have hypertension affecting the arterial elastance. Obesity affects cardiac contractility as well. This study demonstrated that in a group of young patients after CoA repair, body mass index (BMI) has a relationship with left ventricular (LV) contractility and myocardial performance. This relationship was independent of blood pressure. BMI itself was not seen to affect the determinants of diastolic function in this study, suggesting that LV contractility may be affected before one can notice a change in the diastolic function secondary to BMI.

Masked Hypertension in Pediatric Heart Transplant Recipients.

BACKGROUND: Masked hypertension (HTN), especially, isolated nocturnal HTN (INH) has been shown to be a risk factor for cardiovascular disease (CVD) but is not studied well in pediatric heart transplant (PHT) patients. Ambulatory blood pressure monitoring (ABPM) is known to identify patients with HTN but is not used routinely in PHT. METHODS: A single-center, prospective, cross-sectional study of PHT recipients was performed to observe the incidence of masked HTN using 24-h ABPM. The relationship between ABPM parameters and clinical variables was assessed using Spearman correlation coefficient. p value < 0.05 was considered significant. RESULTS: ABPM was performed in 34 patients, mean age 14 ± 5 years, median 5.5 years post-PHT. All patients had normal cardiac function, left ventricular mass index and blood pressure measurements in the clinic. Four patients had known prior HTN and on medications, one of them was uncontrolled. Of the remaining 30 patients, 18 new patients were diagnosed with masked HTN, of which 14 had INH. Diurnal variation was abnormal in 82% (28/34) patients. 24-h diastolic blood pressure (DBP) index correlated with glomerular filtration rate (GFR) (r = - 0.44, p = 0.01). There was no correlation between other ABPM parameters with tacrolimus trough levels. CONCLUSIONS: ABPM identified masked HTN in 60% of patients, with majority being INH. Abnormal circadian BP patterns were present in 82% and an association was found between GFR and DBP parameters. HTN, especially INH, is under-recognized in PHT recipients and ABPM has a role in their long-term care.

Impact of Z score system on the management of coronary artery lesions in Kawasaki disease.

BACKGROUND: Coronary artery aneurysms are well-described in Kawasaki disease and the Multisystem Inflammatory Syndrome in Children and are graded using Z scores. Three Z score systems (Boston, Montreal, and DC) are widely used in North America. The recent Pediatric Heart Network Z score system is derived from the largest diverse sample to-date. The impact of Z score system on the rate of coronary dilation and management was assessed in a large real-world dataset. METHODS: Using a combined dataset of patients with acute Kawasaki disease from the Children's Hospital at Montefiore and the National Heart, Lung, and Blood Institute Kawasaki Disease Study, coronary Z scores and the rate of coronary lesions (Z ≥ 2.0) and aneurysms (Z ≥ 2.5) were determined using four Z score systems. Agreement among Z scores and the effect on Kawasaki management were assessed. RESULTS: Of 333 patients analysed, 136 were from Montefiore and 197 from the Kawasaki Disease Study. Age, sex, body surface area, and rate of coronary lesions did not differ between the samples. Among the four Z score systems, the rate of acute coronary lesions varied from 24 to 55%. The mean left anterior descending Z scores from Pediatric Heart Network and Boston had a large uniform discrepancy of 1.3. Differences in Z scores among the four systems may change anticoagulation management in up to 22% of a Kawasaki population. CONCLUSIONS: Choice of Z score system alone may impact Kawasaki disease diagnosis and management. Further research is necessary to determine the ideal coronary Z score system.

Ambulatory Blood Pressure Patterns in Children, Adolescents, and Young Adults With Childhood-Onset Systemic Lupus Erythematosus and Normal Office Blood Pressure.

OBJECTIVE: Cardiovascular disease is a major cause of morbidity and mortality in systemic lupus erythematosus (SLE). Hypertension (HTN) and nondipping are modifiable risk factors for cardiovascular disease. Limited studies are available for childhood-onset SLE (cSLE). We aimed to assess ambulatory blood pressure monitoring (ABPM) pattern in cSLE patients with normal office blood pressure. METHODS: This cross-sectional single-center study enrolled 25 patients with cSLE, normal office blood pressure and normal renal function. We performed 24-hour ABPM and echocardiography to assess end-organ damage. Descriptive statistics were obtained, and comparison of variables using Fisher exact test, t test, and Mann-Whitney U test was performed to identify potential risk factors for nondipping. RESULTS: Of the 25 patients, 22 were women; the median age was 18 years (interquartile range, 16-20 years). Median SLE duration was 4.2 years (interquartile range, 2.9-8.1 years); 18 patients had a history of lupus nephritis (LN). Four patients, 3 of whom had LN, had masked HTN. Fourteen patients (56%) were nondipping. The majority of patients without LN (71%) had a nondipping profile. Echocardiography was done for 15 patients. Left ventricular mass index, relative wall thickness, and ejection fraction were normal in all patients. Ambulatory blood pressure monitoring results led to changes in therapy in 5 patients. CONCLUSION: Our data provide evidence of high prevalence of nondipping and masked HTN in patients with cSLE, even in patients without LN. Identifying ABPM abnormalities in these patients could potentially improve outcomes.

Nocturnal hypertension associated with stroke and silent cerebral infarcts in children with sickle cell disease.

BACKGROUND: Strokes and silent cerebral infarcts (SCIs) lead to significant morbidity and mortality in children with sickle cell disease (SCD). Higher systolic blood pressures increase risk for stroke and SCIs; however, patients with SCD often have lower clinic blood pressures than the general population. Twenty-four-hour ambulatory blood pressure monitoring (ABPM) allows for more robust examination of blood pressures. This study evaluated associations between abnormal ABPM measurements with stroke and SCIs. PROCEDURE: A cross-sectional study was performed. Children with SCD completed 24-hour ABPMs. Children with a documented magnetic resonance imaging (MRI) brain within a year of the ABPM were included in the analysis. Bivariate analyses were performed to identify associations between ABPM parameters with cerebrovascular outcomes. RESULTS: Forty-two children with a median age of 13 years (10, 17) were included in the analysis. Seven (17%) had history of stroke and seven (17%) had SCIs. Nocturnal hypertension, elucidated via 24-hour ABPM, was noted in 25% of subjects. The presence of nocturnal hypertension was significantly higher in the SCI/stroke group (55% vs 12%, P = .01). Sensitivity analyses were performed during which stroke patients were removed from analysis. Nocturnal hypertension remained significantly associated with the presence of SCIs (P = .006). CONCLUSIONS: This study reveals an association between nocturnal hypertension and a higher prevalence of SCI and stroke in children with SCD. Larger, prospective studies are needed to confirm these findings and evaluate the contributory nature of blood pressure abnormalities to cerebrovascular events in children with SCD.

Association of Anemia and Blood Pressure With Novel Markers of Diastolic Function in Pediatric Sickle Cell Disease.

Diastolic dysfunction is a known cause of mortality in adults with sickle cell disease (SCD). Left atrial function (LAf) and strain (LAS) are novel echocardiographic parameters to assess early diastolic dysfunction, which have not been assessed in pediatric SCD. Through a retrospective single-center study, we describe echocardiographic parameters of diastology in children with SCD and evaluate their relationship with clinical variables including anemia and blood pressure. Baseline clinical data, 24-hour ambulatory blood pressure monitoring data and echocardiography results were collected. LAf and LAS were measured using volumetric data and speckle-tracking echocardiography, respectively. Sixty-seven children with SCD (13.5±7 y, 47% male, 7% hypertensive) with a mean hemoglobin of 8.8±1.3 g/dL, LAf of 61±8% (n=53) and LAS of 46.3±7.4% (n=28) were included. LAS was significantly associated with hemoglobin (ρ=0.43, P=0.022) but not with maximal left atrial (LA) volume (ρ=-0.05, P=0.79) or any blood pressure parameters. On multivariate analysis, LAS decreased by 3.2% (1.3, 5.1) and LA volume increased by 1.6 mL/m2 (3.1, 0.08) for every 1 g/dL decrease in hemoglobin. Thus, severity of baseline anemia in pediatric SCD correlates with diastolic function as measured by LAS, independent of LA dilation.

Height Versus Body Surface Area to Normalize Cardiovascular Measurements in Children Using the Pediatric Heart Network Echocardiographic Z-Score Database.

Normalizing cardiovascular measurements for body size allows for comparison among children of different ages and for distinguishing pathologic changes from normal physiologic growth. Because of growing interest to use height for normalization, the aim of this study was to develop height-based normalization models and compare them to body surface area (BSA)-based normalization for aortic and left ventricular (LV) measurements. The study population consisted of healthy, non-obese children between 2 and 18 years of age enrolled in the Pediatric Heart Network Echo Z-Score Project. The echocardiographic study parameters included proximal aortic diameters at 3 locations, LV end-diastolic volume, and LV mass. Using the statistical methodology described in the original project, Z-scores based on height and BSA were determined for the study parameters and tested for any clinically significant relationships with age, sex, race, ethnicity, and body mass index (BMI). Normalization models based on height versus BSA were compared among underweight, normal weight, and overweight (but not obese) children in the study population. Z-scores based on height and BSA were calculated for the 5 study parameters and revealed no clinically significant relationships with age, sex, race, and ethnicity. Normalization based on height resulted in lower Z-scores in the underweight group compared to the overweight group, whereas normalization based on BSA resulted in higher Z-scores in the underweight group compared to the overweight group. In other words, increasing BMI had an opposite effect on height-based Z-scores compared to BSA-based Z-scores. Allometric normalization based on height and BSA for aortic and LV sizes is feasible. However, height-based normalization results in higher cardiovascular Z-scores in heavier children, and BSA-based normalization results in higher cardiovascular Z-scores in lighter children. Further studies are needed to assess the performance of these approaches in obese children with or without cardiac disease.

Speckle Tracking Echocardiography in Pediatric Patients with Premature Ventricular Contractions.

Premature ventricular contractions (PVCs) in pediatric patients without structural heart disease and normal left ventricular systolic function rarely require therapy, though it is unknown whether these patients have subclinical cardiac dysfunction. Speckle tracking echocardiography is an additional means of evaluating cardiac function in asymptomatic pediatric PVC patients with normal standard measures of left ventricular (LV) function. Asymptomatic pediatric patients (< 21 years) without congenital heart disease, LV ejection fraction (LVEF) ≥ 55% and PVC burden ≥ 5% on 24-h Holter monitor were included. Demographic information, exercise stress test results, standard echocardiographic measures of LV systolic function and PVC morphology by 12-lead ECG were collected. Peak global systolic longitudinal strain (GLS) from apical four-chamber view was analyzed offline. 29 patients were identified (mean age 11.7 ± 5.8 years, 49.2 ± 25.3 kg, 59% male). Mean PVC burden was 12.0 ± 7.0% (range 5-37.5%). 14/29 (48%) had exercise stress testing with evidence of PVCs; 9/14 (64%) had PVC suppression at a mean heart rate (HR) of 160 ± 23 bpm and 5/14 (36%) did not suppress at a mean maximum HR of 188 ± 9 bpm. All patients had normal strain values by speckle tracking echocardiography (mean LV GLS - 22.5 ± 2.0%, LV global circumferential strain - 25.3 ± 3.9 and RV GLS - 24.1 ± 3.0%). There was no correlation between PVC burden and cardiac function parameters. Asymptomatic pediatric patients without structural heart disease, preserved LVEF/shortening fraction and PVC burden ≥ 5% demonstrated normal cardiac function including strain patterns indicating no evidence of subclinical cardiac dysfunction. Larger scale studies and longitudinal evaluation of left ventricular function using speckle tracking echocardiography is warranted in this population.

Challenges and lessons learned from the Pediatric Heart Network Normal Echocardiogram Database study.

BACKGROUND: The Pediatric Heart Network Normal Echocardiogram Database Study had unanticipated challenges. We sought to describe these challenges and lessons learned to improve the design of future studies. METHODS: Challenges were divided into three categories: enrolment, echocardiographic imaging, and protocol violations. Memoranda, Core Lab reports, and adjudication logs were reviewed. A centre-level questionnaire provided information regarding local processes for data collection. Descriptive statistics were used, and chi-square tests determined differences in imaging quality. RESULTS: For the 19 participating centres, challenges with enrolment included variations in Institutional Review Board definitions of "retrospective" eligibility, overestimation of non-White participants, centre categorisation of Hispanic participants that differed from National Institutes of Health definitions, and exclusion of potential participants due to missing demographic data. Institutional Review Board amendments resolved many of these challenges. There was an unanticipated burden imposed on centres due to high numbers of echocardiograms that were reviewed but failed to meet submission criteria. Additionally, image transfer software malfunctions delayed Core Lab image review and feedback. Between the early and late study periods, the proportion of unacceptable echocardiograms submitted to the Core Lab decreased (14 versus 7%, p < 0.01). Most protocol violations were from eligibility violations and inadvertent protected health information disclosure (overall 2.5%). Adjudication committee reviews led to protocol changes. CONCLUSIONS: Numerous challenges encountered during the Normal Echocardiogram Database Study prolonged study enrolment. The retrospective design and flaws in image transfer software were key impediments to study completion and should be considered when designing future studies collecting echocardiographic images as a primary outcome.

Ventricular Arterial Coupling: A Novel Echocardiographic Risk Factor for Disease Progression in Pediatric Dilated Cardiomyopathy.

In adult heart failure (HF) patients, a higher ventricular arterial (VA) coupling ratio measured non-invasively is associated with worse HF prognosis and response to treatment. There are no data regarding the relationship of VA coupling to outcome in pediatric dilated cardiomyopathy (DCM) patients. We investigated the association of VA coupling ratio with worse outcome (mechanical circulatory support, transplant, or death) in 48 children with DCM and 97 age-gender matched controls. Mean age at presentation was 9 ± 7 years; DCM patients had a higher arterial elastance (3.8 ± 1.7 vs 2.7 ± 0.7 respectively p = 0.001), a lower LV elastance (1.1 ± 0.65 vs 4.5 ± 1.4, respectively p = 0.001) and higher VA coupling ratio (5.0 ± 3.9 vs 0.34 ± 0.14, respectively p = 0.001). Outcome events occurred in 27/48 (56%) patients. Patients with an outcome event had a higher NYHA class (p = 0.001), lower LV elastance (0.8 ± 0.47 vs 1.6 ± 0.57, respectively p = 0.001), higher arterial elastance (4.5 ± 1.8 vs 2.9 ± 1.1, respectively p = 0.002), and a higher VA coupling ratio (7.1 ± 3.8 vs 2.2 ± 1.5, respectively p = 0.001) compared to those without. In a multivariate CART analysis, VA coupling was the top and only discriminator of poor outcome. In conclusion, a higher VA coupling ratio is associated with worse outcome in pediatric patients with DCM. VA coupling is promising as a bedside analysis tool that may provide insight into the mechanisms of HF in pediatric DCM and identify potential targets for therapy.

The Prevalence of Left Ventricular Hypertrophy in Obese Children Varies Depending on the Method Utilized to Determine Left Ventricular Mass.

Obesity and left ventricular hypertrophy (LVH) have been identified as independent risk factors for cardiovascular events. The definition of LVH depends on the geometric algorithm used to calculate LV mass (LVM) by echocardiography and the method used to normalize LVM for body size. This study evaluates the effect of these methods on the prevalence of LVH in obese children. LVM for 109 obese and 109 age-matched non-obese children was calculated using M-mode or two-dimensional echocardiography (2DE). LVM was then normalized to height 2.7 as indexed LVM (LVMI), to body surface area (BSA), height, and lean body mass (LBM) as LVM Z-scores. LVH was defined as LVMI >95th ‰ using age-specific normal reference values or LVM Z-scores ≥2. The prevalence of LVH by LVMI and LVM Z-scores was compared. There was a correlation between LVM determined by M-mode and by 2DE (R (2) = 0.91), although M-mode LVM was greater than 2DE LVM. However, the difference between these values was greater in obese children than in non-obese children. Based on the method of normalization, the prevalence of LVH among obese children was 64 % using LVMI, 15 % using LVM Z-scores for height, 8 % using LVM Z-scores for BSA and 1 % using LVM Z-scores for LBM. Height-based normalization correlates with obesity and hypertension. The methods used to measure and normalize LVM have a profound influence on the diagnosis of LVH in obese children. Further study is needed to determine which method identifies children at risk for cardiovascular morbidity and mortality.

Unplanned Repeat Echocardiography with Sedation in Children: Patient Risk Factors.

Patient selection criteria for echocardiography with sedation in children are not well defined. We attempted to identify predictors of unplanned repeat echocardiography with sedation. This was a single-center, case-control study of echocardiograms performed in children aged 1-36 months. Cases underwent unplanned repeat examinations with sedation, while controls did not. Patient variables and study indications were compared. Logistic regression identified the most significant predictors. Cases (n = 104, median time to repeat echocardiogram 17 days, median age 12.9 months) were older than controls (n = 212, median age 5.0 months, P < 0.001). Significantly more cases than controls had structural cardiac disease (64 vs. 23 %) and anatomic complexity ≥moderate (38 vs. 5 %, P < 0.001 for both). Cases more often had Kawasaki disease (11 vs. 2 %), and controls more often had murmur (56 vs. 11 %, P < 0.001 for both). Logistic regression identified age 6 months to <2 years (OR 3.26, 95 % CI 1.70-6.28, P < 0.001), Kawasaki disease (OR 5.20, 95 % CI 1.46-18.50, P = 0.01), and known pre-echocardiogram anatomic complexity ≥moderate (OR 3.99, 95 % CI 1.64-9.66, P = 0.002) as significant risk factors. An indication for murmur was protective (OR 0.32, 95 % CI 0.13-0.76, P = 0.01). We identified several risk factors for unplanned repeat echocardiography with sedation in children, including age 6 months to <2 years, higher anatomic complexity, and Kawasaki disease. Murmur was a protective factor. These results may help pediatric echocardiography laboratories establish criteria for sedation.

Lone atrial fibrillation in the young - perhaps not so "lone"?

OBJECTIVE: To determine if pediatric patients with a history of lone atrial fibrillation (AF) have other forms of supraventricular tachycardia (SVT) that may potentially trigger AF. STUDY DESIGN: A multicenter review of patients with lone AF who underwent electrophysiology (EP) study from 2006-2011 was performed. INCLUSION CRITERIA: age ≤21 years, normal ventricular function, structurally normal heart, history of AF, and EP study and/or ablation performed. EXCLUSION CRITERIA: congenital heart disease or cardiomyopathy. Patient demographics, findings at EP study and follow-up data were recorded. RESULTS: Eighteen patients met inclusion criteria. The mean age was 17.9 ± 2.2 years, weight was 82 ± 21 kg, body mass index was 27 ± 6, and 15 (83%) were males. Eleven (61%) were overweight or obese. Seven (39%) had inducible SVT during EP study: 5 atrioventricular nodal re-entry tachycardia (71%) and 2 concealed accessory pathways with inducible atrioventricular re-entry tachycardia (29%). All 7 patients with inducible SVT underwent radiofrequency ablation. There were no complications during EP study and/or ablation for all 18 patients. The mean follow-up was 1.7 ± 1.5 years and there were no recurrences in the 7 patients who underwent ablation. There were 2 recurrences of AF in patients with no other form of SVT during EP study. CONCLUSIONS: Inducible SVT was found in 39% of pediatric patients undergoing EP study for lone AF. EP study should be considered for pediatric patients presenting with lone AF.

Use of the Melody™ transcatheter pulmonary valve as a "covered stent" to repair conduit perforation during pulmonary valve implantation.

Right ventricular to pulmonary artery conduit tear after balloon dilation is a recognized potential complication, which can, in theory, be treated with a covered stent. We describe use of the Melody™ valve as a so-called "covered" stent for containment of bleeding from RV-PA conduit tear.

Pericardiectomy for Successful Treatment of Constrictive Pericarditis in a Pediatric Patient.

A 15-year-old girl with history of asthma and obesity presented with recurrent anasarca without systolic heart failure or significant renal disease. She was diagnosed with constrictive pericarditis and successfully underwent pericardiectomy with pericardial stripping and a waffle procedure. (Level of Difficulty: Advanced.).

Complementary and alternative medicine for children with sickle cell disease: A systematic review.

BACKGROUND: Complementary and alternative medicine (CAM) is a popular alternative to opioid and other analgesics in sickle cell disease (SCD). We review the effectiveness, prevalence, and factors associated with CAM use in the pediatric SCD population. METHODS: The review protocol was created based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search was conducted in MEDLINE, Embase, Cochrane Library, PubMed, and Web of Science. RESULTS: Twenty-four studies were examined. The prevalence of CAM use in pediatric patients with SCD ranged from 36 to 84.5%. Common inpatient CAM interventions were yoga, virtual reality, and acupuncture, which decreased pain scale scores. Outpatient CAMs were consisted of cognitive behavioral therapy, massage therapy, and guided-imagery, which increased pain tolerability and decreased pain scale scores. CONCLUSIONS: CAM modalities can decrease pain scale scores. However, the impact of specific CAM modalities on emergency department visits, hospitalizations, and school absences were inconclusive.

A new "tool" for transcatheter atrial defect closure: the St. Jude SL2™ sheath.

BACKGROUND: Orienting the left atrial disc of an atrial septal defect (ASD) closure device parallel to the septum is important, particularly in cases of ASD with deficient retroaortic rim. Standard vascular sheaths can make this challenging. We report the use of an electrophysiologic sheath, the SL2™ St. Jude Vascular sheath (St. Jude Medical, St. Paul, MN) for closure of ASD. METHODS: All patients undergoing ASD closure between July 2010 and February 2011 at The Children's Hospital at Montefiore in which the SL2 sheath was used were reviewed. RESULTS: Nine patients underwent transcatheter ASD or PFO (1/9) closure with the SL2 sheath. Mean age was 22.7 years (range, 3-58); weight was 46.5 kg (range, 14.7-78.6). The Amplatzer ASD Occluder (AGA Medical Corp., Plymouth, MN) was used in all cases. The mean measurement of the ASDs via "stop-flow" technique was 13.3 mm (range, 4-19). The mean device size was 13.9 mm (range, 5-20) or 105% the size of the defect. The retroaortic rim was deficient (<2 mm) in 3 of 9. ASD closure was achieved in 9 of 9. In all, the left atrial disk was brought toward the atrial septum parallel to the atrial septum, and repositioning or recapturing of the device was unnecessary in any case. Mean fluoroscopy time was 9.3 min (range, 2.2-18). No significant complications. CONCLUSIONS: The SL2 sheath was useful to position the ASD device parallel to the atrial septum, eliminating the need for redeployment during the procedure. This sheath was useful in those cases of deficient retroaortic rim in this study.

Prevalence of elevated right ventricular pressure in children with obstructive sleep apnea syndrome undergoing pulmonary hypertension screening.

STUDY OBJECTIVES: Our objective was to determine the prevalence of elevated right ventricular pressure (RVP) as a surrogate marker for pulmonary hypertension in children with obstructive sleep apnea syndrome (OSAS) undergoing echocardiography. METHODS: This was a retrospective chart review of children ages 2-21 years diagnosed with OSAS by an overnight polysomnogram who underwent cardiac echocardiogram to screen for pulmonary hypertension within 6 months of polysomnogram in a tertiary inner-city pediatric hospital. The primary outcome was elevated RVP defined by estimated RVP ≥ 25 mm Hg above right atrial pressure or ventricular septal configuration consistent with elevated RVP. RESULTS: A total of 174 children were included. The median (interquartile range) age was 8.9 (5.5-13.1) years with 59.2% male, 41.4% Hispanic, and 25.9% non-Hispanic Black patients. The prevalence of obesity was 72.0% and severe or very severe OSAS was present in 93.1%. The median (interquartile range) apnea-hypopnea index was 28.3 events/h (18.8-52.7 events/h). Seven children (4.0%) had elevated RVP. There was no association between elevated RVP and age, sex, race, body mass index percentile, apnea-hypopnea index, oxygen nadir, or severe OSAS (apnea-hypopnea index ≥ 10 events/h). CONCLUSIONS: Elevated RVP was rare and was not associated with OSAS severity. The prevalence in this cohort is higher than the prevalence of pulmonary hypertension noted in similar studies (0%-1.8%), which may be related to differences in methodology or unassessed cohort characteristics. Further effort to determine the optimal role for pulmonary hypertension screening in pediatric OSAS is needed. CITATION: Bitners AC, Arens R, Mahgerefteh J, et al. Prevalence of elevated right ventricular pressure in children with obstructive sleep apnea syndrome undergoing pulmonary hypertension screening. J Clin Sleep Med. 2021;17(11):2225-2232.