Opportunities and Barriers to Rural Telerobotic Surgical Health Care in 2021: Report and Research Agenda from a Stakeholder Workshop.

Background: There are well-recognized challenges to delivering specialty health care in rural settings. These challenges are particularly evident for specialized surgical health care due to the lack of trained operators in rural communities. Telerobotic surgery could have a significant impact on the rural-urban health care gap, but thus far, the promise of this method of health care delivery has gone unrealized. With the increasing adoption of telehealth over the past year, along with the maturation of telecommunication and robotic technologies over the past 2 decades, a reappraisal of the opportunities and barriers to widespread implementation of telerobotic surgery is warranted. Here we report the outcome of a rural telerobotic stakeholder workshop to explore modern-day issues critical to the advancement of telerobotic surgical health care. Materials and Methods: We assembled a multidisciplinary stakeholder panel to participate in a 2-day Rural Telerobotic Surgery Stakeholder Workshop. Participants had diverse expertise, including specialty surgeons, technology experts, and representatives of the broader telerobotic health care ecosystem, including economists, lawyers, regulatory consultants, public health advocates, rural hospital administrators, nurses, and payers. The research team reviewed transcripts from the workshop with themes identified and research questions generated based on stakeholder comments and feedback. Results: Stakeholder discussions fell into four general themes, including (1) operating room team interactions, (2) education and training, (3) network and security, and (4) economic issues. The research team then identified several research questions within each of these themes and provided specific research strategies to address these questions. Conclusions: There are still important unanswered questions regarding the implementation and adoption of rural telerobotic surgery. Based on stakeholder feedback, we have developed a research agenda along with suggested strategies to address outstanding research questions. The successful execution of these research opportunities will fill critical gaps in our understanding of how to advance the widespread adoption of rural telerobotic health care.

Nomenclature for Pediatric and Congenital Cardiac Care: Unification of Clinical and Administrative Nomenclature - The 2021 International Paediatric and Congenital Cardiac Code (IPCCC) and the Eleventh Revision of the International Classification of Diseases (ICD-11).

Substantial progress has been made in the standardization of nomenclature for paediatric and congenital cardiac care. In 1936, Maude Abbott published her Atlas of Congenital Cardiac Disease, which was the first formal attempt to classify congenital heart disease. The International Paediatric and Congenital Cardiac Code (IPCCC) is now utilized worldwide and has most recently become the paediatric and congenital cardiac component of the Eleventh Revision of the International Classification of Diseases (ICD-11). The most recent publication of the IPCCC was in 2017. This manuscript provides an updated 2021 version of the IPCCC.The International Society for Nomenclature of Paediatric and Congenital Heart Disease (ISNPCHD), in collaboration with the World Health Organization (WHO), developed the paediatric and congenital cardiac nomenclature that is now within the eleventh version of the International Classification of Diseases (ICD-11). This unification of IPCCC and ICD-11 is the IPCCC ICD-11 Nomenclature and is the first time that the clinical nomenclature for paediatric and congenital cardiac care and the administrative nomenclature for paediatric and congenital cardiac care are harmonized. The resultant congenital cardiac component of ICD-11 was increased from 29 congenital cardiac codes in ICD-9 and 73 congenital cardiac codes in ICD-10 to 318 codes submitted by ISNPCHD through 2018 for incorporation into ICD-11. After these 318 terms were incorporated into ICD-11 in 2018, the WHO ICD-11 team added an additional 49 terms, some of which are acceptable legacy terms from ICD-10, while others provide greater granularity than the ISNPCHD thought was originally acceptable. Thus, the total number of paediatric and congenital cardiac terms in ICD-11 is 367. In this manuscript, we describe and review the terminology, hierarchy, and definitions of the IPCCC ICD-11 Nomenclature. This article, therefore, presents a global system of nomenclature for paediatric and congenital cardiac care that unifies clinical and administrative nomenclature.The members of ISNPCHD realize that the nomenclature published in this manuscript will continue to evolve. The version of the IPCCC that was published in 2017 has evolved and changed, and it is now replaced by this 2021 version. In the future, ISNPCHD will again publish updated versions of IPCCC, as IPCCC continues to evolve.

Initial experience with a novel electrophysiology mapping simulator.

BACKGROUND: Despite data supporting the use of simulation training in procedural specialties and accreditation requirements, few options exist for electrophysiology (EP) training. We aimed to develop a low-cost, accessible simulator for training in EP mapping, and to test the simulator in a group of novice users. METHODS: Our mapping simulator is composed of three components: an acrylic case representing torso and thigh; three-dimensional (3D) printed cardiac models; and a commercially available mapping system. Using a proprietary flexible material that mimics the consistency of human heart tissue, we created an anatomically accurate model of a normal right atrium (RA) from computed tomography data. We developed a test protocol consisting of two activities: creation of a RA shell and timed navigation to specific locations within the RA shell. Seventeen participants were randomized to either practice versus no practice on the simulator, and repeated simulator and self-assessment tests were performed after 1 week. We measured volume of the RA map and time taken and distance from the target sites for each target location. RESULTS: Both groups showed improvement in generation of geometry, volume, time to target, and self-assessed comfort level after initial exposure to the simulator. Compared with no-practice, the practice group demonstrated an improved sense of confidence in mapping. CONCLUSIONS: Focused training in EP mapping using a novel simulator created with 3D printed heart models and a standard mapping system is feasible for use in the training environment. Exposure to the simulator is associated with improved mapping skills and trainee comfort level.

Intravenous sotalol use in a complex critically ill child: balancing the systems in choosing antiarrhythmic medication.

In critically ill children, multi-organ-system disease can influence the choice of antiarrhythmic medication. Intravenous therapy is often necessary. There is a scarcity of paediatric critical-care cases demonstrating the dosing, monitoring, and efficacy of intravenous sotalol. This case demonstrates the effective use of intravenous sotalol in an adolescent with renal, hepatic, and haematological dysfunctions.

Nomenclature for congenital and paediatric cardiac disease: the International Paediatric and Congenital Cardiac Code (IPCCC) and the Eleventh Iteration of the International Classification of Diseases (ICD-11).

An internationally approved and globally used classification scheme for the diagnosis of CHD has long been sought. The International Paediatric and Congenital Cardiac Code (IPCCC), which was produced and has been maintained by the International Society for Nomenclature of Paediatric and Congenital Heart Disease (the International Nomenclature Society), is used widely, but has spawned many "short list" versions that differ in content depending on the user. Thus, efforts to have a uniform identification of patients with CHD using a single up-to-date and coordinated nomenclature system continue to be thwarted, even if a common nomenclature has been used as a basis for composing various "short lists". In an attempt to solve this problem, the International Nomenclature Society has linked its efforts with those of the World Health Organization to obtain a globally accepted nomenclature tree for CHD within the 11th iteration of the International Classification of Diseases (ICD-11). The International Nomenclature Society has submitted a hierarchical nomenclature tree for CHD to the World Health Organization that is expected to serve increasingly as the "short list" for all communities interested in coding for congenital cardiology. This article reviews the history of the International Classification of Diseases and of the IPCCC, and outlines the process used in developing the ICD-11 congenital cardiac disease diagnostic list and the definitions for each term on the list. An overview of the content of the congenital heart anomaly section of the Foundation Component of ICD-11, published herein in its entirety, is also included. Future plans for the International Nomenclature Society include linking again with the World Health Organization to tackle procedural nomenclature as it relates to cardiac malformations. By doing so, the Society will continue its role in standardising nomenclature for CHD across the globe, thereby promoting research and better outcomes for fetuses, children, and adults with congenital heart anomalies.

Premature ventricular contraction-induced cardiomyopathy in children.

BACKGROUND: Adults with high premature ventricular contraction burden can develop left ventricular dilation, dysfunction, and strain, consistent with a cardiomyopathy, which is reversible with radiofrequency ablation of the premature ventricular contractions. Evidence in children with similar ectopy burden is limited. We performed a single-centre retrospective review to examine the prevalence of premature ventricular contraction-induced cardiomyopathy, natural history of ventricular ectopy, and progression to ventricular tachycardia in children with frequent premature ventricular contractions. METHODS: Children aged between 6 months and 18 years, with premature ventricular contractions comprising at least 20% of rhythm on 24-hour Holter monitor, were included in our study. Those with significant structural heart disease, ventricular tachycardia greater than 1% of rhythm at the time of premature ventricular contraction diagnosis, or family history of cardiomyopathy - except tachycardia-induced - were excluded. Cardiomyopathy was defined by echocardiographic assessment. RESULTS: A total of 36 children met the study criteria; seven patients (19.4%, 95% CI 6.2-32.6%) met the criteria for cardiomyopathy, mostly at initial presentation. Ectopy decreased to <10% of beats without intervention in 16.7% (95% CI 4.3-29.1%) of the patients. No patient progressed to having ventricular tachycardia as more than 1% of beats on follow-up Holter. Radiofrequency ablation was performed in three patients without cardiomyopathy. CONCLUSIONS: Our study demonstrates a higher prevalence of cardiomyopathy among children with high premature ventricular contraction burden than that previously shown. Ectopy tended to persist throughout follow-up. These trends suggest the need for a multi-centre study on frequent premature ventricular contractions in children. In the interim, regular follow-up with imaging to evaluate for cardiomyopathy is warranted.

A multi-institutional analysis of inpatient treatment for supraventricular tachycardia in newborns and infants.

This study aimed to examine practice patterns in the inpatient medical treatment of newborns and infants with supraventricular tachycardia (SVT) using the Pediatric Health Information System (PHIS) database, a large, multi-institutional administrative database. A retrospective examination of pediatric hospital discharge data was performed during the study period from January 2003 to September 2008. Data were extracted from the index hospitalization of all individuals younger than 1 year with the principal discharge diagnosis of SVT. Those with coexisting congenital or acquired structural heart disease were excluded from the study. The analysis included 171 patients. No deaths occurred, and 95 % of the infants were discharged to home. More than half (53 %) of the patients spent a portion of their hospital stay in an intensive care unit (ICU) setting. Multidrug therapy was common, with 45 % of the patients receiving two or more antiarrhythmic agents on the day of discharge. The five most commonly used antiarrhythmic drugs, in order of decreasing frequency of use, were propranolol, digoxin, amiodarone, flecainide, and sotalol. The median hospital stay for the group was 4 days, and this value increased as a function of the number of antiarrhythmic drugs used (median, 7 days for three or more agents) and the need for intensive care (median, 6 days). The information provided in this study helps to define common practice patterns and should allow caregivers to provide meaningful expectations to families regarding their potential treatment course and to anticipate the hospital length of stay.

Health care resource utilization and costs associated with atrial fibrillation and rural-urban disparities.

BACKGROUND: Atrial fibrillation (AF) imposes substantial health care and economic burden on health care systems and patients. Previous studies failed to examine health care resource utilization (HCRU) and costs among patients with incident AF and potential disparity with regard to geographic location. OBJECTIVES: To examine HCRU and costs among patients with incident AF compared with patients without AF and examine whether a geographic disparity exists. METHODS: This was a retrospective cohort study. We selected patients with AF and patients without AF from IBM/Watson MarketScan Research Databases 2014-2019. HCRU and costs were collected 12 months following an AF index date. We used 2-part models with bootstrapping to obtain the marginal estimates and CIs. Rural status was identified based on Metropolitan Statistical Area. We adjusted for age, sex, plan type, US region, and comorbidities. RESULTS: Among 156,732 patients with AF and 3,398,490 patients without AF, patients with AF had 9.04 (95% CI = 8.96-9.12) more outpatient visits, 0.82 (95% CI = 0.81-0.83) more emergency department (ED) visits, 0.33 (95% CI = 0.33-0.34) more inpatient admission, and $15,095 (95% CI = 14,871-15,324) higher total costs, compared with patients without AF. Among patients with AF, rural patients had 1.99 fewer (95% CI = -2.26 to -1.71) outpatient visits and 0.05 (95% CI = 0.02-0.08) more ED visits than urban patients. Overall, rural patients with AF had decreased total costs compared with urban patients (mean = $751; 95% CI = -1,227 to -228). CONCLUSIONS: Incident AF was associated with substantial burden of health care resources and an economic burden, and the burden was not equally distributed across patients in urban vs rural settings. DISCLOSURES: Dr Hansen reports grants from the National Science Foundation during the conduct of the study.

Exploring telerobotic cardiac catheter ablation in a rural community hospital: A pilot study.

Background: Telerobotic surgery could improve access to specialty procedures such as cardiac catheter ablation in rural and underserved regions in the United States and worldwide. Advancements in telecommunications, internet infrastructure, and surgical robotics are lowering the technical hurdles for this future healthcare delivery paradigm. Nonetheless, important questions remain regarding the safe implementation of telerobotic surgery in rural community hospital settings. Objective: The purpose of this study was to pilot test a system and methods to explore telerobotic cardiac catheter ablation in a rural community hospital setting. Methods: We assembled a portable preclinical telerobotic catheter ablation system from commercial-grade components using third-party vendors. We then carried out 4 telerobotic surgery simulations with an urban surgeon and a rural community hospital operating room (OR) team spanning a distance of more than 2000 miles. Two challenge scenarios were incorporated into the simulations, including loss of network connection and cardiac perforation with subsequent life-threatening tamponade physiology. An ethnographic analysis was then performed. Results: Interviews and observations suggested that rural OR teams readily adapt to the telesurgery context. However, participant perceptions of team trust, communication, and emergency management were significantly altered by the remote location of the surgeon. In addition, most participants believed the OR team would have been better equipped for the challenges had they received formal training or had prior experience with the procedure being simulated. Conclusion: We demonstrate the utility and feasibility of a system and methods for studying specialty telerobotic surgery in a rural hospital OR setting.

Medical Management of Infants With Supraventricular Tachycardia: Results From a Registry and Review of the Literature.

Background: Several medication choices are available for acute and prophylactic treatment of refractory supraventricular tachycardia (SVT) in infants. There are almost no controlled trials, and medication choices are not necessarily evidence based. Our objective was to report the effectiveness of management strategies for infant SVT. Methods: A registry of infants admitted to hospital with re-entrant SVT and no haemodynamically significant heart disease were prospectively followed at 11 international tertiary care centres. In addition, a systematic review of studies on infant re-entrant SVT in MEDLINE and EMBASE was conducted. Data on demographics, symptoms, acute and maintenance treatments, and outcomes were collected. Results: A total of 2534 infants were included: n = 108 from the registry (median age, 9 days [0-324 days], 70.8% male) and n = 2426 from the literature review (median age, 14 days; 62.3% male). Propranolol was the most prevalent acute (61.4%) and maintenance treatment (53.8%) in the Registry, whereas digoxin was used sparingly (4.0% and 3.8%, respectively). Propranolol and digoxin were used frequently in the literature acutely (31% and 33.2%) and for maintenance (17.8% and 10.1%) (P < 0.001). No differences in acute or prophylactic effectiveness between medications were observed. Recurrence was higher in the Registry (25.0%) vs literature (13.4%) (P < 0.001), and 22 (0.9%) deaths were reported in the literature vs none in the Registry. Conclusion: This was the largest cohort of infants with SVT analysed to date. Digoxin monotherapy use was rare amongst contemporary paediatric cardiologists. There was limited evidence to support one medication over another. Overall, recurrence and mortality rates on antiarrhythmic treatment were low.

Contexte: De nombreux choix de médicaments existent pour le traitement aigu et prophylactique de la tachycardie supraventriculaire (TSV) réfractaire chez les nourrissons. Or, il n'y a presque pas d'essais contrôlés à ce sujet, et les choix de médicaments ne sont pas nécessairement fondés sur des données probantes. Notre objectif était de faire état de l'efficacité des stratégies de prise en charge de la TSV chez les nourrissons. Méthodologie: Un registre des nourrissons admis à l'hôpital pour une TSV par réentrée, sans cardiopathie d'importance hémodynamique, a été tenu de façon prospective dans 11 centres de soins tertiaires à l'échelle mondiale. De plus, une revue systématique des études sur la TSV par réentrée chez le nourrisson a été effectuée dans MEDLINE et EMBASE. Des données sur les caractéristiques démographiques, les symptômes, les traitements aigus et d'entretien, et les résultats ont été recueillis. Résultats: Un total de 2 534 nourrissons ont été inclus : n = 108 du registre (âge médian de 9 jours [0-324 jours], 70,8 % de sexe masculin) et n = 2 426 de la revue de la littérature (âge médian de 14 jours; 62,3 % de sexe masculin). Le propranolol était le traitement de soins aigus (61,4 %) et d'entretien (53,8 %) le plus fréquent dans le registre, alors que la digoxine a été utilisée occasionnellement (respectivement dans 4,0 % et 3,8 % des cas). Dans la littérature, le propranolol et la digoxine étaient fréquemment utilisés en soins aigus (31 % et 33,2 %) et en traitement d'entretien (17,8 % et 10,1 %) (p < 0,001). Aucune différence n'a été observée entre les médicaments au chapitre de l'efficacité du traitement de soins aigus ou du traitement prophylactique. Le taux de récurrence était plus élevé dans le registre (25,0 %) que dans la littérature (13,4 %) (p < 0,001), et 22 (0,9 %) décès ont été signalés dans la littérature, mais aucun dans le registre. Conclusion: Il s'agit de la plus grande cohorte de nourrissons atteints de TSV analysée à ce jour. De nos jours, les cardiologues pédiatriques prescrivent rarement la digoxine en monothérapie. Peu de données probantes favorisent l'utilisation d'un médicament par rapport à l'autre. Dans l'ensemble, les taux de récurrence et de mortalité sous traitement antiarythmique étaient faibles.

Case fatality in children with supraventricular tachycardia in the United States.

BACKGROUND: The prognosis for most patients with supraventricular tachycardia (SVT) is thought to be excellent. However, the fatality rate in children with SVT is poorly defined and there are no large-scale, multicenter studies to support this commonly held belief. METHODS: We reviewed an administrative database containing inpatient records from 41 stand-alone children's hospitals and identified all hospitalized patients younger than 25 years with a discharge diagnosis of SVT between January 2003 and September 2008. RESULTS: We analyzed the index hospitalization of 1,755 patients with the discharge diagnosis of SVT, of whom 58% were male and 52% had comorbid structural heart disease (SHD). There were a total of 68 patient deaths (4%) with 56 of 68 (82%) of the deaths occurring in patients with SHD. In total, 6% of the patients with SHD died, whereas only 1% of the patients without SHD died. Regression analysis revealed that case fatality is increased in patients less than 1 month of age (OR 2.41, 95% CI 1.35 to 4.32), in patients with SHD (OR 2.67, 95% CI 1.22 to 5.80), and in those having cardiomyopathy with (OR 6.72, 95% CI 1.79 to 25.28) and without SHD (OR 6.74, 95% CI 1.67 to 27.26). CONCLUSIONS: The case fatality in patients who have SVT without SHD is low. It is increased in the very young and in those with comorbid cardiovascular disease. Case fatality is highest in patients with a cardiomyopathy regardless of SHD.

QTc prolongation in children following congenital cardiac disease surgery.

UNLABELLED: IntroductionQTc prolongation has been reported in adults following cardiopulmonary bypass; however, this phenomenon has not been studied in children with congenital cardiac disease. This study's aim was to formally assess QTc in children undergoing cardiac surgery. METHODS: Pre-operative and post-operative electrocardiograms during hospital stays were prospectively analysed on 107 consecutive patients under 18 years of age undergoing cardiac surgery. QTc was measured manually in leads II, V4, and V5. Measurements of 440 and 480 milliseconds were used to categorise patients. Peri-procedural data included bypass and cross-clamp time, medications, and electrolyte measurements. Outcome data included arrhythmias, length of mechanical ventilation, and hospital stay. Patients with post-operative new bundle branch block or ventricularly paced rhythm were excluded. RESULTS: In all, 59 children were included, out of which 26 had new QTc over 440 milliseconds and 6 of 59 had new QTc over 480 milliseconds post-operatively. The mean increase in post-operative QTc was 25 milliseconds, p=0.0001. QTc over 480 was associated with longer cross-clamp time, p=0.003. Other risk factors were not associated with post-operative QTc prolongation. This phenomenon was transient with normalisation occurring in 67% of patients over 60 hours on average. One patient with post-operative QTc over 440 milliseconds developed ventricular tachycardia. There was no correlation between prolonged QTc and duration of mechanical ventilation, or hospital stay.ConclusionA significant number of children undergoing cardiac surgery showed transient QTc prolongation. The precise aetiology of QT prolongation was not discerned, though new QTc over 480 milliseconds was associated with longer cross-clamp time. In this cohort, transient QTc prolongation was not associated with adverse sequela.

Initial Experience with a Novel Pericardiocentesis Training Simulator Incorporating a Three-dimensional Printed Cardiac Model.

Pericardial effusion is a rare but serious complication in cardiac electrophysiology procedures. To avoid progression to acute tamponade and reduce the risk of adverse patient outcomes, emergent pericardiocentesis is often necessary. The conduct of more pericardiocentesis training may further mitigate this risk. However, teaching and practice opportunities are rare, creating the need for pericardiocentesis simulators. While various pericardiocentesis simulators exist, their applications have been limited; further, commercial simulators are anatomically realistic but can be expensive. As such, cheaper homemade simulators have been developed, yet these may lack the cardiac anatomical features for a high-fidelity simulation or may be overly complex to assemble. The purpose of this study is to report initial findings from a pericardiocentesis simulator that incorporates a three-dimensional (3D) cardiac model that is economical, simple to assemble, and anatomically accurate. A 3D-printed cardiac model was printed from a computed tomography file. The model was fitted with a latex balloon-in-a-balloon pericardium filled with colored saline and placed in an ultrasound-compatible gelatin mold to create a pericardiocentesis simulator. The simulator was then tested with experienced and novice trainees at an academic hospital. A total of 10 participants (four interventional cardiology faculty members and six cardiology fellows) performed simulated pericardiocentesis using the simulator and completed a questionnaire to evaluate the model's features and usefulness. The overall feedback regarding this novel simulation approach was positive and the model exhibited important anatomical features to accurately simulate ultrasound-guided pericardiocentesis. All participants were able to successfully insert the needle into the pericardial space and all but one successfully placed the pericardial drain. Survey results indicated that the model was largely perceived as useful for training. This work suggests incorporating a 3D-printed cardiac model into a gelatin mold results in a simple and inexpensive yet high-fidelity pericardiocentesis simulation experience. This novel approach may be useful for teaching pericardiocentesis in an academic hospital.

Nomenclature for Pediatric and Congenital Cardiac Care: Unification of Clinical and Administrative Nomenclature - The 2021 International Paediatric and Congenital Cardiac Code (IPCCC) and the Eleventh Revision of the International Classification of Diseases (ICD-11).

Substantial progress has been made in the standardization of nomenclature for paediatric and congenital cardiac care. In 1936, Maude Abbott published her Atlas of Congenital Cardiac Disease, which was the first formal attempt to classify congenital heart disease. The International Paediatric and Congenital Cardiac Code (IPCCC) is now utilized worldwide and has most recently become the paediatric and congenital cardiac component of the Eleventh Revision of the International Classification of Diseases (ICD-11). The most recent publication of the IPCCC was in 2017. This manuscript provides an updated 2021 version of the IPCCC.The International Society for Nomenclature of Paediatric and Congenital Heart Disease (ISNPCHD), in collaboration with the World Health Organization (WHO), developed the paediatric and congenital cardiac nomenclature that is now within the eleventh version of the International Classification of Diseases (ICD-11). This unification of IPCCC and ICD-11 is the IPCCC ICD-11 Nomenclature and is the first time that the clinical nomenclature for paediatric and congenital cardiac care and the administrative nomenclature for paediatric and congenital cardiac care are harmonized. The resultant congenital cardiac component of ICD-11 was increased from 29 congenital cardiac codes in ICD-9 and 73 congenital cardiac codes in ICD-10 to 318 codes submitted by ISNPCHD through 2018 for incorporation into ICD-11. After these 318 terms were incorporated into ICD-11 in 2018, the WHO ICD-11 team added an additional 49 terms, some of which are acceptable legacy terms from ICD-10, while others provide greater granularity than the ISNPCHD thought was originally acceptable. Thus, the total number of paediatric and congenital cardiac terms in ICD-11 is 367. In this manuscript, we describe and review the terminology, hierarchy, and definitions of the IPCCC ICD-11 Nomenclature. This article, therefore, presents a global system of nomenclature for paediatric and congenital cardiac care that unifies clinical and administrative nomenclature.The members of ISNPCHD realize that the nomenclature published in this manuscript will continue to evolve. The version of the IPCCC that was published in 2017 has evolved and changed, and it is now replaced by this 2021 version. In the future, ISNPCHD will again publish updated versions of IPCCC, as IPCCC continues to evolve.

Surgical approaches to epicardial pacemaker placement: does pocket location affect lead survival?

Permanent cardiac pacing in pediatric patients presents challenges related to small patient size, complex anatomy, electrophysiologic abnormalities, and limited access to cardiac chambers. Epicardial pacing currently remains the conventional technique for infants and patients with complex congenital heart disease. Pacemaker lead failure is the major source of failure for such epicardial systems. The authors hypothesized that a retrocostal surgical approach would reduce the rate of lead failure due to fracture compared with the more traditional subrectus and subxiphoid approaches. To evaluate this hypothesis, a retrospective chart review analyzed patients with epicardial pacemaker systems implanted or followed at Rady Children's Hospital San Diego between January 1980 and May 2007. The study cohort consisted of 219 patients and a total of 620 leads with epicardial pacemakers. Among these patients, 84% had structural congenital heart disease, and 45% were younger than 3 years at time of the first implantation. The estimated lead survival was 93% at 2 years and 83% at 5 years. The majority of leads failed due to pacing problems (54%), followed by lead fracture (31%) and sensing problems (14%). When lead failure was adjusted for length of follow-up period, no significant differences in the rates of failure by pocket location were found.

Virtual-Reality Guided Versus Fluoroscopy-Guided Transseptal Puncture in a Cardiac Phantom.

OBJECTIVES: We compared virtual-reality guided versus fluoroscopy-guided transseptal puncture by novice and experienced operators in a cardiac phantom. Outcome measures included accuracy, time, transseptal path distance, and a survey of the operator experience. METHODS: A transseptal simulator was created using a Plexiglas case and a 3D-printed cardiac phantom with a replaceable fossa ovalis, a customized support, and an electromagnetic tracking system. A precisely registered virtual-reality rendering was constructed. To display the transseptal instruments in virtual reality, we attached electromagnetic sensors to standard transseptal instruments, including the needle, dilator, and sheath. Each subject completed 6 simulated transseptal punctures (3 fluoroscopy-guided and 3 virtual-reality guided). We measured the distance traversed by the transseptal needle, accuracy, and time for each simulated transseptal puncture. Operators were then surveyed regarding their experience. RESULTS: A total of 8 subjects (6 faculty, 2 fellows) completed the trial. We found that virtual-reality guidance resulted in significantly more accurate puncture site selection and, subjectively, was more intuitive for the operator, particularly for novices. None of the participants experienced negative symptoms in virtual reality that required cessation of the procedure. CONCLUSIONS: Virtual reality compared with fluoroscopic guidance for transseptal puncture shows considerable promise, particularly for novice trainees, where it could lessen the learning curve. Current barriers to widespread implementation are discussed.

Loss of ventricular preexcitation during noninvasive testing does not exclude high-risk accessory pathways: A multicenter study of WPW in children.

BACKGROUND: Abrupt loss of ventricular preexcitation on noninvasive evaluation, or nonpersistent preexcitation, in Wolff-Parkinson-White syndrome (WPW) is thought to indicate a low risk of life-threatening events. OBJECTIVE: The purpose of this study was to compare accessory pathway (AP) characteristics and occurrences of sudden cardiac arrest (SCA) and rapidly conducted preexcited atrial fibrillation (RC-AF) in patients with nonpersistent and persistent preexcitation. METHODS: Patients 21 years or younger with WPW and invasive electrophysiology study (EPS) data, SCA, or RC-AF were identified from multicenter databases. Nonpersistent preexcitation was defined as absence/sudden loss of preexcitation on electrocardiogram, Holter monitoring, or exercise stress test. RC-AF was defined as clinical preexcited atrial fibrillation with shortest preexcited R-R interval (SPERRI) ≤ 250 ms. AP effective refractory period (APERP), SPERRI at EPS , and shortest preexcited paced cycle length (SPPCL) were collected. High-risk APs were defined as APERP, SPERRI, or SPPCL ≤ 250 ms. RESULTS: Of 1589 patients, 244 (15%) had nonpersistent preexcitation and 1345 (85%) had persistent preexcitation. There were no differences in sex (58% vs 60% male; P=.49) or age (13.3±3.6 years vs 13.1±3.9 years; P=.43) between groups. Although APERP (344±76 ms vs 312±61 ms; P<.001) and SPPCL (394±123 ms vs 317±82 ms; P<.001) were longer in nonpersistent vs persistent preexcitation, there was no difference in SPERRI at EPS (331±71 ms vs 316±73 ms; P=.15). Nonpersistent preexcitation was associated with fewer high-risk APs (13% vs 23%; P<.001) than persistent preexcitation. Of 61 patients with SCA or RC-AF, 6 (10%) had nonpersistent preexcitation (3 SCA, 3 RC-AF). CONCLUSION: Nonpersistent preexcitation was associated with fewer high-risk APs, though it did not exclude the risk of SCA or RC-AF in children with WPW.

What have we learned in the last 20 years? A comparison of a modern era pediatric and congenital catheter ablation registry to previous pediatric ablation registries.

BACKGROUND: Since the onset of pediatric catheter ablation, the pediatric electrophysiology community has reported outcomes via various registries (PAPCA [Prospective Assessment After Pediatric Cardiac Ablation], PCAR [Pediatric Catheter Ablation Registry]). Most recently, a modern era pediatric and congenital ablation registry (MAP-IT [Multicenter Pediatric and Congenital EP Quality Initiative]) was developed for eventual incorporation into the National Cardiovascular Data Registry (NCDR) IMPACT (Improving Pediatric and Adult Congenital Treatment) registry. OBJECTIVE: The purpose of this study was to describe initial findings from the MAP-IT pilot registry and to compare these findings to earlier registries. METHODS: Before entering the NCDR IMPACT registry, MAP-IT was active at 12 centers (11 in the United States) between October 2014 and April 2016. All electrophysiological studies for patients younger than 21 years and for patients of all ages with structural congenital heart disease were included. We compared the acute success, fluoroscopy and procedural times, and frequency of complications between MAP-IT and the earlier registries. RESULTS: Acute success rates have improved from the initial PCAR registry for both accessory and slow pathway substrates. Both fluoroscopy and procedural times have significantly decreased across the time periods (fluoroscopy time 47.6 ± 40 minutes to 7.0 ± 9.2 minutes; P <.001; procedural time 257 ± 157 minutes to 166 ± 84 minutes; P <.001). CONCLUSION: Acute success rates and fluoroscopy and procedural times in pediatric ablation all have improved over the last 25 years.

Human embryonic stem cell-derived cardiomyocytes restore function in infarcted hearts of non-human primates.

Pluripotent stem cell-derived cardiomyocyte grafts can remuscularize substantial amounts of infarcted myocardium and beat in synchrony with the heart, but in some settings cause ventricular arrhythmias. It is unknown whether human cardiomyocytes can restore cardiac function in a physiologically relevant large animal model. Here we show that transplantation of ∼750 million cryopreserved human embryonic stem cell-derived cardiomyocytes (hESC-CMs) enhances cardiac function in macaque monkeys with large myocardial infarctions. One month after hESC-CM transplantation, global left ventricular ejection fraction improved 10.6 ± 0.9% vs. 2.5 ± 0.8% in controls, and by 3 months there was an additional 12.4% improvement in treated vs. a 3.5% decline in controls. Grafts averaged 11.6% of infarct size, formed electromechanical junctions with the host heart, and by 3 months contained ∼99% ventricular myocytes. A subset of animals experienced graft-associated ventricular arrhythmias, shown by electrical mapping to originate from a point-source acting as an ectopic pacemaker. Our data demonstrate that remuscularization of the infarcted macaque heart with human myocardium provides durable improvement in left ventricular function.