Percutaneous melody valve implantation in a native tricuspid valve following failed surgical repair.

Transcatheter valve-in-valve and valve-in-ring implantation has become a common approach to treating patients with failed bioprosthetic tricuspid valves as well as failed surgical repairs of the tricuspid valve where an annuloplasty ring has been utilized. We describe a case where a Melody valve was percutaneously implanted in a native tricuspid valve with severe stenosis following surgical repair without a supporting annuloplasty ring.

Factors Associated with Non-Completion of a Pediatric Metabolic and Bariatric Surgery Program.

BACKGROUND: Childhood obesity is a devastating disease process disproportionately affecting minority and low-income populations. Though bariatric surgery leads to durable weight loss and reversal of multiple obesity-related comorbidities, only a small fraction of pediatric patients undergoes the procedure. We sought to identify factors associated with non-completion in a pediatric bariatric surgery program. METHODS: Retrospective review of consecutive patients ≤18-years-old referred to an academic adolescent bariatric surgery program between 2017 and 2022 (n = 20 completers, 40 non-completers) was completed. Demographics and medical and psychosocial histories were summarized by completion status. RESULTS: Of the 33% (20/60; 85% female, 30% racial minorities) who successfully completed the program, the median age was 16 years [IQR 16, 17]. The median age of non-completers was 16 years [IQR 15, 17] (55% female, 56% racial minorities). Non-completion was associated with male gender (15% of completers vs 45% of non-completers, p = 0.022), neighborhood income <150% poverty level (0 completers vs 17.5% of non-completers, p = 0.047), and presence of environmental or family stressors (22% of completers vs 65% of non-completers, p = 0.008). Though not statistically significant, non-completers tended to be racial minorities (p = 0.054). CONCLUSIONS: Non-completion of the bariatric surgery pathway was more prevalent among male patients from lower-income neighborhoods with significant environmental or family stressors. These patients also tended to be racial and ethnic minorities. The findings underscore the need for further investigation into barriers to pediatric bariatric surgery. LEVEL OF EVIDENCE: Level III.

Cardiac Physical Exam Skills and Auscultation Session for Pediatric Interns.

Introduction: Physicians need adequate physical exam skills. Unfortunately, interns have variable physical exam skills, and teaching is often limited to rounds, an inconsistent setting. Physical exam skills, particularly those involving auscultation, require practice. Our goal was to create a cardiac physical exam workshop for pediatric interns that would improve their performance on an interactive assessment of their ability and understanding in physical exam and murmur interpretation. Methods: We completed a targeted needs assessment and then developed a 2-hour workshop on the pediatric cardiac physical exam targeted to pediatrics residents. The workshop included didactics, group discussion, and practice interpreting common pediatric murmurs. Pediatrics residents completed the assessment as a pretest and then participated in the workshop. At the end of the workshop, the assessment was administered as a posttest, followed by a reassessment 3 months later. Nonparametric statistical analysis was conducted. Pre- and posttest scores were compared using the Wilcoxon signed rank test. Results: Twenty-five residents completed the workshop, including 22 pediatrics residents, one pediatrics/anesthesia combined resident, one pediatric neurology resident, and one resident completing a preliminary year in pediatrics prior to dermatology residency. There was a significant increase in the mean score on the assessment from pre- to posttest (pretest M = 54%, posttest M = 71%, p < .001). This increase was sustained at the 3-month reassessment (M = 67%). Discussion: This cardiac physical exam workshop demonstrated improvement in physical exam knowledge and interpretation ability as measured by an online pre-/posttest.

Evaluating Chest Pain and Heart Murmurs in Pediatric and Adolescent Patients.

Chest pain and heart murmurs are common issues primary care providers must evaluate and manage. Both are a source of anxiety for patients, parents, and providers, necessitating evaluation and understanding to ensure appropriate management. Most pediatric chest pain can be treated symptomatically and with reassurance. This article examines the approach to pediatric chest pain including identification of key historical points, common causes of chest pain, and when to refer. The article also delineates our approach to auscultation, describes common benign murmurs, and offers suggestions on when to refer for further evaluation.