COVID-19: The disease, the vaccine and the heart.

Coronavirus SARS-CoV-2 has fundamentally affected the health, healthcare delivery and daily life in all populations and age groups in Australia. The aim of this report is to summarise how it has affected the paediatric population with an emphasis on, but not limited to, the cardiac manifestations. A literature review and appraisal of data relating to SARS-CoV-2 cardiac manifestations and vaccination in the paediatric population was undertaken.The majority of children with SARS-CoV-2 infection recover well. However, a very small proportion may develop severe acute disease. In the sub-acute phase, children may also develop a Kawasaki like illness, Paediatric Inflammatory Multisystem Syndrome temporally associated with SARS-CoV-2. Whilst not directly cardiac in nature, SARS-CoV-2 also affected children in other profound ways. Public health measures with widespread lockdowns appeared to disproportionately affect the paediatric population causing physical deconditioning and psychological harm. Vaccination against SARS-CoV-2 has proven to be safe and effective, but the small rate of complications did disproportionately affect teenage children with risks of myocarditis and pericarditis. The long term outcomes following myocarditis related to SARS-Cov-2 vaccination are yet to be clarified. When treating children in the era of SARS-CoV-2, Paediatricians need to be well aware of the risks of infection in the acute and sub-acute phases, have a good understanding of the well-established recommendations for vaccination, and also be cognisant of psychological impacts.

Outcomes of interventional electrophysiology in children under 2 years of age.

BACKGROUND: Despite the increasing utilisation of interventional electrophysiology in adults and older children with arrhythmias, there are few data reflecting the safety and efficacy of this procedure in the age group under 2 years. AIM: We describe our experience in assessing the efficacy and safety with this group of children. METHODS: We undertook a retrospective review of all infants under 2 years of age who underwent an interventional electrophysiology procedure between 1995 and 2009 to determine indications, procedural details, short- and long-term success, and complication rate. RESULTS: A total of 23 interventional electrophysiology procedures were performed in 17 patients initially under 2 years of age. Of these, three patients had congenital heart disease. The most common indication was arrhythmia resistant to pharmacological agents (59%), with the remaining cases being arrhythmia complicated by cardiovascular instability (41%). There was initial success in 15 patients after the first procedure, with early recurrence in four. Following six repeat procedures, there was long-term success in 15 patients (88%), with three repeat procedures being performed after 2 years of age. There was one non-procedural death related to persisting arrhythmia. There were three minor complications. In one patient, cryotherapy was used successfully. CONCLUSIONS: The interventional electrophysiology procedure is a viable therapeutic option in infants under 2 years with arrhythmia resistant to other conventional medical management.

Update on the use and outcomes of implantable cardioverter defibrillators in pediatric patients.

OPINION STATEMENT: The vast majority of implantable cardioverter defibrillators (ICDs) continue to be implanted in the adult population. Accordingly, manufacturers develop devices and leads primarily for the adult population. Whilst the number of ICDs implanted in children is small in comparison, the potential benefits are large to this group. It is a common frustration among pediatric cardiologists whom implant devices that impressive technological developments continue to be developed for the adult population; as the population of children with ICDs is small, robust clinical studies often lag behind. By necessity, pediatric cardiologists and cardiothoracic surgeons have developed innovative techniques utilizing adult components in unusual configurations for children with complex congenital heart disease. As in the adult population, inappropriate shocks are one of the most limiting and concerning complications in the use of ICDs. Unfortunately, as will be discussed below, children are at increased risk of inappropriate shocks when compared with adults. The true impact of inappropriate shocks is increasingly being realized, and much of the focus in management of children with ICDs surrounds the prevention of inappropriate shocks.

Phenobarbital for the management of severe acute alcohol withdrawal (the PHENOMANAL trial): a pilot randomized controlled trial.

BACKGROUND: Benzodiazepines are considered first-line treatment for patients experiencing severe acute alcohol withdrawal syndrome (sAAWS). Although several medications have been evaluated as potential adjuvant treatments for sAAWS, barbiturates show particular promise. OBJECTIVE: In the PHENOMANAL trial, we will assess the feasibility of conducting an allocation-concealed, quadruple-blinded, randomized controlled trial (RCT) comparing symptom-triggered benzodiazepine therapy with either a single dose of adjuvant intravenous (IV) phenobarbital (7.5 mg/kg of ideal body weight) or a single dose of matching IV placebo for patients with sAAWS. METHODS: We will recruit adult patients from the Emergency Department, Intensive Care Unit, or hospital wards with a Clinical Institute of Withdrawal - Adult revised (CIWA-Ar) score of 16 or more after receipt of at least 60 mg of diazepam or equivalent within 16 h of diagnosis of sAAWS, and an anticipated need for hospitalization. We will randomize participants (n=39) in a 2:1 manner to treatment and placebo groups, respectively. The primary objective of the PHENOMANAL pilot trial will be to demonstrate our ability to recruit the desired population over the trial period. As secondary objectives, we will evaluate clinician compliance with the treatment protocols, assess crossover rates from the placebo arm to the treatment arm, and obtain preliminary estimates of treatment effect. All trial participants will be followed for 7 days or until hospital discharge. RELEVANCE: The PHENOMANAL trial is novel in investigating a new treatment for a common and understudied condition, repurposing an existing medication for a novel indication, and addressing an important evidence gap. Through conduct of the multidisciplinary pilot trial, we aim to advance methodology in acute care research through the use of a hybrid consent model and inform the design of a large-scale trial. TRIAL REGISTRATION: ClinicalTrials.gov Registration NCT03586089 ; first registered July 13, 2018.

Interdisciplinary psychosocial care for families with inherited cardiovascular diseases.

Inherited cardiovascular diseases pose unique and complex psychosocial challenges for families, including coming to terms with life-long cardiac disease, risk of sudden death, grief related to the sudden death of a loved one, activity restrictions, and inheritance risk to other family members. Psychosocial factors impact not only mental health but also physical health and cooperation with clinical recommendations. We describe an interdisciplinary approach to the care of families with inherited cardiovascular disease, in which psychological care provided by specialized cardiac genetic counselors, nurses, and psychologists is embedded within the cardiovascular care team. We report illustrative cases and the supporting literature to demonstrate common scenarios, as well as practical guidance for clinicians working in the inherited cardiovascular disease setting.