Determination of the Frequency of Right and Left Internal Mammary Artery Embolization in Single Ventricle Patients: A Two-Center Study.

Embolization of systemic to pulmonary artery collaterals to regulate pulmonary arterial flow or pressure of the cavopulmonary circulation in patients with single ventricle is a common practice. The relative incidence and impact of this practice on future interventions like coronary artery bypass grafting is poorly understood. This study aims to evaluate the frequency and implications of internal mammary artery (IMA) embolization in the single ventricle (SV) population. A retrospective chart review was performed of SV patients who underwent cardiac catheterization before and after Fontan procedure between February 2007 and 2017. Data were collected from two tertiary care centers in the Midwest. Of the 304 SV patients, 62 (20.4%) underwent embolization of one or more IMAs, whereas 242 (79.6%) did not. The rate of embolization of IMA was 40.5% in one center and 14.5% in the second center. Among patients who received IMA embolization, left internal mammary artery (LIMA) embolization was seen in 6 (9.7%) patients. Majority of patients underwent either right internal mammary artery (RIMA) embolization (n = 25; 40.3%) or RIMA and LIMA embolization (n = 27; 43.5%). IMA embolization in SV patients is common. Embolizing IMAs early in life will likely eliminate a valuable graft option for coronary artery bypass grafting should it be required in the future care of these patients. Multi-center, prospective, nation-wide studies are warranted to examine coronary artery disease in the SV population and true frequency of IMA embolization. Delineation of which IMAs were embolized is a necessary in surgical and cardiac intervention national data, such as Society of Thoracic Surgeons (STS) database. All measures should be taken to preserve IMAs patency, if deemed feasible and safe.

Identifying Predictors of Psychological Problems Among Adolescents With Congenital Heart Disease for Referral to Psychological Care: A Pilot Study.

Background: The lifelong care of patients with congenital heart disease (CHD) typically begins at a young age, giving paediatric cardiologists a unique perspective on the mental health of their patients. Our aim was to describe and predict reported psychological problems among adolescents with CHD. Methods: A retrospective review was performed on patients aged 12-17 years who presented to the congenital cardiology clinic during a 1-year timeframe. The presence of psychological problems was collected along with CHD class, clinical history, developmental delay, and patient demographics. We described the prevalence of psychological problems and then, using machine learning algorithms, trained and tested optimal predictive models. Results: Of the 397 patients who met inclusion criteria, the lifetime prevalence of any reported psychological problem was 35.5%. The most prevalent reported problems were attention-deficit/hyperactivity disorder (18.9%), anxiety (17.6%), and depression (16.1%). Contrary to our expectations, we could not predict the presence or absence of any psychological problem using routine clinical data. Instead, we found multivariate models predicting depression and attention-deficit/hyperactivity disorder with promising accuracy. Prediction of anxiety was less successful. Conclusions: Approximately 1 of 3 adolescents with CHD presented with the lifetime prevalence of 1 or more psychological problems. Congenital cardiac programmes are in a position of influence to respond to these problems and impact their patients' mental health as part of a comprehensive care plan. The discovered models using routine clinical data predicted specific psychological problems with varying accuracy. With further validation, these models could become the tools of routine recommendations for referral to psychological care.

Contexte: Le traitement à vie des patients atteints d'une cardiopathie congénitale commence habituellement dès un jeune âge. Ainsi, les cardiologues pédiatriques ont un point de vue unique sur la santé mentale de leurs patients. Notre objectif était de décrire et de prédire les troubles psychologiques signalés chez les adolescents atteints d'une cardiopathie congénitale. Méthodologie: Nous avons effectué une revue rétrospective des dossiers de patients âgés de 12 à 17 ans qui se sont présentés dans une clinique de cardiologie pour anomalies congénitales sur une période d'un an. Nous avons recensé toute présence de problèmes psychologiques, en plus de la classe de la cardiopathie congénitale, des antécédents cliniques, des retards de développement et des caractéristiques démographiques des patients. Nous avons également décrit la prévalence des troubles psychologiques; puis, à l'aide d'algorithmes d'apprentissage automatique, nous avons donné une formation sur des modèles prédictifs optimaux et les avons testés. Résultats: Chez les 397 patients qui avaient répondu aux critères d'inclusion, la prévalence de la survenue d'un problème psychologique au cours de leur vie s'élevait à 35,5 %. Les troubles signalés le plus souvent étaient le trouble déficitaire de l'attention avec hyperactivité (TDAH) (18,9 %), l'anxiété (17,6 %) et la dépression (16,1 %). Contrairement à nos attentes, nous n'avons pas pu prédire la présence ou l'absence de troubles psychologiques à l'aide des données cliniques courantes. Nous avons par contre découvert des modèles multivariés pouvant prédire la dépression et le TDAH avec une précision prometteuse. Toutefois, les prédictions relatives à l'anxiété se sont avérées moins exactes. Conclusion: La prévalence de la survenue d'au moins un problème psychologique chez les adolescents atteints de cardiopathie congénitale au cours de leur vie était d'environ un adolescent sur trois. Dans le cadre d'un plan de soins complet, les programmes en cardiologie congénitale se trouvent en position d'influence pour répondre à ces problèmes et ainsi améliorer la santé mentale des patients. Par ailleurs, les modèles que nous avons découverts à l'aide des données cliniques courantes ont permis de prédire des problèmes psychologiques en particulier, mais avec une précision variable. Après une validation plus poussée, nous pourrions recommander ces modèles de façon systématique afin d'orienter les patients vers des soins psychologiques.

Complex Determinants of Work Ability in Adults With Congenital Heart Disease and Implications for Clinical Practice.

BACKGROUND: "Work ability" is the employees' capacity to meet the demands of their job. As more patients with complex congenital heart disease (CHD) are now reaching adulthood, we assessed work ability and factors impacting livelihood in adult CHD. METHODS: The work ability index (WAI) questionnaire and patient health questionnaire-9 (PHQ-9) were administered at 2 Midwest adult CHD centres from February 2017 to 2018. RESULTS: Of the 267 participants (n = 157 males, 59%) with an average age of 35 ± 13 years, the majority (n = 204, 76%) were employed. Patients with complex CHD (n = 103, 39%) were less likely to have enrolled in college or completed a graduate degree (P = 0.0115), and more likely to have an annual income of < $50,000 (P = 0.0056) and lower WAI scores (P = 0.0026) than patients with simple and moderate CHD. Unemployed patients (n = 63, 24%) with complex CHD (n = 27, 43%) were more likely to have higher PHQ-9 scores (P = 0.0242) indicating mild, moderate, or severe depression (P = 0.0482) than unemployed patients with simple and moderate CHD. Patients with complex CHD had lower self-perception of work ability compared with patients with simple and moderate CHD (P = 0.0007). Finally, patients in NYHA Functional Class I had higher WAI scores than NYHA Class III-IV (P < 0.0001). CONCLUSIONS: This study demonstrates that employed patients with complex CHD have lower education level, income, and work ability. Unemployed patients are more likely to exhibit symptoms of depression and have low self-perception of work ability. Occupational health programs focusing on promoting general health perception, increasing exercise capacity, and improving psychosocial health must be considered to improve work ability in patients with adult CHD to maintain livelihood.

Electronic health record associated stress: A survey study of adult congenital heart disease specialists.

BACKGROUND: Physician burnout has many undesirable consequences, including negative impact on patient care delivery and physician career satisfaction. Electronic health records (EHRs) may exacerbate burnout by increasing physician workload. OBJECTIVE: To determine burnout in adult congenital heart disease (ACHD) specialists by assessing stress associated with EHRs. DESIGN: Electronic survey study of ACHD providers. SETTING: Canada and United States. PARTICIPANTS: Three hundred eighty-three ACHD specialists listed on the Adult Congenital Heart Association directory between February and April 2017. OUTCOME MEASURES: Burnout was measured using the Maslach Burnout Inventory (MBI) to understand factors contributing to work life and EHR satisfaction. Chi-square and Wilcoxon Rank Sum tests were used for statistical analysis. RESULTS: Of the 383 invited participants, 110 (28.7%) completed surveys with the majority (n = 88, 80.7%) reporting from an academic medical center. Burnout was defined as high scores on the emotional exhaustion and/or depersonalization MBI subscales. When comparing the 40% (n = 44) that met criteria for burnout with those that did not, there was strong disagreement that a reasonable amount of time is spent on clerical tasks related to direct (P = .0043) or indirect (P = .0004) patient care. There was strong disagreement that EHRs increased efficiency (P = .006) or the patient portal improved patient care (P = .0215). Finally, physicians who met criteria for burnout had lower personal accomplishment scores (P = .0355). CONCLUSIONS: Our results suggest time spent on EHRs creates clerical burden exacerbating ACHD physician burnout. The high levels of emotional exhaustion may decrease quality of ACHD care by directing focus away from physician-patient interaction. Health care systems must develop best practice for EHR design and implementation to optimize patient advocacy and care, and decrease physician burnout.

The Basic Helix-Loop-Helix Gene Nato3 Drives Expression of Dopaminergic Neuron Transcription Factors in Neural Progenitors.

The floor plate of the developing midbrain gives rise to dopaminergic (DA) neurons, an important class of cells involved in Parkinson's disease (PD). Neural progenitors of the midbrain floor plate utilize key genes in transcriptional networks to drive dopamine neurogenesis. Identifying factors that promote dopaminergic neuron transcriptional networks can provide insight into strategies for therapies in PD. Using the chick embryo, we developed a quantitative PCR (qPCR) based method to assess the potential of a candidate factor to drive DA neuron gene expression, including the basic helix-loop-helix transcription factor Nato3 (Ferd3l). We then showed that overexpression of Nato3 in the developing chick mesencephalon produces a regionally dependent increase in genes associated with the DA neurogenesis, (such as Foxa2, Lmx1b and Shh) as well as DA neuron genes Nurr1 (an immature DA neuron marker) and mRNA expression of tyrosine hydroxylase (TH, a mature DA neuron marker). Interestingly, our data also showed that Nato3 is a potent regulator of Lmx1b by its broad induction of Lmx1b expression in neural progenitors of multiple regions of the CNS, including the midbrain and spinal cord. These data introduce a new, in vivo approach to identifying a gene that can drive DA transcriptional networks and provide the new insight that Nato3 can drive expression of key DA neuron genes, including Lmx1b, in neural progenitors.