Déjà Vu: Recurrent Sudden Cardiac Arrests in a Child With an Anomalous Left Coronary Artery.

Sudden cardiac arrest from anomalous coronary artery from the opposite sinus of Valsalva is rarely observed in children under 10 years of age. We report a 7-week-old infant with a brief resolved unexplained event from left anomalous aortic origin of a coronary artery who underwent unroofing and again developed syncope at 8 years of age. Ischemia was detected by stress echocardiography both times. (Level of Difficulty: Advanced.).

Tricuspid Regurgitant Jet Velocity Point-of-Care Ultrasound Curriculum Development and Validation.

Introduction: The American College of Emergency Physicians (ACEP) recommends that Emergency Medicine physicians with advanced training can evaluate right ventricular (RV) pressures via point-of-care ultrasound (POCUS) by measuring a tricuspid regurgitant jet (TRJ). We were unable to find a published curriculum to deliver education for this at any skill level. Therefore, we developed, delivered, and evaluated a curriculum for the assessment of TRJ for novice physician sonographers. Methods: We designed an educational intervention for novice physician sonographers. The curriculum was created using a modified Delphi methodology. All novice sonographers participated in the educational intervention which consisted of a didactic lecture followed by hands-on-deliberate practice on healthy medical student volunteers with expert feedback in a simulated setting. Sonographer's knowledge was assessed at 3 time points: pre-intervention, immediately post-intervention, and 3 months post-intervention (retention assessment) by multiple choice exam. Results: Nine novice physician sonographers participated in the intervention. Mean exam performance increased from 55.6% [standard deviation (SD) 11.3%] on the pre-intervention exam to 94.4% (SD 7.3%) on the post-intervention exam and 92.9% (SD 12.5%) on the retention exam. The mean improvement between the pre- and post- exam was +38.9% (95% CI 31.8 - 46.0), and between the pre-exam and retention exam +37.1% (95% CI 22.3 - 52.0). Conclusion: Sonographer knowledge of TRJ assessment improved following a brief educational intervention as measured by exam performance. Given the expanding role of POCUS it is increasingly important to provide effective resources for teaching these skills. This work establishes the basis for further study and implementation of our TRJ curriculum.

Novice Physician Ultrasound Evaluation of Pediatric Tricuspid Regurgitant Jet Velocity.

INTRODUCTION: Pulmonary hypertension, associated with high mortality in pediatric patients, is traditionally screened for by trained professionals by measuring a tricuspid regurgitant jet velocity (TRJV). Our objective was to test the feasibility of novice physician sonographers (NPS) to perform echocardiograms of adequate quality to exclude pathology (defined as TRJV > 2.5 meters per second). METHODS: We conducted a cross-sectional study of NPS to assess TRJV by echocardiogram in an urban pediatric emergency department. NPS completed an educational course consisting of a didactic curriculum and hands-on workshop. NPS enrolled a convenience sample of patients aged 7-21 years. Our primary outcome was the proportion of echocardiograms with images of adequate quality to exclude pathology. Our secondary outcome was NPS performance on four image elements. We present descriptive statistics, binomial proportions, kappa coefficients, and logistic regression analysis. RESULTS: Eight NPS completed 80 echocardiograms. We found 82.5% (95% confidence interval [CI], 74.2-90.8) of echocardiograms had images of adequate quality to exclude pathology. Among image elements, NPS obtained a satisfactory, apical 4-chamber view in 85% (95% CI, 77.1-92.9); positioned the color box accurately 65% (95% CI, 54.5-75.5); optimized TRJV color signal 78.7% (95% CI, 69.8-87.7); and optimized continuous-wave Doppler in 55% (95% CI, 44.1-66.0) of echocardiograms. CONCLUSION: NPS obtained images of adequate quality to exclude pathology in a majority of studies; however, optimized acquisition of specific image elements varied. This work establishes the basis for future study of NPS assessment of TRJV pathology when elevated pulmonary pressures are of clinical concern.

Left ventricular diastolic dysfunction in HIV-uninfected infants exposed in utero to antiretroviral therapy.

OBJECTIVES: To longitudinally measure LV diastolic function in HIV-exposed but uninfected (HEU) children perinatally exposed to ART. DESIGN: HEU children who were perinatally exposed to antiretroviral therapy (ART) may be at risk for adverse cardiac effects. We have previously reported that those children have decreased left ventricular (LV) mass, dimension, and septal thickness with increased contractility. METHODS: Serial echocardiograms were obtained at specific times from birth to 48 months from two groups of HIV-uninfected children: 148 HIV-negative children who were perinatally exposed to ART and 130 non-ART-exposed HIV-unexposed healthy controls. The following LV diastolic indices were obtained: mitral valve early and late diastolic velocity (E and A), tissue Doppler-derived LV-free wall and septal early diastolic velocity (LV e' and sep e'). RESULTS: All echocardiographic indices were significantly different in ART-exposed children compared with ART-unexposed healthy controls. Both E and A were overall lower at all ages by 8.28 cm/s (P = 0.0002) and 13.46 cm/s (P < 0.0001) respectively. E/A ratio was higher by 0.27, 0.46, and 0.28 units at birth, 1 year and 2 years of age, respectively (all P ≤ 0.01). Moreover, LV e' and sep e' were overall lower at all ages by 0.84 cm/s (P = 0.01) and 0.47 cm/s (P = 0.02), respectively. CONCLUSION: Children who were exposed to ART in utero have subclinical yet significant differences in specific LV diastolic indices. Follow-up with serial echocardiograms are recommended in this population to further assess the potential cardiac toxicity of perinatal exposure to ART.

Census tract based income level and lipid levels in urban pediatric primary care: a retrospective study.

BACKGROUND: Lower socioeconomic status has been associated with adverse lipid levels in adult populations. Childhood dyslipidemia is a risk factor for future cardiovascular disease. However, studies examining relationships between socioeconomic indicators and lipid levels in children are limited. To examine the relationship between income level and lipid levels in childhood. METHODS: We conducted a retrospective chart review of primary care patients, ages 2 to 18 years, who had lipid levels drawn at two large pediatric practices in Boston, MA between August 01, 2008 and August 31, 2010. Income level was determined using geocoding census tract data. Analysis was performed using t-test, Anova and Spearman correlation coefficients. BMI percentile, age, sex, race/ethnicity, and site were adjusted for on multivariate analyses. RESULTS: Reviewing 930 charts of patients with measured lipid levels, 730 had a valid address, no previously diagnosed lipid disorder and met other study eligibility criteria. Mean total cholesterol level did not vary by income level (low 155.5 mg/dl ±26.9, moderate 153.5 mg/dl ±30.4, middle 155.3 mg/dl ±26.6 and high income 155.5 mg/dl ±27.9; p = .87) on multivariate analysis. Income level was not related to LDL, HDL, or triglycerides. CONCLUSIONS: In this analysis of children cared for in two urban pediatric primary practices, there was no association between income level determined by census tract and lipid levels in childhood. If confirmed in prospective investigations in other geographical locations, income level may not be a key driver of childhood lipid levels.

Cardiovascular outcomes of pediatric seroreverters perinatally exposed to HAART: design of a longitudinal clinical study.

Seroreverters (uninfected children of HIV-infected mothers) have exhibited left ventricular (LV) dysfunction. Mitochondrial toxicity associated with in utero or postnatal exposure to highly active antiretroviral therapy (HAART) is a possible mechanism. Adult and animal models have demonstrated associations between LV abnormalities, cardiomyopathy, and components of HAART. Yet, outcomes in children are poorly understood. In this study, we explore HAART-associated LV abnormalities in seroreverters exposed to HAART (n = 144) or never exposed (n = 252). Subjects are drawn from the Women and Infants Transmission Study and the Pediatric Pulmonary and Cardiovascular Complications of HIV Study, respectively. Data include (1) echocardiographic studies of LV structure and function and (2) serologic cardiac biomarkers (cardiac troponin, probrain natriuretic peptide, high-sensitivity C reactive protein), both collected during the first month of life, and again at 6, 12, 24, 36, and 48 months postnatally. Planned analyses include several regression models. At this time, we have access to data for all 252 unexposed children, and 53 exposed subjects are enrolled. The cohorts are similar in terms of gender and race and the recruited subjects are representative of all eligible subjects in terms of exposure to HAART. Recruitment will continue into 2006.