Pulmonary Atresia and Ventricular Septal Defect Without Major Aortopulmonary Collateral Arteries: Diagnostic Evaluation and the Role of Ductal Stenting.

Patients with pulmonary atresia (PA) and a ventricular septal defect (VSD), similar to those with tetralogy of Fallot and PA without major aortopulmonary collateral arteries, lack antegrade pulmonary blood flow, and thus require a neonatal intervention for stabilization or augmentation of pulmonary blood flow. The role of ductal stenting in the management of these patients, and the current literature supporting it, will be reviewed.

Off-label uses of the Amplatzer Piccolo Occluder in children with congenital and acquired heart diseases.

Aim: The Amplatzer Piccolo Occluder (APO) is approved for patent ductus arteriosus (PDA) occlusion in infants weighing >700 g but could offer versatility to treat other lesions.Methods: Retrospective review of children in whom APO was utilized for defects other than PDA between January 2022 and June 2023.Results: The APO was used in nine patients; three for ventricular septal defects, four with coronary fistulas, one for a ventricular pseudoaneurysm and one where APO deployed within a fenestration of a previously placed Amplatzer Septal Occluder. All nine patients had successful occlusions without complications.Conclusion: The APO is a versatile device that can be used to treat various small diameter lesions in children besides the PDA for which it is currently approved for.

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Fast, automated, real-time 3D passive balloon catheter tracking during MRI-guided cardiac catheterization using orthogonal projection imaging and real-time image-based catheter detection.

PURPOSE: MRI-guidance of cardiac catheterization is currently performed using one or multiple 2D imaging planes, which may be suboptimal for catheter navigation, especially in patients with complex anatomies. The purpose of the work was to develop a robust real-time 3D catheter tracking method and 3D visualization strategy for improved MRI-guidance of cardiac catheterization procedures. METHODS: A fast 3D tracking technique was developed using continuous acquisition of two orthogonal 2D-projection images. Each projection corresponds to a gradient echo stack of slices with only the central k-space lines being collected for each slice. To enhance catheter contrast, a saturation pulse is added ahead of the projection pair. An offline image processing algorithm was developed to identify the 2D coordinates of the balloon in each projection image and to estimate its corresponding 3D coordinates. Post-processing includes background signal suppression using an atlas of background 2D-projection images. 3D visualization of the catheter and anatomy is proposed using three live sagittal, coronal, and axial (MPR) views and 3D rendering. The technique was tested in a subset of a catheterization step in three patients undergoing MRI-guided cardiac catheterization using a passive balloon catheter. RESULTS: The extraction of the catheter balloon 3D coordinates was successful in all patients and for the majority of time-points (accuracy >96%). This tracking method enabled a novel 3D visualization strategy for passive balloon catheter, providing enhanced anatomical context during catheter navigation. CONCLUSION: The proposed tracking strategy shows promise for robust tracking of passive balloon catheter and may enable enhanced visualization during MRI-guided cardiac catheterization.

Experience and perspective with intravascular imaging and invasive coronary physiology: Insights from allied health professionals.

BACKGROUND: Although intravascular imaging (IVI) and invasive coronary physiology (ICP) are utilized in percutaneous coronary intervention (PCI) with robust positive clinical evidence, their adoption in cardiac catheterization laboratories (CCLs) is still limited. AIMS: The aim of our survey was to assess the perspectives on the experiences of allied health professionals in CCLs' utility of IVI and ICP. METHODS: An anonymous online survey was conducted through multiple channels, including the Cardiovascular Research Technologies (CRT) 2023 Nurses and Technologists Symposium, social media, Cath Lab Digest link, and field requests, leading to diverse representation of allied health professionals. RESULTS: A total of 101 CCL members participated in the survey. First, 59% of responders noted an increased use of IVI in their institutions over recent years. For those experiencing an increase, 49% credited training, 45% emerging evidence, and 34% attributed new CCL members. Barriers to IVI usage were perceived increased procedure time (58%), staff resistance (56%), procedural cost (48%), and difficulty interpreting findings (44%). Regarding ICP, 61% reported using it in approximately 25% to 75% of cases, while 10% utilized it in 75% to 100% of CCL procedures. Interpreting ICP results was mixed, with 56% confident in interpreting all ICP results and 6% unable to interpret any ICP results. CONCLUSION: Our findings highlight opportunities for increasing routine utilization of IVI and ICP in the CCL through allied health professionals. By providing education and training, we can elevate familiarity with the equipment and subsequently build a CCL culture that advocates for both IVI and ICP.

Assessing the Readability of Patient Education Materials on Cardiac Catheterization From Artificial Intelligence Chatbots: An Observational Cross-Sectional Study.

BACKGROUND: Artificial intelligence (AI) is a burgeoning new field that has increased in popularity over the past couple of years, coinciding with the public release of large language model (LLM)-driven chatbots. These chatbots, such as ChatGPT, can be engaged directly in conversation, allowing users to ask them questions or issue other commands. Since LLMs are trained on large amounts of text data, they can also answer questions reliably and factually, an ability that has allowed them to serve as a source for medical inquiries. This study seeks to assess the readability of patient education materials on cardiac catheterization across four of the most common chatbots: ChatGPT, Microsoft Copilot, Google Gemini, and Meta AI. METHODOLOGY: A set of 10 questions regarding cardiac catheterization was developed using website-based patient education materials on the topic. We then asked these questions in consecutive order to four of the most common chatbots: ChatGPT, Microsoft Copilot, Google Gemini, and Meta AI. The Flesch Reading Ease Score (FRES) was used to assess the readability score. Readability grade levels were assessed using six tools: Flesch-Kincaid Grade Level (FKGL), Gunning Fog Index (GFI), Coleman-Liau Index (CLI), Simple Measure of Gobbledygook (SMOG) Index, Automated Readability Index (ARI), and FORCAST Grade Level. RESULTS: The mean FRES across all four chatbots was 40.2, while overall mean grade levels for the four chatbots were 11.2, 13.7, 13.7, 13.3, 11.2, and 11.6 across the FKGL, GFI, CLI, SMOG, ARI, and FORCAST indices, respectively. Mean reading grade levels across the six tools were 14.8 for ChatGPT, 12.3 for Microsoft Copilot, 13.1 for Google Gemini, and 9.6 for Meta AI. Further, FRES values for the four chatbots were 31, 35.8, 36.4, and 57.7, respectively. CONCLUSIONS: This study shows that AI chatbots are capable of providing answers to medical questions regarding cardiac catheterization. However, the responses across the four chatbots had overall mean reading grade levels at the 11th-13th-grade level, depending on the tool used. This means that the materials were at the high school and even college reading level, which far exceeds the recommended sixth-grade level for patient education materials. Further, there is significant variability in the readability levels provided by different chatbots as, across all six grade-level assessments, Meta AI had the lowest scores and ChatGPT generally had the highest.

From Other Journals: A Review of Recent Articles by Our Editorial Team.

In this review we provide a brief description of recently published articles addressing topics relevant to pediatric cardiologists. Our hope is to provide a summary of the latest articles published recently in other journals in our field. The articles address: 1- The use of AI in fetal echocardiography, 2- The role of Apixaban in thromboembolism prevention in pediatric congenital heart disease, 3- Cardiovascular events in childhood cancer survivors, and lastly 4- the new consensus statement on cardiac catheterization for pediatrics and adults with congenital heart disease.

Circulating High Mobility Group Box-1 Does Not Predict Pulmonary Arterial Hypertension in Children with Congenital Heart Disease: A Prospective Cohort Study.

OBJECTIVES: Pulmonary arterial hypertension (PAH) is a devastating complication of pediatric congenital heart disease (CHD). A recent study has identified the protein high mobility group box-1 (HMGB1) as a diagnostic tool in adults with CHD-associated PAH. HMGB1 levels in adults with CHD-associated PAH correlated with mean pulmonary artery pressure and pulmonary vascular resistance, and HGMB1 levels fell in response to sildenafil therapy. We wanted to assess if HGMB1 was a biomarker of pediatric CHD-PAH. DESIGN: Prospective cohort study. SETTING: Quaternary pediatric academic hospital PARTICIPANTS: Children ≤18 years with CHD with and without known pulmonary hypertension. Controls were children undergoing dental or urologic surgery with no known heart disease. INTERVENTIONS: Pulmonary hemodynamics, echocardiographic assessment, and biomarker measurement. Controls had biomarker measurement only. MEASUREMENTS AND MAIN RESULTS: Patients with CHD-PAH had mean pulmonary vascular resistance index of 10 Wood units/m2. Neither HGMB1 nor N-terminal pro-brain-type natriuretic peptide levels were significantly different between the groups. Neither marker correlated with pulmonary hypertension. CONCLUSIONS: Unlike in adults, HGMB1 is not a biomarker of PAH in pediatric CHD. Further work will continue to explore for biomarkers for this high-risk population.

Hidradenitis suppurativa patient requiring cardiac procedure with inguinal access: Case management with ertapenem.

Hidradenitis suppurativa is a chronic inflammatory skin disease that usually presents in young adults with painful abscesses in intertriginous areas. We present a case of severe hidradenitis suppurativa (Hidradenitis Suppurativa Investigator Global Assessment (HS-IGA) = 5; Hurley stage III) investigated by cardiology and respirology specialists for dyspnea. The patient's symptoms required right-sided cardiac catheterization via the right femoral vein in the inguinal area. The patient was able to undergo this invasive cardiac procedure without infectious complications using multidisciplinary management (dermatology, cardiology, respirology, internal medicine, and infectious diseases specialists), intravenous ertapenem 1 g/day for 6 weeks perioperatively, biologic therapy, and treatment of diabetes with semaglutide. The administration of ertapenem preoperatively and postoperatively of an invasive procedure can be beneficial, particularly when the upcoming intervention requires access to skin areas severely affected by hidradenitis suppurativa. Comorbidities such as obesity and diabetes should be addressed as their treatment might contribute to improve hidradenitis suppurativa.

Advancements in Cardiac Catheterization Safety: Novel Radiation Protection Approaches Redefining Occupational Health.

Radiation exposure poses a substantial occupational risk for healthcare professionals in the catheterization laboratory (cath lab). The escalating complexity and frequency of interventional procedures, such as cardiac catheterizations and percutaneous coronary interventions, underscore the need for innovative strategies to mitigate radiation exposure. While traditional measures like lead aprons, thyroid collars, and goggles have been pivotal in reducing radiation exposure, they have limitations, especially during prolonged and intricate procedures. Consequently, there is a growing demand for advanced radiation protection methods that prioritize safety without compromising procedural efficacy. Recent strides in radiation protection technology have given rise to novel shielding devices and zero-radiation approaches tailored for cath lab use. The novel shields leverage innovative materials and designs to achieve superior attenuation of both scattered and direct radiation. Their ergonomic and adjustable features also ensure optimal shielding coverage without impeding the operator's skill or workflow. Multiple studies have validated the effectiveness of these advanced radiation protection methods in diminishing occupational radiation exposure in the cath lab. Initial findings suggest a significant reduction in doses for operators and staff, potentially lowering the risk of radiation-induced health complications over the long term. This article provides a comprehensive review of the current landscape of radiation protection shields in the cath lab, emphasizing the efficacy and potential of these cuttingedge shielding technologies.

Rescue one-stage hybrid perventricular and percutaneous device closure of multiple muscular ventricular septal defects using the new multifunctional occluder.

Data on the safety and efficiency of perventricular device closure of complex ventricular septal defects (VSDs) are scarce. We report successful one-stage combined hybrid perventricular and percutaneous closure of the muscular VSDs in a critically ill 4-kg infant, using the new multifunctional occluder.

Dual-drainage pulmonary venous return of the left upper lobe.

Dual drainage of a pulmonary vein is an unusual anomaly of pulmonary venous drainage. While being evaluated for hypertension, a child was found with dual drainage of the upper left lobe through a vertical vein that connects to the normal pulmonary vein as well as the innominate vein with no symptoms from his effective left-to-right shunt.

Are Hospital Admissions (Costs) and Mortality Rate Impacted by Guideline-driven Treatment of Heart Failure?: A Comparison between Participants in the "CorBene" CMP and Standard-care Patients on the Basis of Propensity Score Matching.

Heart failure (HF) is one of the most common diagnoses on admission to hospital in Germany, and one which incurs high costs. Integrated care in case management programs (CMPs) aims to improve treatment quality in the sense of guideline-driven treatment, while reducing hospital admissions, hospital costs, and mortality. A total of 1,844 patient data records from 11 German statutory health insurance companies enrolled in the CMP (intervention group [IG]) were compared with 1,844 standard-care patients (control group) using propensity score matching. The two groups were assessed over three follow-up observation periods regarding the endpoints' treatment costs, hospitalization rate, indicators for treatment quality (diagnostics, physician contact), and mortality. The evaluation revealed no significant differences regarding overall costs. The IG incurred significantly higher outpatient costs, but the medication costs and inpatient costs were not significantly different. There were also no significant differences in the number of hospital admissions. Patients within the CMP had significantly more frequent contact with a cardiologist, and underwent echocardiographic examination significantly more frequently. Mortality during the first follow-up observation year was considerably more favorable for the IG. There are indications that treatment quality is improved in HF patients.

Is catheterization via distal transradial access feasible in children? From vessel diameter perspective.

Background: Distal radial artery (DRA) access is an infrequent alternative access for pediatric catheterization. The feasibility of using the DRA for arterial catheterization in children depends on the vessel's size. Objectives: This study aims to provide a reference for pediatric catheterization via DRA access by evaluating the diameter of the DRA in the anatomic snuffbox (AS). Methods: We conducted a retrospective review of clinical and vascular ultrasound data of 412 children (ages 3-12) who were scheduled for arterial blood gas analysis via the DRA due to serious respiratory diseases between June 2023 and October 2023. Results: The corrected DRA diameter in the AS was 1.97 ± 0.37 mm overall, with no significant difference between males (1.98 ± 0.38 mm) and females (1.95 ± 0.35 mm) (p = 0.457). The anteroposterior, transverse, and corrected DRA diameters increased significantly with age (p < 0.05). The DRA diameter was significantly smaller than the proximal radial artery (PRA) diameter (1.97 ± 0.37 mm vs. 2.05 ± 0.33 mm, p < 0.001) but larger than the ulnar artery (UA) diameter (1.97 ± 0.37 mm vs. 1.88 ± 0.33 mm, p < 0.001). The proportions of patients with a DRA diameter greater than 2.0 mm and 1.5 mm were 38.83% and 86.89%, respectively. The proportions of patients with DRA diameters >2.0 mm and >1.5 mm increased significantly with age (p < 0.01). The percentages of individuals with a DRA/PRA ratio ≥1.0 were 55.10% overall, 52.12% in males, and 58.60% in females. DRA diameter showed significant correlations with age (r = 0.275, p < 0.01), height (r = 0.319, p < 0.01), weight (r = 0.319, p < 0.01), BMI (r = 0.241, p < 0.01), wrist circumference (r = 0.354, p < 0.01), PRA diameter (r = 0.521, p < 0.01), and UA diameter (r = 0.272, p < 0.01). Conclusion: The DRA diameter in children increases with age and size, making cardiac catheterization is theoretically feasible. Preoperative evaluation of the vessel diameter and intraoperative ultrasound-guided intervention are recommended for paediatric catheterization via the DRA access.

Anomalous Coronary Artery Identified Post Heart Transplantation.

The following case details a 67-year-old male with a history of heart failure with reduced ejection fraction secondary to cardiac amyloidosis who underwent orthotopic heart transplantation and was later found to have an anomalous left circumflex arising from the right coronary artery in the donor heart.

Prognostic Significance of Hemodynamics in Patients With Transposition of the Great Arteries and Systemic Right Ventricle.

BACKGROUND: Patients with transposition of the great arteries (TGA) and systemic right ventricle often confront significant adverse cardiac events. The prognostic significance of invasive hemodynamic parameters in this context remains uncertain. Our hypothesis is that the aortic pulsatility index and hemodynamic profiling utilizing invasive measures provide prognostic insights for patients with TGA and a systemic right ventricle. METHODS: This retrospective multicenter cohort study encompasses adults with TGA and a systemic right ventricle who underwent cardiac catheterization. Data collection, spanning from 1994 to 2020, encompasses clinical and hemodynamic parameters, including measured and calculated values such as pulmonary capillary wedge pressure, aortic pulsatility index, and cardiac index. Pulmonary capillary wedge pressure and cardiac index values were used to establish 4 distinct hemodynamic profiles. A pulmonary capillary wedge pressure of ≥15 mm Hg indicated congestion, termed wet, while a cardiac index <2.2 L/min per m2 signified inadequate perfusion, labeled cold. The primary outcome comprised a composite of all-cause death, heart transplantation, or the requirement for mechanical circulatory support. RESULTS: Of 1721 patients with TGA, 242 individuals with available invasive hemodynamic data were included. The median follow-up duration after cardiac catheterization was 11.4 (interquartile range, 7.5-15.9) years, with a mean age of 38.5±10.8 years at the time of cardiac catheterization. Among hemodynamic parameters, an aortic pulsatility index <1.5 emerged as a robust predictor of the primary outcome, with adjusted hazard ratios of 5.90 (95% CI, 3.01-11.62; P<0.001). Among the identified 4 hemodynamic profiles, the cold/wet profile was associated with the highest risk for the primary outcome, with an adjusted hazard ratio of 3.83 (95% CI, 1.63-9.02; P<0.001). CONCLUSIONS: A low aortic pulsatility index (<1.5) and the cold/wet hemodynamic profile are linked with an elevated risk of adverse long-term cardiac outcomes in patients with TGA and systemic right ventricle.

Congenital heart disease cardiac catheterization at Uganda Heart Institute, a 12-year retrospective study of immediate outcomes.

BACKGROUND: Cardiac catheterization is an invasive diagnostic and treatment tool for congenital heart disease (CHD) with potential complications. OBJECTIVE: To describe the immediate outcomes of patients who underwent cardiac catheterization for CHD at the Uganda Heart Institute (UHI). METHODS: The study was a retrospective chart review of 857 patients who underwent cardiac catheterization for CHD at UHI from 1st February 2012 to 30th June 2023. Precardiac catheterization clinical data, procedure details, and post-procedure data were recorded. The statistical software SPSS was used for data analysis. RESULTS: We studied 857 patients who underwent cardiac catheterization for CHD at UHI. Females comprised 62.8% (n = 528). The age range was 3 days to 64 years, with a mean of 5.1 years (SD 7.4). Advanced heart failure was present in 24(2.8%) of the study participants. The most common procedures were patent ductus arteriosus device closure (n = 500, 58.3%), diagnostic catheterization (n = 194, 22.5%), and balloon pulmonary valvuloplasty (n = 114, 13.0%). PDA device closure had 89.4% optimal results while BPV had 75.9% optimal performance outcome. Adverse events occurred in 52 out of 857 study participants (6.1%). Clinically meaningful adverse events (CMAES) occurred in 3.9%, (n = 33), high severity adverse events in 2.9% (n = 25) and mortality in 1.5% (n = 13). Advanced heart failure at the time of cardiac catheterization, was significantly associated with clinically meaningful adverse events (OR 52 p-value < 0.001) and mortality (OR 564, p value < 0.001). CONCLUSION: Many patients with CHD have benefited from the cardiac catheterization program at UHI with high optimal procedure outcome results. Patients with advanced heart failure at the time of cardiac catheterization have less favorable outcomes emphasizing the need for early detection and early intervention.

Intra-arterial nicardipine versus verapamil during transradial access coronary catheterization.

INTRODUCTION: Intra-arterial (IA) vasodilators are recommended during transradial access (TRA) to prevent radial artery spasm (RAS). The American Heart Association (AHA) recommends either IA verapamil, diltiazem, nicardipine, or nitroglycerin to prevent RAS. To our knowledge, the efficacy of RAS prevention and patient tolerability of verapamil and nicardipine has not been directly compared in a randomized fashion. METHODS: We conducted a prospective, single-blinded randomized clinical trial comparing the discomfort experienced by patients receiving either 400 µg of IA nicardipine (n = 26) or 5 mg of IA verapamil (n = 29). Patient discomfort and/or pain was assessed using the Visual Analogue Scale (VAS) both before and after IA administration of nicardipine or verapamil. RESULTS: There was a statistically significant difference in mean change in VAS scores between the 2 groups, with an average increase in VAS score of 0.88 in the nicardipine group and 4.81 in the verapamil group (p < 0.0001). The overall rate of RAS was low in our study (5.5 %) with no significant difference in RAS incidence between the 2 groups (p = 0.465). The nicardipine group had 2 RAS cases (7.7 %), with 1 requiring a change in strategy (3.8 %). The verapamil group had 1 RAS case (3.4 %) that did not require a change in strategy. CONCLUSION: In this trial, we showed that nicardipine causes significantly less discomfort and pain compared to verapamil during IA administration for TRA cardiac catheterization.

Pseudocoarctation of the Aorta: A Rare Incidental Finding During a Preoperative Assessment.

Pseudocoarctation of the aorta (PCoA) is a rare congenital anomaly characterized by the abnormal kinking of the thoracic aorta. It is often incidentally diagnosed but gained clinical significance due to its propensity to develop aortic aneurysm and rupture. A standard diagnostic and treatment algorithm for PCoA is lacking, and also, the natural history of the disease is not well studied. We present here a case of PCoA with a fusiform aneurysm of the thoracic aorta to emphasize the need to differentiate it from true coarctation and to rule out associated complications.

Additive value of invasive haemodynamic assessment for predicting post-operative outcomes after Fontan.

Routine pre-Fontan cardiac catheterization remains standard practice at most centres. However, with advances in non-invasive risk assessment, an invasive haemodynamic assessment may not be necessary for all patients.Using retrospective data from patients undergoing Fontan palliation at our institution, we developed a multivariable model to predict the likelihood of a composite adverse post-operative outcome including prolonged length of stay ≥ 30 days, hospital readmission within 6 months, and death and/or transplant within 6 months. Our baseline model included non-invasive risk factors obtained from clinical history and echocardiogram. We then incrementally incorporated invasive haemodynamic data to determine if these variables improved risk prediction.Our baseline model correctly predicted favourable versus adverse post-Fontan outcomes in 118/174 (68%) patients. Covariates associated with adverse outcomes included the presence of a systemic right ventricle (adjusted adds ratio [aOR] 2.9; 95% CI 1.4, 5.8; p = 0.004), earlier surgical era (aOR 3.1 for era 1 vs 2; 95% CI 1.5, 6.5; p = 0.002), and performance of concomitant surgical procedures at the time of Fontan surgery (aOR 2.5; 95% CI 1.1, 5.0; p = 0.026). Incremental addition of invasively acquired haemodynamic data did not improve model performance or percentage of outcomes predicted.Invasively acquired haemodynamic data does not add substantially to non-invasive risk stratification in the majority of patients. Pre-Fontan catheterization may still be beneficial for angiographic evaluation of anatomy, for therapeutic intervention, and in select patients with equivocal risk stratification.