Aortic arch recoarctation after the Norwood stage I palliation: the comparative accuracy of blood pressure cuff and echocardiographic Doppler gradients in detecting significant obstruction.

OBJECTIVE: Aortic arch recoarctation is responsible for significant morbidity and mortality after the Norwood Stage I procedure. Cuff blood pressure (BP) gradients and echocardiographic Doppler gradients are routinely used as noninvasive screening tests for early detection, but accuracy has not been systematically tested. We sought to evaluate the ability of cuff BP and Doppler gradients, measured at routine outpatient clinic visits, to predict significant arch obstruction in single ventricle patients after the Norwood operation. DESIGN: Consecutive patients who underwent Norwood operation at our institution were identified retrospectively. Cuff and echocardiographic gradients measured prior to the pre-Glenn catheterization were compared to peak-to-peak systolic neoaortic arch gradients obtained at catheterization. Statistical analyses, including Receiver Operator Characteristic (ROC) curves, were performed using different cutpoints for cuff and echocardiographic gradients, evaluating their ability to predict a clinically significant catheter gradient. RESULTS: Data were obtained in 68 patients. Echocardiographic gradient cutpoints were more sensitive but less specific than cuff BP gradient cutpoints at detecting a catheter gradient > or = 10 mm Hg. Echo gradients > or = 20 mm Hg showed 85% sensitivity and 95% specificity in detecting a systolic catheter gradient > or = 10 mm Hg. CONCLUSION: chocardiographic Doppler outperforms cuff BP as a sensitive noninvasive screening tool for early detection of significant arch obstruction in infants after the Norwood operation.

Development of a pediatric cardiology quality improvement collaborative: from inception to implementation. From the Joint Council on Congenital Heart Disease Quality Improvement Task Force.

While clinical outcomes in pediatric cardiac disease have improved in recent years, marked institutional and individual cardiology practice variability exists. Quality improvement science has demonstrated that reducing process variation leads to more favorable outcomes, safer practices, cost savings, and improved operating efficiency. This report describes the process undertaken to develop the first collaborative quality improvement project of the Joint Council on Congenital Heart Disease. The project chosen aims to reduce mortality and improve the quality of life of infants with hypoplastic left heart syndrome during the interstage period between discharge from the Norwood procedure and admission for the bidirectional Glenn procedure. The objective of this special article is to inform the pediatric cardiology and cardiac surgery communities of the project to help ensure that the early work by the project pilot participants will spread to clinicians caring for children with cardiovascular disease. It is anticipated that this project will add to our understanding of care for this challenging group of children with hypoplastic left heart syndrome, identifying clinical care changes with the potential to lead to improvements in outcome. It will also introduce the field of pediatric cardiology to the science of collaborative quality improvement and assist in reducing clinical process variation and improving patient outcomes across centers. Finally, it will establish an ongoing network of pediatric cardiologists and their teams linked through a longitudinal data set and collaboration for improvement and research.

Databases for assessing the outcomes of the treatment of patients with congenital and paediatric cardiac disease--the perspective of cardiology.

This review includes a brief discussion, from the perspective of the pediatric cardiologist, of the rationale for creation and maintenance of multi-institutional databases of outcomes of the treatment of patients with congenital and paediatric cardiac disease, together with a history of the evolution of such databases, and a description of the current state of the art. A number of projects designed to have broad-based impact are currently in the design phase, or have already been implemented. Not surprisingly, most of the efforts thus far have focused on catheterization procedures and interventions, although some work examining other aspects of paediatric cardiology practice is also beginning. This review briefly describes several European and North American initiatives related to databases for pediatric and congenital cardiology including the Central Cardiac Audit Database of the United Kingdom, national database initiatives for pediatric cardiology in Switzerland and Germany, various database initiatives under the leadership of the Working Groups of The Association for European Paediatric Cardiology, the IMPACT Registry (IMproving Pediatric and Adult Congenital Treatment) of the National Cardiovascular Data Registry of The American College of Cardiology Foundation and The Society for Cardiovascular Angiography and Interventions (SCAI), the Mid-Atlantic Group of Interventional Cardiology (MAGIC) Catheterization Outcomes Project, the Congenital Cardiac Catheterization Project on Outcomes (C3PO), the Congenital Cardiovascular Interventional Study Consortium (CCISC), and the Joint Council on Congenital Heart Disease (JCCHD) National Quality Improvement Initiative. These projects, each leveraging multicentre data and collaboration, demonstrate the enormous progress that has occurred over the last several years to improve the quality and consistency of information about nonsurgical treatment for congenital cardiac disease. The paediatric cardiology field is well-poised to move quickly beyond outcome assessment and benchmarking, to collaborative quality improvement.