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Ecocardiografía Tridimensional , Ecocardiografía Transesofágica , Estudios de Factibilidad , Humanos , Ecocardiografía Transesofágica/métodos , Ecocardiografía Tridimensional/métodos , Niño , Masculino , Femenino , Preescolar , Adolescente , Lactante , Cardiopatías Congénitas/diagnóstico por imagenRESUMEN
Background: Following prenatal diagnosis of critical congenital heart disease (CCHD), parents encounter emotional distress while facing caregiving challenges. Supportive psycho-educational interventions using mobile health (mHealth) can make care more accessible. Objectives: We tested a novel nurse-guided mHealth care program, Preparing Heart and Mind™ (PHM™), with the objectives of examining feasibility and estimating the effect of the intervention on parents' emotional distress. Methods: This pilot study design randomized participants using a 2:1 intervention to control ratio. Analysis involved description of retention, and intervention attendance and engagement, and adjusted linear mixed models to estimate group differences in depressive (CES-D), anxiety (STAI-S), and traumatic stress (IES-r) symptoms. Results: The sample included 55 parents (n=38 PHM™ group, n=17 control). Complete retention of 37 (67%) parents included 29 (76%) in the PHM™ group and 8 (47%) control. Most attrition was due to infant death (7 parents), transplant referral (2 parents), or postnatal diagnostic ineligibility (4 parents). For the PHM™ group, ≥96% of parents attended pre- and postnatal sessions and most (65%) messaged with the nurse. mHealth engagement was highest prenatally, with handling uncertainty the most viewed topic (average 94% pages viewed). In linear mixed models analyses, the PHM™ group had on average 4.84 points lower depression (95% CI: -10.68-1.04), 6.56 points lower anxiety (-14.04-0.92), and 6.28 points lower trauma (-14.44-1.88) scores by study end. Conclusion: Findings suggest that a nurse-guided mHealth approach is feasible and may contribute to a clinically important reduction in parents' emotional distress.
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Objective: To provide an overview of the development of the Preparing Heart and Mind™ (PHM™) care program designed for parents with a prenatal diagnosis of critical congenital heart disease (CCHD) and describe issues of parental concern, caregiving competencies, and type and timing of PHM™ topics. Methods: Guided participation theory underpinned intervention development and a mixed methods pilot of a novel, nurse-guided mHealth intervention. Parents were enrolled from the third trimester of pregnancy-12 weeks postnatally. Online surveys, session transcripts, and app use were descriptively analyzed. Results: The sample included 19 mothers/birthing persons and 15 caregiving partners randomized to the intervention group. In 49 sessions, mental health/wellbeing (94%) and condition-specific information (86%) were top issues. Many caregiving competencies were developed, with mothers/birthing persons often focused on feeding (86%). Regulating emotions and co-parenting consistently needed support. PHM™ topics of preparing for hospitalization (47%) and handling uncertainty (45%) were most discussed. Two cases further characterize findings. Conclusion: Nurse-parent collaborative understanding of issues emphasized the need for mental health assessments. Prenatal intervention opportunities were underscored through discussions of caregiving issues and PHM™ topics. Innovation: PHM™ represents an innovative approach that holds promise for supporting parents' mental health and caregiving needs outside the healthcare setting.
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Background Fetal diagnosis of congenitally corrected transposition of the great arteries (ccTGA) has been increasingly reported; however, predictors of clinical outcomes remain underexplored. We undertook a multicenter, retrospective study to investigate natural history, associated anomalies, and outcomes of fetal ccTGA. Methods and Results Fetuses with ccTGA diagnosed from January 2004 to July 2020 within 20 North American programs were included. Fetuses with severe ventricular hypoplasia thought to definitively preclude biventricular repair were excluded. We included 205 fetuses diagnosed with ccTGA at a median gestational age of 23 (interquartile range, 21-27) weeks. Genetic abnormalities were found in 5.9% tested, with extracardiac anomalies in 6.3%. Associated cardiac defects were diagnosed in 161 (78.5%), with atrioventricular block in 23 (11.3%). On serial fetal echocardiogram, 39% demonstrated a functional or anatomic change, most commonly increased tricuspid regurgitation (6.7%) or pulmonary outflow obstruction (11.1%). Of 194 fetuses with follow-up, 26 were terminated, 3 experienced fetal death (2 with atrioventricular block), and 165 were live-born. Of 158 with postnatal data (median follow-up 3.7 years), 10 (6.6%) had death/transplant before 1 year. On univariable analysis, fetal factors associated with fetal death or death/transplant by 1 year included ≥ mild tricuspid regurgitation, pulmonary atresia, aortic obstruction, fetal arrhythmia, and worsening hemodynamics on serial fetal echocardiogram (defined as worse right ventricular function, tricuspid regurgitation, or effusion). Conclusions Associated cardiac lesions and arrhythmias are common in fetal ccTGA, and functional changes commonly occur through gestation. Worse outcomes are associated with fetal tricuspid regurgitation (≥mild), any arrhythmia, pulmonary atresia, aortic obstruction, and worsening hemodynamics on serial echocardiograms. These findings can inform prenatal counseling and perinatal management planning.
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Bloqueo Atrioventricular , Cardiopatías Congénitas , Atresia Pulmonar , Transposición de los Grandes Vasos , Insuficiencia de la Válvula Tricúspide , Femenino , Humanos , Embarazo , Lactante , Transposición Congénitamente Corregida de las Grandes Arterias , Transposición de los Grandes Vasos/diagnóstico por imagen , Transposición de los Grandes Vasos/cirugía , Transposición de los Grandes Vasos/complicaciones , Insuficiencia de la Válvula Tricúspide/complicaciones , Bloqueo Atrioventricular/complicaciones , Estudios Retrospectivos , Estudios de Seguimiento , Diagnóstico Prenatal , Cardiopatías Congénitas/diagnóstico por imagen , Cardiopatías Congénitas/cirugía , Cardiopatías Congénitas/complicaciones , Corazón Fetal/diagnóstico por imagen , Corazón Fetal/patología , Arritmias Cardíacas/complicaciones , Muerte FetalRESUMEN
PURPOSE: Left ventricular ejection fraction (LVEF) is routinely used to monitor cardiac function in cancer patients. Global longitudinal strain (GLS) detects subclinical myocardial dysfunction. There is no consensus on what constitutes a significant change in GLS in pediatric cancer patients. We aim to determine the change in GLS associated with a simultaneous decline in LVEF in pediatric cancer patients. METHODS: This is a retrospective longitudinal study of pediatric cancer patients treated with anthracyclines between October 2017 and November 2019. GLS was measured by 2-dimensional speckle tracking. The study outcome was a decline in LVEF, defined as a decrease in LVEF of ≥ 10% points from baseline or LVEF < 55%. We evaluated two echocardiograms per patient, one baseline, and one follow-up. The follow-up echocardiogram was either (1) the first study that met the outcome or (2) the last echocardiogram available in patients without the outcome. Statistical analyses included receiver operator characteristic curves and univariable and multivariable Cox proportional hazards regression. RESULTS: Out of 161 patients, 33 (20.5%) had a decline in LVEF within one year of follow-up. GLS reduction by ≥ 15% from baseline and follow-up GLS >-18% had sensitivities of 85% and 78%, respectively, and specificities of 86% and 83%, respectively, to detect LVEF decline. GLS reduction by ≥ 15% from baseline and follow-up GLS >-18% were independently associated with simultaneous LVEF decline [hazard ratio (95% confidence intervals): 16.71 (5.47-51.06), and 12.83 (4.62-35.63), respectively]. CONCLUSION: Monitoring GLS validates the decline in LVEF in pediatric cancer patients.
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Neoplasias , Disfunción Ventricular Izquierda , Niño , Humanos , Función Ventricular Izquierda , Volumen Sistólico , Estudios Longitudinales , Estudios Retrospectivos , Disfunción Ventricular Izquierda/diagnóstico por imagen , Disfunción Ventricular Izquierda/etiología , Valor Predictivo de las Pruebas , Neoplasias/diagnóstico por imagen , Neoplasias/tratamiento farmacológicoRESUMEN
There is a lack of current, multi-institutional data regarding hospital outcomes of infants with interrupted aortic arch (IAA). We analyzed the Pediatric Health Information System database to identify infants with IAA who underwent repair during 2004 to 2019. We classified patients as simple or complex based on associated heart defects. We evaluated factors associated with hospital mortality and complications related to 22q11.2 deletion syndrome (22q11.2del) using mixed logistic regression, accounting for hospital clustering. In 1,283 infants included (904 simple, 379 complex), mortality was higher in the complex group (11.7% vs 4.4%, p <0.001). Factors associated with mortality in the simple group were low birth weight (adjusted risk ratio [aRR] 3.77, 95% confidence interval [95% CI] 1.83 to 7.77), non-22q11.2del genetic conditions (aRR 6.44, 95% CI 1.73 to 23.96), and gastrointestinal anomalies (aRR 8.47, 95% CI 3.12 to 22.95), whereas surgery between 2012 and 2015 (aRR 0.36, 95% CI 0.13 to 0.99) was protective. In the complex group, factors associated with mortality were male (aRR 2.32, 95% CI 1.10 to 4.24) and central nervous system anomalies (aRR 3.73, 95% CI 1.62 to 8.59). Compared with their nonsyndromic counterparts, infants with simple IAA and 22q11.2del were at higher risk of sepsis (aRR 1.63, 95% CI 1.02 to 2.39) and gastrostomy tube placement (aRR 3.18, 95% CI 2.13 to 4.74), and infants with complex IAA and 22q11.2del were at higher risk of gastrostomy tube placement (aRR 2.42, 95% CI 1.20 to 4.88). In conclusion, presence of complex cardiac lesions is associated with increased mortality after IAA repair. The co-occurrence of extracardiac congenital anomalies and non-22q11.2del genetic conditions elevates mortality risk. Presence of 22q11.2del is associated with hospital complications.
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Coartación Aórtica , Síndrome de DiGeorge , Cardiopatías Congénitas , Aorta Torácica/anomalías , Aorta Torácica/cirugía , Coartación Aórtica/complicaciones , Niño , Deleción Cromosómica , Síndrome de DiGeorge/complicaciones , Femenino , Hospitales , Humanos , Lactante , MasculinoRESUMEN
PURPOSE OF REVIEW: This review aims to describe the assessment of pulmonary hypertension and ventricular function in neonates with congenital diaphragmatic hernia and the long-term follow-up of their pulmonary vascular disease. RECENT FINDINGS: In 2015, the pediatric pulmonary hypertension guidelines from the American Heart Association and American Thoracic Society suggested class I level of evidence B guidelines for routine evaluation of patients with congenital diaphragmatic hernia, including longitudinal care in an interdisciplinary pulmonary hypertension program and following the recommendations offered for all children with pulmonary hypertension. Congenital diaphragmatic hernia causes compression of the lungs during critical stages of fetal development and results in lung hypoplasia. As a result, there is abnormal development of pulmonary vasculature that leads to post-natal pulmonary hypertension and increased afterload to the right ventricle. Left ventricular filling is affected by decreased pre-load and mechanical compression by abdominal content leading to decreased systemic perfusion. Persistent pulmonary hypertension after surgical repair of congenital diaphragmatic hernia is associated with increased mortality. Assessment and monitoring of pulmonary hypertension and ventricular function in this population of neonates is crucial to determine response to medical treatment, the need for extracorporeal membrane oxygenation, and the timing of surgical repair.
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BACKGROUND: Establishment of the range of normal values and associated variations of two-dimensional (2D) speckle-tracking echocardiography (STE)-derived right ventricular (RV) strain is a prerequisite for its routine clinical application in children. The objectives of this study were to perform a meta-analysis of normal ranges of RV longitudinal strain measurements derived by 2D STE in children and to identify confounders that may contribute to differences in reported measures. METHODS: A systematic review was conducted in PubMed, Embase, Scopus, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. Search hedges were created to cover the concepts of pediatrics, STE, and the right heart ventricle. Two investigators independently identified and included studies if they reported the 2D STE-derived RV strain measure RV peak global longitudinal strain, peak global longitudinal systolic strain rate, peak global longitudinal early diastolic strain rate, peak global longitudinal late diastolic strain rate, or segmental longitudinal strain at the apical, middle, and basal ventricular levels in healthy children. Quality and reporting of the studies were assessed. The weighted mean was estimated using random effects with 95% confidence intervals (CIs), heterogeneity was assessed using Cochran's Q statistic and the inconsistency index (I(2)), and publication bias was evaluated using funnel plots and Egger's test. Effects of demographic, clinical, equipment, and software variables were assessed in a metaregression. RESULTS: The search identified 226 children from 10 studies. The reported normal mean values of peak global longitudinal strain among the studies varied from -20.80% to -34.10% (mean, -29.03%; 95% CI, -31.52% to -26.54%), peak global longitudinal systolic strain rate varied from -1.30 to -2.40 sec(-1) (mean, -1.88 sec(-1); 95% CI, -2.10 to -1.59 sec(-1)), peak global longitudinal early diastolic strain rate ranged from 1.7 to 2.69 sec(-1) (mean, 2.34 sec(-1); 95% CI, 2.00 to 2.67 sec(-1)), and peak global longitudinal late diastolic strain rate ranged from 1.00 to 1.30 sec(-1) (mean, 1.18 sec(-1); 95% CI, 1.04 to 1.33 sec(-1)). A significant base-to-apex segmental strain gradient (P < .05) was observed in the RV free wall. There was significant between-study heterogeneity and inconsistency (I(2) > 88% and P < .01 for each strain measure), which was not explained by age, gender, body surface area, heart rate, frame rate, tissue-tracking methodology, equipment, or software. The metaregression showed that these effects were not significant determinants of variations among normal ranges of strain values. There was no evidence of publication bias (P = .59). CONCLUSIONS: This study is the first to define normal values of 2D STE-derived RV strain in children on the basis of a meta-analysis. The normal mean value in children for RV global strain is -29.03% (95% CI, -31.52% to -26.54%). The normal mean value for RV global systolic strain rate is -1.88 sec(-1) (95% CI, -2.10 to -1.59 sec(-1)). RV segmental strain has a stable base-to-apex gradient that highlights the dominance of deep longitudinal layers of the right ventricle that are aligned base to apex. Variations among different normal ranges did not appear to be dependent on differences in demographic, clinical, or equipment parameters in this meta-analysis. All of the eligible studies used equipment and software from one manufacturer (GE Healthcare).
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Ecocardiografía/estadística & datos numéricos , Ecocardiografía/normas , Diagnóstico por Imagen de Elasticidad/estadística & datos numéricos , Diagnóstico por Imagen de Elasticidad/normas , Ventrículos Cardíacos/diagnóstico por imagen , Función Ventricular Derecha/fisiología , Adolescente , Niño , Preescolar , Diástole/fisiología , Módulo de Elasticidad/fisiología , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Valores de Referencia , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Sístole/fisiología , Adulto JovenRESUMEN
The Doppler Tei index is an independent predictor of outcomes in adult heart failure. Tissue Doppler imaging (TDI) may be a superior method to measure the Tei index in children because it is less affected by heart rate variability. We hypothesized that the TDI Tei index reflects severity of illness in pediatric heart failure. Twenty-five pediatric heart failure patients were prospectively enrolled. Listing for heart transplantation or death were the outcomes used to define severity of illness. Baseline demographics, brain natriuretic peptide (BNP), and standard echocardiographic and TDI-derived parameters were analyzed to determine outcome indicators. Ten of the 25 patients (40%) were listed for transplantation. There were no deaths. Multivariate analysis combining age, heart rate, standard echocardiographic parameters, and BNP resulted in shortening fraction (p = 0.002) as the best indicator of listing for transplantation (R(2) = 0.32). A second multivariate analysis combining age, heart rate, TDI parameters, and BNP resulted in age (p = 0.03) and septal Tei index (p = 0.03) as the best predictive model (R(2) = 0.36). The area under the receiver operating characteristic (ROC) curve for septal Tei index was 0.84 (95% confidence interval = 0.64-0.96,), and it was comparable with the ROC curve for shortening fraction, p = 0.76. Optimal values of sensitivity (100%) and specificity (60%) were obtained with septal Tei index values >0.51. The TDI septal Tei index is an indicator of disease severity in pediatric heart failure patients and offers potential advantages compared with standard echocardiographic measures of left-ventricular ejection.
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Ecocardiografía Doppler , Insuficiencia Cardíaca/diagnóstico por imagen , Insuficiencia Cardíaca/fisiopatología , Adolescente , Biomarcadores/sangre , Niño , Preescolar , Femenino , Frecuencia Cardíaca/fisiología , Humanos , Lactante , Masculino , Péptido Natriurético Encefálico/sangre , Valor Predictivo de las Pruebas , Estudios Prospectivos , Índice de Severidad de la EnfermedadRESUMEN
We report a rare case of a 5-year-old child who presented with chronic hypoxemia and a normal cardiac examination, and was found to have a persistent left superior vena cava draining directly into the left atrium. The coronary sinus was absent. This case introduces a contradiction to the generally accepted concept that this anomalous connection can only occur in the presence of a partly or completely unroofed coronary sinus. High index of suspicion is required to include this pathology in the differential diagnosis for a patient with persistent cyanosis with normal cardiac examination.
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Seno Coronario/anomalías , Cianosis/etiología , Ecocardiografía/métodos , Atrios Cardíacos/anomalías , Tomografía Computarizada por Rayos X/métodos , Malformaciones Vasculares/complicaciones , Vena Cava Superior/anomalías , Preescolar , Seno Coronario/diagnóstico por imagen , Cianosis/diagnóstico , Diagnóstico Diferencial , Femenino , Atrios Cardíacos/diagnóstico por imagen , Humanos , Malformaciones Vasculares/diagnóstico , Vena Cava Superior/diagnóstico por imagen , Vena Cava Superior/cirugíaRESUMEN
We report the case of a young adult with a history of an allergic reaction to a sulfonamide antibiotic who developed toxoplasmosis after his second orthotopic heart transplant. As a result of this drug allergy, the patient did not receive prophylaxis with trimethoprim and sulfamethoxazole. He was successfully treated with clindamycin, pyrimethamine, and folic acid.
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Profilaxis Antibiótica , Antiparasitarios/uso terapéutico , Trasplante de Corazón , Sulfonamidas/efectos adversos , Toxoplasmosis/tratamiento farmacológico , Adulto , Clindamicina/uso terapéutico , Hipersensibilidad a las Drogas , Ácido Fólico/uso terapéutico , Humanos , Masculino , Pirimetamina/uso terapéutico , Sulfonamidas/uso terapéuticoRESUMEN
Medicina basada en la evidencia (MBE) es actualmente sinónimo de práctica médica moderna e innovadora. Sin embargo, poco se sabe de su real dimensión y principios. Su relación con la investigación y la evidencia es entendida como la interpretación de la literatura medica, la realización de mega ensayos clínicos o meta-análisis. MBE implica el uso juicioso de la mejor evidencia disponible, gracias a la evaluación rigurosa de la calidad metodológica de la información científica, así como de su aplicabilidad. La MBE rescata la experiencia y pericia clínica del médico. Adicionalmente, incorpora como tercer elemento fundamental las preferencias y valores de los pacientes acerca del cuidado de su salud. La intersección de estos tres aspectos constituye la esencia de la MBE. La práctica así entendida de la MBE ubica al paciente y sus circunstancias en el centro mismo del acto médico y lo revaloriza como ciencia y arte. En esta revisión buscamos destacar como la práctica de la MBE guía hacia una toma de decisiones correcta y democrática. Así mismo, se revisa los diversos aportes en la práctica medica actual, las distorsiones creadas alrededor de ella y las limitaciones para su aplicación en nuestra realidad.
Evidence Based Medicine (EBM) is currently a synonym for modern and innovative medical practice. However, too little is known about its principles and preponderance. Its relation with research and evidence is understood as the interpretation of medical literature or the performance of mega clinical trials or meta-analysis. EBM involves a wiser use of the best available evidence, due to a rigorous assessment of the methodological quality of the scientific information, as well as its applicability. EBM redeems the physician clinical experience and expertise. Additionally, it incorporates as a third fundamental element, the preferences and values of patients in relation to their own health care. The overlapping of these three aspects constitutes the essence of EBM. In this way, medical practice is centered in patients and their circumstances, being revalued as science and art. This review aims to emphasize how practicing EBM guides us to make right and democratic decisions. Likewise, we review its contributions to current medical practice, misinterpretations created about it and limitations to its application in our reality.