Screening and diagnostic imaging at centres performing congenital heart surgery in middle-income countries.

BACKGROUND: Surgical care for CHD is increasingly available in low- and middle-income countries, and efforts to optimise outcomes are growing. This study characterises cardiac imaging and prenatal diagnosis infrastructure in this setting. METHODS: An infrastructure survey was administered to sites participating in the International Quality Improvement Collaborative for CHD. Questions regarding transthoracic, transesophageal and epicardial echocardiography, cardiac CT, cardiac magnetic resonance, prenatal screening and fetal echocardiography were included. Associations with in-hospital and 30-day mortality were assessed. RESULTS: Thirty-seven sites in 17 countries responded. Programme size and geography varied considerably: < 250 cases (n = 13), 250-500 cases (n = 9), > 500 cases (n = 15); Americas (n = 13), Asia (n = 18), and Eastern Europe (n = 6). All had access to transthoracic echo. Most reported transesophageal and epicardial echocardiography availability (86 and 89%, respectively). Most (81%) had cardiac CT, but only 54% had cardiac magnetic resonance. A third reported impediments to imaging, including lack of portable machines, age/size-appropriate equipment and advanced cardiac imaging access and training. Only 19% of centres reported universal prenatal CHD screening in their catchment area, and only 46% always performed fetal echocardiography if screening raised concern for CHD. No statistically significant associations were identified between imaging modality availability and surgical outcomes. CONCLUSIONS: Although access to echocardiography is available in most middle-income countries; advanced imaging modalities (cardiac CT and magnetic resonance) are not always accessible. Prenatal screening for CHD is low, and availability of fetal echocardiography is limited. Imaging infrastructure in low- and middle-income countries and associations with outcomes merits additional study.

Machine Learning to Predict Executive Function in Adolescents with Repaired d-Transposition of the Great Arteries, Tetralogy of Fallot, and Fontan Palliation.

OBJECTIVE: To identify predictors of impaired executive function in adolescents after surgical repair of critical congenital heart disease (CHD). STUDY DESIGN: We analyzed patient factors, medical and surgical history, and family social class from 3 single-center studies of adolescents with d-transposition of the great arteries (d-TGA), tetralogy of Fallot (TOF), and Fontan repair. Machine learning models were developed using recursive partitioning to predict an executive function composite score based on five subtests (population mean 10, SD 3) of the Delis-Kaplan Executive Function System. RESULTS: The sample included 386 patients (139 d-TGA, 91 TOF, 156 Fontan) of age 15.1 ± 2.1 (mean ± SD) years and an executive function composite score of 8.6 ± 2.4. Family social class emerged as the most important predictive factor. The lowest (worst) mean executive function score (5.3) occurred in patients with low to medium social class (Hollingshead index <56) with one or more neurologic events and a diagnosis of TOF. The highest (best) mean score (9.7) occurred in subjects with high social class (Hollingshead index ≥56) and shorter duration of deep hypothermic circulatory arrest. Other factors predicting lower executive function scores included low birth weight and a greater number of catheterizations. CONCLUSIONS: In regression tree modeling, family social class was the strongest predictor of executive function in adolescents with critical CHD, even in the presence of medical risk factors. Additional predictors included CHD diagnosis, birth weight, neurologic events, and number of procedures. These data highlight the importance of social class in mitigating risks of executive dysfunction in CHD.

Cardiac MRI predictors of good long-term outcomes in patients with repaired TOF.

BACKGROUND: Risk stratification in patients with repaired tetralogy of Fallot (rTOF) have focused on poor clinical outcomes while predictors of a benign clinical course have not been characterized. OBJECTIVE: The goal of this study was to Identify cardiac magnetic resonance (CMR) markers of a good clinical course late after TOF repair. METHODS: Clinical and CMR data from the International Multicenter TOF Registry (INDICATOR) were analyzed. The primary outcome was time to the earliest occurrence of a composite of death, aborted sudden death, and sustained ventricular tachycardia (VT). The secondary outcome was time to the earliest occurrence of atrial arrhythmia, nonsustained VT, and NYHA class >II. Multinomial regression was used to identify predictors of the 3-category outcome: (a) good outcome, defined as freedom from the primary AND secondary outcomes at age 50 years; (b) poor outcome, defined as presence of the primary outcome before age 50 years; and (c) intermediate outcome, defined as not fulfilling criteria for good or poor outcomes. RESULTS: Among 1088 eligible patients, 96 had good outcome, 60 experienced poor outcome, and 932 had intermediate outcome. Patients were age 25.8±10.8 years at the time of the index CMR. Median follow-up was 5.8 years (IQR 3.0, 9.9) after CMR in event-free patients. By univariate analysis, smaller right ventricular (RV) end-systolic and end-diastolic volume index, smaller left ventricular end-systolic volume index, higher right and left ventricular ejection fraction, lower right and left ventricular mass index, and lower left ventricular mass/volume ratio were associated with good outcome. Multivariable modeling identified higher RV ejection fraction (OR 2.38 per 10% increase, P = .002) and lower RV mass index (OR 1.72, per 10 g/m2 decrease, P = .002) as independently associated with good outcome after adjusting for age at CMR. Classification and regression tree analysis identified important thresholds associated with good outcome that were specific to patients age ≥37 years at the time of CMR; these were RV ejection fraction ≥42% and RV mass index <39 g/m2. CONCLUSIONS: Adults with rTOF and no more than mild RV dysfunction combined with no significant RV hypertrophy are likely to be free from serious adverse clinical events into their sixth decade of life and may require less frequent cardiac testing.

Myofiber organization in the failing systemic right ventricle.

BACKGROUND: The right ventricle (RV) often fails when functioning as the systemic ventricle, but the cause is not understood. We tested the hypothesis that myofiber organization is abnormal in the failing systemic right ventricle. METHODS: We used diffusion-weighted cardiovascular magnetic resonance imaging to examine 3 failing hearts explanted from young patients with a systemic RV and one structurally normal heart with postnatally acquired RV hypertrophy for comparison. Diffusion compartment imaging was computed to separate the free diffusive component representing free water from an anisotropic component characterizing the orientation and diffusion characteristics of myofibers. The orientation of each anisotropic compartment was displayed in glyph format and used for qualitative description of myofibers and for construction of tractograms. The helix angle was calculated across the ventricular walls in 5 locations and displayed graphically. Scalar parameters (fractional anisotropy and mean diffusivity) were compared among specimens. RESULTS: The hypertrophied systemic RV has an inner layer, comprising about 2/3 of the wall, composed of hypertrophied trabeculae and an epicardial layer of circumferential myofibers. Myofibers within smaller trabeculae are aligned and organized with parallel fibers while larger, composite bundles show marked disarray, largely between component trabeculae. We observed a narrow range of helix angles in the outer, compact part of the wall consistent with aligned, approximately circumferential fibers. However, there was marked variation of helix angle in the inner, trabecular part of the wall consistent with marked variation in fiber orientation. The apical whorl was disrupted or incomplete and we observed myocardial whorls or vortices at other locations. Fractional anisotropy was lower in abnormal hearts while mean diffusivity was more variable, being higher in 2 but lower in 1 heart, compared to the structurally normal heart. CONCLUSIONS: Myofiber organization is abnormal in the failing systemic RV and might be an important substrate for heart failure and arrhythmia. It is unclear if myofiber disorganization is due to hemodynamic factors, developmental problems, or both.

Advancing Advocacy: Implementation of a Child Health Advocacy Curriculum in a Pediatrics Residency Program.

Introduction: ACGME program requirements for graduate medical education state that pediatric residency programs should include elements of child advocacy education. Finding readily available, easily implementable advocacy curricula for pediatric residency programs is challenging. We conducted a generalized curricular needs assessment via literature review and a targeted needs assessment with health care providers and advocacy leaders and developed and implemented a child health advocacy curriculum in a pediatrics residency program. Methods: Delivered across 9 months, the curriculum included three components: electronic resources, didactic sessions, and interactive workshops aimed at developing advocacy skills in the context of pressing child health issues. The learner audience was PGY 1 through PGY 4. The curriculum was evaluated using pre- and postcurriculum surveys. Results: Our curriculum advanced child advocacy locally by establishing partnerships with state and federal American Academy of Pediatrics and pediatric residency programs, teaching residents to generate advocacy action plans, and implanting a longitudinal advocacy curriculum in the residency program. Sixty-four of 70 residents participated in the curriculum: 33% were PGY 1, 31% were PGY 2, 30% were PGY 3, and 6% were PGY 4. Pre- and postcurriculum surveys demonstrated improved knowledge of and comfort level with advocacy after curriculum completion. Discussion: Child advocacy teaching improved resident and faculty awareness about child health issues in the community, as well as understanding of pathways to advocate for child health. The curriculum is reproducible and feasible and can assist other institutions to develop advocacy education and skill development programs.

Can Ultrasound in Early Gestation Improve Visualization of Fetal Cardiac Structures in Obese Pregnant Women?

OBJECTIVES: To determine whether ultrasound (US) imaging of obese pregnant women in early gestation improves fetal cardiac visualization. METHODS: We report a prospective longitudinal trial comparing late first- and early second-trimester US to traditional second-trimester US for fetal cardiac screening in maternal obesity. All study participants received US for fetal cardiac screening at a gestational age of 13 weeks to 15 weeks 6 days using a transvaginal or transabdominal approach (UST1). All patients also underwent a traditional transabdominal examination at 20 to 22 weeks (UST2). If UST2 failed to complete the cardiac visualization, a follow up examination (second UST2) was performed 2 to 4 weeks later. Imaging was considered complete if the visceral situs, 4 chambers, outflow tracts, and 3 vessels were visualized. The completion rates between UST1 and UST2 were the primary outcomes. A power analysis (85%) and sample size calculation (n = 145) were performed. RESULTS: A total of 152 pregnancies met study criteria. Completion rates of cardiac screening were 77% for UST1 and 70% for UST2 (P = .143). This comparison reached statistical significance in patients with a body mass index of greater than 40 kg/m2 (UST1 [69%] versus UST2 [38%]; P = .001). Sixty-two percent of patients with a body mass index of greater than 40 kg/m2 required second UST2. The highest fetal cardiac screening completion rate was achieved when UST1 was combined with UST2 (96.1%). In 1 fetus, congenital heart disease was detected at UST1 and later confirmed. CONCLUSIONS: This study represents the largest prospective trial assessing early-gestation US for fetal cardiac screening in the setting of maternal obesity. In obese pregnancies, the addition of early-gestation US to the 20- to 22-week US substantially improves the visualization of fetal cardiac anatomy.

Photo-oxidized bovine pericardium in congenital cardiac surgery: single-centre experience.

Objectives: Dye-mediated photo-oxidation of pericardium is an alternative method to chemical treatment with glutaraldehyde for cross-linking collagen, providing biostability of the patch material while avoiding late calcification and cytotoxicity. There are few data available, on using photo-oxidation-treated pericardium, in congenital cardiac surgery. This study reports the outcomes using Photofix™ bovine pericardium in neonates, infants, children and young adults undergoing paediatric cardiac surgery. Methods: A total of 490 patches in 383 consecutive operations (364 patients) were used in the surgical repair of congenital heart defects at our institution from October 2008 to October 2011. Recorded variables included demographic data, age at operation, primary cardiac diagnosis, associated complications and number, type and location of patches placed and patch-related reintervention. Results: Median age at operation was 5.3 years, ranging from <1 month to 56 years. The overall survival rate at late follow-up was 92%, and no deaths were related to failure of the tissue substitute. Two patients (0.5%) underwent reintervention late due to patch material failure: one for residual shunt after Rastelli repair and one for aneurysmal dilatation of a right ventricular outflow tract patch. The patch material was explanted in 8 patients at a mean of 20 months (range, 1-72 months) following implantation. Histological examination revealed mild to moderate inflammation with variable calcification. Conclusions: Photo-oxidized bovine pericardium demonstrated excellent performance when used as a patch material in cardiovascular repair in children. Its handling characteristics and biocompatibility are consistent with a wide range of applications.

Histology of Pericardial Tissue Substitutes Used in Congenital Heart Surgery.

Pericardium is used as a tissue substitute during pediatric heart surgery. However, little is known about the histological characteristics of pericardial tissue substitutes. We searched our clinical and Pathology databases to identify cases in which glutaraldehyde-preserved autologous pericardium, PhotoFix bovine pericardium, or Peri-Guard Repair Patch glutaraldehyde-preserved bovine pericardium was used as patch material during cardiac surgery and in which explanted tissue substitute was available for histologic examination. Tissue sections were stained with hematoxylin and eosin, Masson trichrome, and Movat pentachrome, and were graded for inflammation, tissue substitute degeneration, neointima formation, and calcification. Nonparametric statistical methods were used to test differences between groups because of small sample size. The eight patients who received PhotoFix pericardium were older (median 10 months vs 10 days, P < 0.05) and the material was in situ longer (median 14 vs 2.5 months, P < 0.05) compared to the eight who received autologous pericardium. Only three patients received glutaraldehyde-preserved bovine pericardium precluding statistical comparison. Inflammation and tissue degeneration were greater in PhotoFix pericardium compared to autologous pericardium but were no more than moderate. Neointima formation and calcification did not differ significantly between the two groups. PhotoFix bovine pericardium is associated with more inflammation and material degeneration but calcification, and neointima formation are similar to autologous pericardium. Although the short-term outcomes are acceptable, calcification and degeneration seen in some cases suggest that long-term outcomes and performance at certain anatomic locations need further study.

Pharmacological basis for the medicinal use of Wrightia tinctoria in hypertension and dyslipidemia.

This study was aimed to offer a possible pharmacological basis regarding the remedial utilization of Wrightia tinctoria in hypertension and dyslipidemia in certain South Asian traditional systems of medicine, using in vivo and in vitro assays. The aqueous methanolic extract of W. tinctoria seeds (Wt.Cr) caused a dose-dependent (1-10 mg/kg) decrease in arterial pressure in anesthetized rats. In the right atria of isolated guinea pigs, Wt.Cr equally inhibited force and rate of spontaneous atrial contractions. When tested on phenylephrine-, high K(+)-, and low K(+)-induced vasoconstrictions in isolated rat aorta, Wt.Cr produced a concentration-dependent vasorelaxation, the most potent being against low K(+)-induced contraction. It also created a rightward shift in the Ca(++) concentration-response curves and suppressed phenylephrine control peaks in a Ca(++)-free environment. In the rat model of tyloxapol-induced dyslipidemia, Wt.Cr produced a decline in the serum levels of total cholesterol and triglycerides. In high fat diet-induced dyslipidemia, it decreased serum total cholesterol and low-density lipoprotein cholesterol, improved high-density lipoprotein cholesterol, and prevented the increase in average body weights by causing a decrease in diet consumption. These data suggest that Wt.Cr(++) lowers blood pressure through a combination of K(+)-channel opening and Ca(++)-channel blocking effects along with antidyslipidemic and weight-reducing properties.

The interconnections between maternal and newborn health--evidence and implications for policy.

The past decade has witnessed increasing global attention and political support for maternal, newborn and child health. Despite this increased attention, actual progress has been slow and sporadic: coverage of key maternal and newborn health interventions remains low and there are wide disparities in access to care, within and across countries. Strategies for improving maternal and newborn health are closely linked, and can be delivered most effectively through a continuum of care approach. While these interventions are largely known, there is little information on which interventions have a positive health impact for both women and newborns. This supplement identifies the interventions during the preconception, pregnancy, intrapartum and postnatal periods found to have a positive, synergistic effect on maternal and neonatal outcomes. These interventions are then grouped into packages of care for delivery at the community, health center or hospital levels.