Accuracy of the Apple Watch iECG in Children With and Without Congenital Heart Disease.

The development of smart technologies paves the way for new diagnostic modalities. The Apple Watch provides an FDA approved iECG function for users from 22 years of age. Yet, there are currently no data on the accuracy of the Apple Watch iECG in children. While arrhythmias are a frequent phenomenon in children, especially those with congenital heart disease, the increasing spread of smart watches provides the possibility to use a smart watch as mobile event recorder in case of suspected arrhythmia. This may help to provide valuable information to the treating physician, without having the patient to come to the hospital. Necessary treatment adjustments might be provided without timely delay. The aim of this study was therefore to evaluate the agreement of measured values of rate, interval, and amplitude with those obtained by a diagnostic quality ECG recording to an Apple Watch iECG in children with and without congenital heart disease. In this prospective, single-arm study, consecutive patients aged 0-16 years presenting to the Heart Center Leipzig, Department for pediatric cardiology were included. After obtaining informed consent from participants' parents, a 12-lead ECG and an iECG using an Apple Watch were performed. Cardiac rhythm was classified, amplitudes and timing intervals were measured and analyzed in iECG and 12-lead ECG for comparability. These measurements were performed blinded to the patients' history by two experienced pediatric cardiologists. Patient demographic data, medical and cardiac history were assessed. 215 children between 0 and 16 years were enrolled. Comparison of amplitudes and timing intervals between ECG and iECG showed excellent correlation (K > 0.7, p < 0.01) in all parameters except for the p-waves. Automatic rhythm classification was inferior to manual interpretation of ECG / iECG, while iECG interpretation was reliable in 94.86% of cases. The study demonstrates equal quality of the Apple Watch derived iECG compared to a lead I in 12-lead ECG in children of all age groups and independent from cardiac anatomy.

The Fontan and the Sea: First-in-Man Data on Swimming and Diving Physiology in Fontan Patients.

While swimming represents a popular recreational activity, the immersion of the human body into the water requires a complex physiologic adaption of the whole cardiopulmonary and circulatory system. While this sport is regarded as beneficial, especially in cardiovascular patients, current guidelines hypothesized a possible hazardous effect of swimming and especially diving in patients with univentricular hearts after Fontan palliation. Yet, actual data to underline or contradict these assumptions are lacking. Therefore, this study aimed to conduct a first feasibility study for the evaluation of these effects on Fontan physiology and elucidate the gap of evidence currently preventing patients after Fontan palliation from being restricted from swimming or diving on doctoral advice. Patients recruited from the Heart Center Leipzig, Department of pediatric cardiology, underwent spiroergometry treadmill testing followed by a spiroergometry swimming stress test in a counter current pool. Physiologic data were recorded. A short apnea diving test was performed. The current study found similar physiologic reactions comparing treadmill and swimming exercise stress testing. Heart rate response and oxygen uptake were comparable on land and in the water. This study presents the first-in-man data on swimming and diving in Fontan patients. In this small study cohort of three Fontan patients, there were no adverse events triggered by swimming and breath-hold diving seen. Basically, the physiologic response to exercise was comparable on land and in the water.

QRS Width as a Predictor of Right Ventricular Remodeling After Percutaneous Pulmonary Valve Implantation.

Recent data showed a right ventricular dyssynchrony in patients with tetralogy of Fallot (TOF). Percutaneous pulmonary valve implantation (PPVI) has become an important procedure to treat a pulmonary stenosis and/or regurgitation of the right ventricular outflow tract in these patients. Despite providing good results, there is still a considerable number of nonresponders to PPVI. The authors speculated that electrical dysfunction of the right ventricle plays an underestimated role in the outcome of patients after PPVI. This study aimed to investigate the influence of right ventricular electrical dysfunction, i.e., right bundle branch block (RBBB) on the RV remodeling after PPVI. The study included consecutive patients after correction of TOF with or without RBBB, who had received a PPVI previously at the Heart Center of the University of Leipzig, Germany during the period from 2012 to 2015. 24 patients were included. Patients without RBBB, i.e., with narrow QRS complexes pre-intervention, had significantly better RV function and had smaller right ventricular volumes. Patients with pre-interventionally QRS width below 150 ms showed a post-interventional remodeling of the right ventricle with the decreasing RV volumes (p = 0.001). The parameters of LV function and volume as well as RV ejection fraction remained unaffected by RBBB. The presented data indicate that the QRS width seems to be a valuable parameter in the prediction of right ventricular remodeling after PPVI, as it represents both electrical and mechanical functions of the right ventricle and may serve as an additional parameter for optimal timing of a PPVI.

Implantation of a Melody valve in tricuspid position.

A transcatheter pulmonary valve (Melody) was implanted within a stenotic biological valve prosthesis in tricuspid position, as an alternative to the fourth major cardiac surgery in a 12-year-old girl. There were no complications. The postinterventional result was very good.

Rupture of the papillary muscle of the tricuspid valve - echocardiographic diagnosis of a rare anomaly leading to critical tricuspid valve regurgitation in the newborn.

We present the case of a male full-term neonate who presented at 4 h of age with severe cyanosis unresponsive to mechanical ventilation and oxygen supplementation. The diagnosis of rupture of the papillary muscle of the tricuspid valve was made by echocardiography. Preoperative stabilization was achieved by adding nitric oxide and extracorporeal membrane oxygenation therapy could be avoided. Corrective surgery was successfully performed on the 7th day of life. Follow-up examination at 2 months of age revealed an excellent postoperative result. Perinatal rupture of the papillary muscle and/or chordae tendineae of the tricuspid valve is exceedingly rare and usually lethal when untreated or diagnosed late. Therefore, timely diagnosis is mandatory for adequate preoperative management and subsequent surgical treatment.

Catheter interventional treatment of Sano shunt obstruction in patients following modified Norwood palliation for hypoplastic left heart syndrome.

UNLABELLED: Shunts placed between the right ventricle and the pulmonary arteries, called Sano shunts, recently modified Norwood surgery for hypoplastic left heart syndrome. Patients with Sano shunts tend to be more stable thus reducing the interstage mortality of this still challenging complex cardiac anomaly. However, Sano shunt stenosis may develop and is a life threatening complication. We report on our experience in patients with Sano shunt obstruction. PATIENTS: Eight infants presenting with decreasing transcutaneous oxygen saturations (43-63%, median 58%) following modified Norwood procedures were shown to have relevant Sano shunt stenosis. None was suited for early stage two surgery (cavopulmonary Glenn anastomosis). Catheterization was performed at the age of 21 to 112 (median 85) days. Weight was 3.9 to 6.0 (median 4.8) kg. TECHNIQUE: Femoral 5F venous access. Long sheaths were not used. The shunt was entered with a 4F right Judkins catheter and a selective angiography was performed. The stenosis was localized proximal in 5, distal in 1 and proximal and distal in 2 patients. Ten coronary stents were implanted. RESULTS: There were no procedure related complications. Oxygen saturation increased immediately to 75-86% (median 80%) and remained above 70% during follow-up in all. Seven patients had successful stage two surgery 61-288 (median 134) days after stent implantation, one is awaiting this. CONCLUSIONS: Sano shunt obstruction can be treated safely and effectively by stent implantation. Early in-stent restenosis does not seem to be a problem.

Occult, life-threatening, cardial tumor in syndactylism in Gorlin Goltz syndrome.

Pediatric, orthopedic, plastic, and hand surgeons perform the surgical correction of syndactylism. It is sometimes forgotten, however, that syndactylism can be part of a syndrome. The components of such a syndrome can each be life threatening. A 7-month-old boy was hospitalized for correction of cutaneous syndactylism. The mother claimed that, with the exception of the syndactylism, her son was healthy. However, review of the admission documents found that the family physician suspected Gorlin Goltz syndrome. A preoperative echocardiography showed 3.9-cm intramural tumor in the wall of the left ventricle. Electrocardiography documented ventricular tachycardia. Because of the danger of life-threatening malignant ventricular tachycardia, the tumor was resected. Before the resection, cardiac transplantation was considered because of the size of the tumor. Histologic examination found a fibroma. When observing syndactylism, one must always be aware of the possibility of a syndromic disease. It is particularly important that screening investigations, including electrocardiography and echocardiography, are performed before surgical treatment.

Permanent epicardial and transvenous single- and dual-chamber cardiac pacing in children.

Between January 1974 and November 1991 33 children received a permanent single- or dual-chamber pacing system, mainly because of postoperative high-degree AV block. The children were followed up retrospectively for pacemaker- and lead-related complications, and for differences between epi- and endocardial stimulation. The overall rate of lead related complications was 35% and did not differ significantly between the epi- and endocardially paced groups, although it tended to be somewhat higher in the epicardially paced children, mainly due to a higher rate of exit blocks in the latter. The epicardially stimulated patients exhibited a significantly higher rate of pacemaker-related complications, which was primarily accounted for by a higher frequency of battery depletions in the epicardial systems. The most impressive differences between both groups, however, was seen with respect to subacute and chronic energy consumption. Chronic energy drain in the epicardially paced patients amounted to almost the sixfold of that seen in the endocardially stimulated children. This resulted in a significantly shorter cumulative pacemaker survival in the epicardial group. Therefore, it is concluded that, whenever possible, the transvenous approach be used in children and small infants too. However, as a rule, in the latter transvenous dualchamber pacing is usually not feasible. In these cases rate-adaptive single-chamber pacing has evolved as a reasonable alternative for improving hemodynamics as well as quality of life. In epicardial pacing the use of pulse generators allowing bidirectional telemetry is advisable. In this way monitoring of lead impedance and battery status can be performed noninvasively, thus permitting individualization of pulse widths and amplitude setting, which is important with respect to energy conservation.