Incorporation of the CardioMEMS™ System During an Exercise Physiology Test in a Pediatric Congenital Heart Disease Patient Contributing to Medical Decision-Making.

Exercise testing among the pediatric congenital heart disease population continues to transform and expand the way patients are evaluated and managed. We describe a case where a stress echocardiogram was performed while successfully collecting data from a previously implanted CardioMEMS™ HF system which helped guide decision-making.

2021 PACES expert consensus statement on the indications and management of cardiovascular implantable electronic devices in pediatric patients.

In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consensus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology (ACC), and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate CIED follow-up in pediatric patients.

Virtual and Augmented Reality in Cardiovascular Care: State-of-the-Art and Future Perspectives.

Applications of virtual reality (VR) and augmented reality (AR) assist both health care providers and patients in cardiovascular education, complementing traditional learning methods. Interventionalists have successfully used VR to plan difficult procedures and AR to facilitate complex interventions. VR/AR has already been used to treat patients, during interventions in rehabilitation programs and in immobilized intensive care patients. There are numerous additional potential applications in the catheterization laboratory. By using AR, interventionalists could combine visual fluoroscopy information projected and registered on the patient body with data derived from preprocedural imaging and live fusion of different imaging modalities such as fluoroscopy with echocardiography. Persistent technical challenges to overcome include the integration of different imaging modalities into VR/AR and the harmonization of data flow and interfaces. Cybersickness might exclude some patients and users from the potential benefits of VR/AR. Critical ethical considerations arise in the application of VR/AR in vulnerable patients. In addition, digital applications must not distract physicians from the patient. It is our duty as physicians to participate in the development of these innovations to ensure a virtual health reality benefit for our patients in a real-world setting. The purpose of this review is to summarize the current and future role of VR and AR in different fields within cardiology, its challenges, and perspectives.

A unique cardiovascular presentation of pheochromocytoma.

We describe a unique presentation of a pheochromocytoma in a normotensive teenager, who presented with symptoms of headache, neck pain, and palpitations. Holter and event monitor tracings revealed intermittent junctional rhythm causing electromechanical dyssynchrony between atrial and ventricular contraction resulting in reported symptoms. Exercise stress testing helped correlate symptomatic junctional rhythm events to episodic hypertension which led to the eventual diagnosis of pheochromocytoma. The exercise test provided insight into the physiologic coupling that the sympathetic and parasympathetic autonomic nervous systems have on the cardiovascular system during exercise and exaggerated hypertension. The patient was found to have MEN2A and partial adrenalectomy resulted in complete resolution of symptoms and arrhythmia. This unusual presentation illustrates the benefit of a comprehensive clinical evaluation, which led to the eventual diagnosis.

Design Considerations for Interacting and Navigating with 2 Dimensional and 3 Dimensional Medical Images in Virtual, Augmented and Mixed Reality Medical Applications.

The extended realities, including virtual, augmented, and mixed realities (VAMR) have recently experienced significant hardware improvement resulting in an expansion in medical applications. These applications can be classified by the target end user (for instance, classifying applications as patient-centric, physician-centric, or both) or by use case (for instance educational, diagnostic tools, therapeutic tools, or some combination). When developing medical applications in VAMR, careful consideration of both the target end user and use case must heavily influence design considerations, particularly methods and tools for interaction and navigation. Medical imaging consists of both 2-dimensional and 3-dimensional medical imaging which impacts design, interaction, and navigation. Additionally, medical applications need to comply with regulatory considerations which will also influence interaction and design considerations. In this manuscript, the authors explore these considerations using three VAMR tools being developed for cardiac electrophysiology procedures.

2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients.

In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consensus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology (ACC), and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate CIED follow-up in pediatric patients.

2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Developed in collaboration with and endorsed by the Heart Rhythm Society (HRS), the American College of Cardiology (ACC), the American Heart Association (AHA), and the Association for European Paediatric and Congenital Cardiology (AEPC) Endorsed by the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS).

In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consensus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology (ACC), and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate CIED follow-up in pediatric patients.

Use of extended realities in cardiology.

Recent miniaturization of electronic components and advances in image processing software have facilitated the entry of extended reality technology into clinical practice. In the last several years, the number of applications in cardiology has multiplied, with many promising to become standard of care. We review many of these applications in the areas of patient and physician education, cardiac rehabilitation, pre-procedural planning and intraprocedural use. The rapid integration of these approaches into the many facets of cardiology suggests that they will one day become an every-day part of physician practice.

Development and Human Factors Considerations for Extended Reality Applications in Medicine: The Enhanced ELectrophysiology Visualization and Interaction System (ELVIS).

With the rapid expansion of hardware options in the extended realities (XRs), there has been widespread development of applications throughout many fields, including engineering, entertainment and medicine. Development of medical applications for the XRs have a unique set of considerations during development and human factors testing. Additionally, understanding the constraints of the user and the use case allow for iterative improvement. In this manuscript, the authors discuss the considerations when developing and performing human factors testing for XR applications, using the Enhanced ELectrophysiology Visualization and Interaction System (ELVIS) as an example. Additionally, usability and critical interpersonal interaction data from first-in-human testing of ELVIS are presented.

Performance Evaluation of Mixed Reality Display for Guidance During Transcatheter Cardiac Mapping and Ablation.

Cardiac electrophysiology procedures present the physician with a wealth of 3D information, typically presented on fixed 2D monitors. New developments in wearable mixed reality displays offer the potential to simplify and enhance 3D visualization while providing hands-free, dynamic control of devices within the procedure room. OBJECTIVE: This work aims to evaluate the performance and quality of a mixed reality system designed for intraprocedural use in cardiac electrophysiology. METHOD: The Enhanced Electrophysiology Visualization and Interaction System (ELVIS) mixed reality system performance criteria, including image quality, hardware performance, and usability were evaluated using existing display validation procedures adapted to the electrophysiology specific use case. Additional performance and user validation were performed through a 10 patient, in-human observational study, the Engineering ELVIS (E2) Study. RESULTS: The ELVIS system achieved acceptable frame rate, latency, and battery runtime with acceptable dynamic range and depth distortion as well as minimal geometric distortion. Bench testing results corresponded with physician feedback in the observational study, and potential improvements in geometric understanding were noted. CONCLUSION: The ELVIS system, based on current commercially available mixed reality hardware, is capable of meeting the hardware performance, image quality, and usability requirements of the electroanatomic mapping display for intraprocedural, real-time use in electrophysiology procedures. Verifying off the shelf mixed reality hardware for specific clinical use can accelerate the adoption of this transformative technology and provide novel visualization, understanding, and control of clinically relevant data in real-time.

Can smartphone wireless ECGs be used to accurately assess ECG intervals in pediatrics? A comparison of mobile health monitoring to standard 12-lead ECG.

BACKGROUND: Arrhythmias in children are often paroxysmal, complicating the ability to capture the abnormal rhythm on routine ECG during an outpatient visit. The Alivecor Kardia Mobile (KM) device is a wireless mobile health (mHealth) device that generates a single lead ECG tracing with a FDA-approved algorithm for detection of atrial fibrillation in adults. OBJECTIVE: The goal of this study is to assess the accuracy of interval measurements on KM tracings by directly comparing to standard 12-lead ECGs in pediatric patients. METHODS: This single center, prospective study enrolled pediatric outpatients, age <18 years presenting for cardiology clinic visits, into 3 groups based on age: 0-5 years, 6-10 years, and 11-18 years. Patients were excluded if 12-lead ECG was not ordered during the visit. Each enrolled subject underwent standard 12-lead ECG followed by 30-second KM tracing. ECG parameters were batch read by 2 blinded pediatric electrophysiologists. RESULTS: Thirty patients were recruited with 10 patients/group. Structural heart disease and/or conduction abnormality was present in 20 patients (67%). Majority of tracings (27/30, 90%) were of diagnostic quality on first attempt. Overall, the ΔPR was 15.2±10.8ms (r = 0.86), ΔQRS was 9.6±8ms (r = 0.86), and ΔQTc was 15.6±12.7ms (r = 0.83). There were 9 patients with ΔQTc measurements >20ms with 4/9 (44%) having a conduction disorder and 2/9 (22%) having marked sinus arrhythmia. Bland-Altman method of agreement demonstrated strong agreement for QRSd and QTc. The AF algorithm reported 4/30 (13%) false positive "possible AF" diagnoses (rhythm over-read on KM demonstrated n = 3 marked sinus arrhythmia, n = 1 sinus rhythm with aberrated PACs) resulting in a specificity of 87%. CONCLUSION: The Alivecor Kardia device produces accurate single lead ECG tracings in both healthy children and children with cardiac disease or rhythm abnormalities across the pediatric spectrum. This mHealth application provides an accurate, non-invasive, real-time approach for ambulatory ECG monitoring in children and adolescents.