Elijah Bolin

Fetal magnetocardiography using optically pumped magnetometers: a more adaptable and less expensive alternative?

Fetal magnetocardiography provides the requisite precision for diagnostic measurement of electrophysiological events in the fetal heart. Despite its significant benefits, this technique with current cryogenic based sensors has been limited to few centers, due to high cost of maintenance. In this study, we show that a less expensive non‐cryogenic alternative, optically pumped magnetometers, can provide similar electrophysiological and quantitative characteristics when subjected to direct comparison with the current technology. Further research can potentially increase its clinical use for fetal magnetocardiography.

Appropriateness and diagnostic yield of inpatient pediatric echocardiograms

OBJECTIVE Multiple reports have shown echocardiograms for certain indications are neither cost-effective nor of high diagnostic yield. Given the ease with which tests can be obtained at a tertiary academic childrens hospital, our aims were to: (1) determine the diagnostic yield of inpatient studies by in-hospital location; (2) evaluate inpatient echocardiograms to determine indications and level of appropriateness; and (3) evaluate the frequency of cardiology involvement prior to those echocardiograms. DESIGN All initial inpatient echocardiograms interpreted at our institution from February 2009 to December 2014 were reviewed retrospectively. Patient location was grouped as pediatric intensive care (PICU), emergency department (ED), and general floor. RESULTS There were 727 first-time inpatient echocardiograms that met inclusion criteria. Pathology was identified in 25% of the study echocardiograms, with 11% of all studies demonstrating pathology that could alter patient management (moderate or severe pathology). The studies performed in the PICU and ED had more severe pathology compared with those from the general floor (P < .001, .003; respectively). Few echocardiograms were performed for rarely appropriate indications on the general floor (7%) and PICU (2.2%). Over 75% of general floor echocardiograms performed for a pathologic murmur yielded normal or incidental findings. Cardiology consultation was documented in only 7.5% of general floor studies. CONCLUSION The diagnostic yield of inpatient, first-time pediatric echocardiograms is relatively low. The majority of studies that identified pathology were performed on patients located in higher acuity units. General floor echocardiograms for murmurs had a low diagnostic yield, raising the question of cardiology consultation versus direct echocardiogram ordering for subjective physical exam signs.

Older Age at Completion of Fontan Procedure Is Associated with Improved Percentage of Predicted Maximum Oxygen Uptake

We tested the hypothesis that later completion of the Fontan procedure is associated with improved exercise capacity in the current period of staged single-ventricle palliation. We performed a retrospective study, in Fontan patients, of exercise stress test data from April 2003 through March 2011. Patients were included if they had received staged palliations in accordance with current surgical strategy, defined as the performance of a superior cavopulmonary connection at ≤1 year of age, followed in subsequent years by Fontan completion. Patients with a pacemaker or respiratory exchange ratio <1 were excluded. Early and late Fontan groups were created on the basis of whether Fontan completion had been performed at <4 or ≥ 4 years of age. The primary predictor variable was age at Fontan completion, and the primary marker of exercise performance was the percentage of predicted maximum oxygen consumption. During the study period, 55 patients were identified (mean age, 11.7 ± 2.8 yr). Older age at Fontan completion correlated positively with higher percentages of predicted maximum oxygen consumption (R=0.286, P=0.034). Patients in whom Fontan completion was performed at ≥4 years of age had higher percentages of predicted maximum oxygen consumption than did those in whom completion was at <4 years of age (84.4 ± 21.5 vs 72.9 ± 18.1; P=0.041). Later Fontan completion might be associated with improved exercise capacity in patients palliated in accordance with contemporary surgical strategy.

Takayasu Arteritis Presenting as Severe Ascending Aortic Arch Dilation and Aortic Regurgitation in a 10-Year-Old Female

Takayasu arteritis (TA) is a large-vessel arteritis affecting the aorta and its major branches. It is a rare disease in children less than 10 years old, and its diagnosis is frequently delayed, likely because of TAs rarity and nonspecific symptoms early in the disease. Females are affected disproportionately, with a female to male ratio of 8.5 to 1. Recently, the European League against Rheumatism published an international consensus statement for making the diagnosis of childhood TA. Criteria include angiographic abnormalities of the aorta and/or its branches, pulse deficit or claudication, blood pressure discrepancy, bruits, hypertension, and elevated acute phase reactants. We described a 10-year-old female with severe TA of the ascending aorta and who presented with classic signs and symptoms of this rare disease.

Cardiac time intervals derived by magnetocardiography in fetuses exposed to pregnancy hypertension syndromes.

Objective:To test the hypothesis that fetuses exposed to maternal preeclampsia or chronic hypertension have deranged development of cardiac time intervals.Study Design:Pregnancies were divided into three groups: Intrauterine Growth Restricted (IUGR), Hypertensive, and Normal. Each group’s mean fetal cardiac time intervals (P, PR, QRS and RR) derived by magnetocardiography were calculated using an analysis of covariance model’s regression-adjusted estimates for a gestational age of 35 weeks.Results:We reviewed 141 recordings from 21 IUGR, 46 Hypertensive and 74 Normal patients. The IUGR, Hypertensive and Normal groups, respectively, had adjusted mean intervals in milliseconds of 66.4, 66.8 and 76.2 for P (P=0.001), 95.9, 101.6 and 109.6 for PR (P=0.002), 77.2, 78.7 and 78.7 for QRS (P=0.81) and 429.8, 429.2 and 428.5 for RR (P=0.97).Conclusion:P and PR intervals are abbreviated in normotrophic fetuses exposed to maternal hypertension, suggesting shortened atrioventricular conduction times.

A review of sensitivity, specificity, and likelihood ratios: evaluating the utility of the electrocardiogram as a screening tool in hypertrophic cardiomyopathy.

Appropriate interpretation of a screening tests validity poses a challenge to the clinician. The purpose of this review is to revisit the terms sensitivity, specificity, likelihood ratio, and pre- and posttest probability and their application to the clinical setting. For illustration, we use a recently published article in the American Journal of Cardiology that investigates the false negative rate of electrocardiograms in athletic preparticipation screening for hypertrophic cardiomyopathy.

Teaching pediatric cardiology with meaning and sense

Pediatric cardiologists teach complicated concepts to a diverse group of learners that include medical students, nurses, residents, fellows, patients, and parents. Unfortunately, much of what is taught is not retained. In order to increase the likelihood of long-term retention, a cardiologist should teach with both meaning and sense. The authors provide a review of these concepts and give specific examples of how to teach in ways that both make sense and are meaningful to a cardiologists leaners.

Unsupervised free-breathing 3D imaging of morphology, function and flow in congenital heart disease

Methods Five patients with CHD were included in this pilot study. The MR studies were performed on a Philips Acheiva 1.5T magnet using a multielement phased array coil with the following sequences in this order: 1. Free-breathing, respiratory synchronized [1], time-resolved MRA following injection of 0.03 mmol/kg of Gadofosveset, and injection rate 2-4cc/second using a power injector. Duration: < 1 minute 2. Free breathing equilibrium phase MRA, acquired voxel size 0.8 × 0.8 × 1.6 mm, 2 NEX. Duration: 2.5-4 minutes 3. Free breathing 3D cine SSFP with respiratory triggering (TR/TE/flip angle: 3/1.5/60; acquired voxel size: 1.5-1.9 × 1.5-2.1 × 7-8 mm3; SENSE acceleration factor: 1.5-2 × 1.5-2; temporal resolution: 30-45 ms). Duration: 4.5-7 minutes 4. Free breathing sagittal 4D phase contrast (PC) imaging with respiratory navigator (18-26 phases/cardiac cycle, Venc 150 cm/sec, spatial resolution 1.6-2.8 mm3.) Duration: 6-12 minutes 5. Free breathing 3D SSFP with respiratory navigator. (acquired voxel size 1 × 1 × 2 mm3) Duration: 5-7 minutes Comparative data was obtained using conventional 2D cine respiratory triggered SSFP sequences (2) in the VLA, 4 chamber and short axis planes, and 2D PC imaging. Data Analysis: Image quality assessment and quantitative volumetric and flow analysis was performed by a single blinded user. MRA images were graded using a semi-quantitative scale from 1-5 for relevant imaging targets in CHD [1], with 1: excellent, no limitations, and 5: non-diagnostic. The clinical scoring system for 2D and 3D cine SSFP was based on blood-myocardial contrast, endocardial edge definition and inter-slice alignment[2]. Paired t-test analysis was performed on LV and RV volumes.

Transcatheter Versus Surgical Pulmonary Valve Replacement in Repaired Tetralogy of Fallot

Transcatheter pulmonary valve replacement (TC-PVR) is an alternative to surgical PVR (S-PVR) in repaired Tetralogy of Fallot (TOF). The purpose of this study is to compare in-hospital outcomes, hospital costs, and projected 5-year total costs of S-PVR to TC-PVR in patients with repaired TOF. We performed a multicenter, retrospective cohort study of children and adults with TOF ≥ 8 years of age who underwent PVR from January 1, 2010 to December 31, 2016 at 46 centers contributing to the Pediatric Health Information Systems database. Baseline characteristics, in-hospital outcomes, and costs were compared between the two groups. Projected 5-year costs were calculated by combining cost data with published reintervention rates. A total of 194 TC-PVR and 1,072 S-PVR were performed. The baseline characteristics of the TC-PVR and S-PVR groups were not significantly different with the exception of greater age in the TC-PVR group (median age of 17 years vs 15 years, p value <0.001). Discharge mortality, hospital charges and estimated cost, surgical complication rates, and acute kidney failure were not significantly different between the groups. Intensive care unit use, intensive care unit length of stay (LOS), mechanical ventilation use, extracorporeal membrane oxygenation use, and total LOS were lower with TC-PVR than S-PVR. Projected 5-year costs were greater with TC-PVR compared with S-PVR (

Unsupervised free-breathing 3-dimensional imaging of morphology, function and flow in congenital heart disease under 30 minutes: pilot study

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