Gaurav Arora

Risk Stratification in Wolff‐Parkinson‐White Syndrome: The Correlation Between Noninvasive and Invasive Testing in Pediatric Patients

Background: In Wolff‐Parkinson‐White (WPW) syndrome, rapid antegrade conduction of atrial tachyarrhythmias can result in ventricular fibrillation and sudden death. Antegrade conduction can be assessed through noninvasive testing or invasive electrophysiology study (EPS). We aimed to determine the correlation between noninvasive testing and EPS in a pediatric WPW population.

Cost-Effectiveness of Implantable Cardioverter-Defibrillators in Children With Dilated Cardiomyopathy

BACKGROUND Implantable cardioverter-defibrillators (ICDs) improve survival and are cost-effective in adults with poor left ventricular function. Because of differences in heart failure etiology, sudden death rates, and ICD complication rates, these findings may not be applicable to children. METHODS AND RESULTS We developed a Markov model to compare typical management of childhood dilated cardiomyopathy with symptomatic heart failure to prophylactic ICD implantation plus typical management. Model costs included costs of outpatient care, medications, complications, and transplantation. Time horizon was up to 20 years from model entry. Total costs were

Formation of Ventricular Aneurysm After Endocarditis in a Child With Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia

433,000 (ICD strategy) and

Adenosine-sensitive Wolff-Parkinson-White: Longer time across the atrioventricular groove

355,000 (typical management). Although quality adjusted survival was greater in the ICD group (6.78 versus 6.43 quality adjusted life-years [QALY]), the incremental cost-utility ratio was

Use of three-dimensional mapping in young patients decreases radiation exposure even without a goal of zero fluoroscopy.

281,622/QALY saved with the ICD strategy. In sensitivity analyses, the ICD strategy cost less than the

Resource utilization at the time of prostacyclin initiation in children in pulmonary arterial hypertension: a multicenter analysis:

100,000/QALY benchmark for cost-effectiveness only when the annual probability of sudden death exceeded 13% or when strong, sustained benefits in quality of life from the ICD were assumed. CONCLUSIONS Prophylactic ICD use in children with dilated cardiomyopathy, poor ventricular function, and symptomatic heart failure does not appear to be cost-effective. This is likely due to lower sudden death rates in this population.

Paroxysmal complete atrioventricular block in pediatric heart transplant recipients following cardiac catheterization: A case series

A 3-year-old previously healthy girl was admitted with fever, leg pain, and refusal to ambulate after minor leg trauma. Her blood culture results at admission were positive for methicillin-resistant Staphylococcus aureus (MRSA), and her inflammatory markers were elevated: erythrocyte sedimentation rate (ESR), 59; C-reactive protein (CRP), 25. Broad-spectrum intravenous antibiotic coverage was initiated. Contrast-enhanced magnetic resonance imaging (MRI) showed extensive osteomyelitis of both lower extremities, bilateral hip septic arthritis, and multiple chest wall abscesses. On hospital day 9, a transthoracic echocardiogram exhibited vegetations near the tricuspid and mitral valves and coronary sinus (Fig. 1). On day 9, the first negative blood culture was obtained, and a follow-up echocardiogram on day 12 showed resolution of vegetations with concurrent improvement of inflammatory markers (ESR, 17). On day 22, the girl experienced high fever and elevated ESR (125), with continuing negative blood cultures. A follow-up echocardiogram showed a 1.3 9 2.3-cm posterior septal pseudoaneurysm in communication with the left ventricle (Fig. 2). To define the anatomic location of the aneurysm further, a contrast-enhanced cardiac MRI was performed, which showed a pear-shaped aneurysm at the posterior crux of the heart measuring 5.8 cm in length, 1.8 cm in width and 1.8 cm anteroposteriorly (Fig. 3). The operative findings during surgical repair on day 28 showed a contained left ventricular rupture just distal to the mitral valve annulus with fibropurulent material at the abscess site. The girl underwent surgical repair with placement of a ventricular septal patch. Postoperative echocardiograms showed no residual aneurysm. She was discharged home with resolution of her symptoms and improvement in her inflammatory markers (ESR, 21). A follow-up echocardiogram 21 months later was unchanged, and at this writing, the girl continues to be asymptomatic. Despite negative blood culture results and continued broad-spectrum antibiotics, our patient had progression of her cardiac findings with development of myocardial abscess. Her inflammatory markers closely corresponded to the disease course. Myocardial abscesses are uncommonly reported among children with a structurally normal heart and no prior evidence of congenital heart disease [2]. However, this lifethreatening complication of endocarditis requires early diagnosis and surgical repair [1]. One recent report showed pancarditis and formation of a ventricular septal abscess associated with staph bacteremia that had good surgical repair in a pediatric patient [3]. According to our L. Gaur (&) Pediatric Cardiology, Children’s National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010, USA e-mail: lgaur@cnmc.org

Automated QT analysis on Holter monitors in pediatric patients can differentiate long QT syndrome from controls

Successful ablation sites in Wolff‐Parkinson‐White syndrome (WPW) are characterized by short atrioventricular (AV) intervals. Approximately 15% of patients with WPW have adenosine‐sensitive accessory pathways (APs). We sought to determine if local AV intervals of adenosine‐sensitive APs are different from those of adenosine‐insensitive APs in patients with WPW.

Ventricular tachycardia in a child with diabetic ketoacidosis without heart disease.

At present, three-dimensional mapping is often used during cardiac ablations with an explicit goal of decreasing radiation exposure; three-dimensional mapping was introduced in our institution in 2007, but not specifically to decrease fluoroscopy time. We document fluoroscopy use and catheterisation times in this setting. Data were obtained retrospectively from patients who underwent ablation for atrioventricular nodal re-entrant tachycardia from January, 2004 to December, 2011. A total of 93 patients were included in the study. Among them, 18 patients who underwent radiofrequency ablation without three-dimensional mapping were included in Group 1, 13 patients who underwent cryoablation without three-dimensional mapping were included in Group 2, and 62 patients who underwent cryoablation with three-dimensional mapping were included in Group 3. Mean fluoroscopy times differed significantly (34.3, 23.4, and 20.3 minutes, p<0.001) when all the groups were compared. Group 3 had a shorter average fluoroscopy time that did not reach significance when compared directly with Group 2 (p=0.29). An unadjusted linear regression model showed a progressive decrease in fluoroscopy time (p=0.002). Mean total catheterisation times differed significantly (180, 211, and 210 minutes, p=0.02) and were related to increased ablation times inherent to cryoablation techniques. Acute success was achieved in 89, 100, and 97% of patients (p=0.25), and chronic success was achieved in 80, 92, and 93% of patients (p=0.38). Complication rates were similar (17, 23, and 7%, p=0.14). In conclusion, three-dimensional mapping systems decrease fluoroscopy times even without an explicit goal of zero fluoroscopy. Efficacy and safety of the procedure have not changed.

RESOURCE UTILIZATION AT THE TIME OF PROSTACYCLIN INITIATION IN CHILDREN WITH PRIMARY PULMONARY HYPERTENSION: A MULTICENTER ANALYSIS

There are limited data investigating the epidemiology and resource utilization associated with parenteral prostacyclin use in children. We sought to examine national trends in treatment practices and resource utilization during prostacyclin initiation for pulmonary arterial hypertension (PAH) at children’s hospitals in the United States. Patients with PAH initiated on parenteral epoprostenol and treprostinil (2004–2014) were identified using a nationwide administrative database. Demographics, clinical characteristics, and resource utilization were compared between epoprostenol and treprostinil groups. Costs were indexed in 2014 US dollars. Among 1448 children admitted with a primary or secondary diagnosis of PAH, 280 (19%) were initiated on parenteral prostacyclins (epoprostenol n = 195 and treprostinil n = 85). Epoprostenol predominated early (97% of initiations in 2005); however, treprostinil predominated recently (52–67% of initiations/year). Children initiated on treprostinil had shorter ICU stays (1 [IQR = 0–4] vs. 4 [0–10] days, P < 0.001), shorter total lengths of stay (4 [2–9] vs. 8 [4–18] days, P = 0.001), and lower in-hospital mortality (1 vs. 12%, P = 0.001) with no difference in 30-day (13 vs. 19%, P = 0.19) or one-year readmission rates (56 vs. 61%, P = 0.41). Inpatient costs were lower for treprostinil initiation (