Jessica Gorentz

Does Initial Shunt Type for the Norwood Procedure Affect Echocardiographic Measures of Cardiac Size and Function During Infancy? The Single Ventricle Reconstruction Trial

Background— The Pediatric Heart Network trial comparing outcomes in 549 infants with single right ventricle undergoing a Norwood procedure randomized to modified Blalock-Taussig shunt or right ventricle–pulmonary artery shunt (RVPAS) found better 1-year transplant-free survival in those who received RVPAS. We sought to compare the impact of shunt type on echocardiographic indices of cardiac size and function up to 14 months of age. Methods and Results— A core laboratory measured indices of cardiac size and function from protocol exams: early after Norwood procedure (age 22.5±13.4 days), before stage II procedure (age 4.8±1.8 months), and at 14 months (age 14.3±1.2 months). Mean right ventricular ejection fraction was <50% at all intervals for both groups and was higher in the RVPAS group after Norwood procedure (49±7% versus 44±8%; P<0.001) but was similar by 14 months. Tricuspid and neoaortic regurgitation, diastolic function, and pulmonary artery and arch dimensions were similar in the 2 groups at all intervals. Neoaortic annulus area (4.2±1.2 versus 4.9±1.2 cm2/m2), systolic ejection times (214.0±29.4 versus 231.3±28.6 ms), neoaortic flow (6.2±2.4 versus 9.4±3.4 L/min per square meter), and peak arch velocity (1.9±0.7 versus 2.2±0.7 m/s) were lower at both interstage examinations in the RVPAS compared with the modified Blalock-Taussig shunt group (P<0.001 for all), but all were similar at 14 months. Conclusions— Indices of cardiac size and function after the Norwood procedure are similar for modified Blalock-Taussig shunt and RVPAS by 14 months of age. Interstage differences between shunt types can likely be explained by the physiology created when the shunts are in place rather than by intrinsic differences in cardiac function. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00115934.

Digital Imaging, Archiving, and Structured Reporting in Pediatric Echocardiography: Impact on Laboratory Efficiency and Physician Communication

BACKGROUND Digital structured reporting (DSR) is an emerging technology in medical information management. In November of 2006, the pediatric echocardiography laboratory at Childrens Hospital of Wisconsin transitioned from transcription-based reporting of results to DSR. METHODS Transthoracic echocardiograms were reviewed for the study duration and time to report completion for October of 2006 (the last month of phone-based transcription) and January of 2007 (the third month of DSR). For both months, the 5 cardiologists responsible for echocardiography reporting were evaluated for report generation time and the 5 sonographers were evaluated for study duration. Data for physicians and sonographers were analyzed individually, as a group between months, between examination types (brief vs comprehensive), and diagnoses (normal vs abnormal findings). RESULTS The time to generate a final report to the electronic medical record/auto-fax to the referring physician for all examination types between months decreased significantly from the transcription month to the DSR month (median 23.8 vs 1.2 hours; P =.001). This decrease was consistent among physicians and occurred despite an increase in monthly echocardiography volume of 12% between the study periods. No difference was noted in report generation times between brief and comprehensive transthoracic echocardiography for transcription (P =.220) or DSR (P =.185). Analysis of diagnoses after instituting DSR revealed significantly shorter report generation time for normal examination findings versus abnormal examination findings (0.97 vs 1.5 hours; P =.001). Study duration decreased significantly from the transcription month to the DSR month for all examination types (32 vs 27 minutes; P =.001). For both months, the study duration was longer for abnormal versus normal transthoracic echocardiography findings (transcription: 37 vs 27 minutes; DSR: 32 vs 23 minutes). CONCLUSIONS DSR is a superior technology for pediatric echocardiography reporting and an important next step to increase efficiency and customer satisfaction. Although congenital heart disease increases DSR study report time, the value of digitally scripted, database-compatible, complete segmental analysis of the heart and vascular structures with direct transfer of quantitative data from the ultrasound machine to the report without the need for a transcription interface justifies the time expense. DSR should be a goal for all pediatric echocardiography laboratories to decrease consumer wait time, increase laboratory efficiency, and improve compliance with Intersocietal Commission for the Accreditation of Echocardiography Laboratories standards.