Ritu Sachdeva

Preemptive Gastrostomy Tube Placement after Norwood Operation

OBJECTIVEnBecause infants undergoing a Norwood operation have poor interstage weight gain, we hypothesized that preemptive gastrostomy tube (GT) placement would result in earlier discharge, improved growth, and higher survival to stage 2.nnnSTUDY DESIGNnRecords of 74 neonates who underwent a Norwood operation were reviewed until stage 2 palliation. The patients were divided into conventional (n = 43) and preemptive GT groups (n = 31). Data included demographics, cardiac surgery, feeding strategy, length of hospitalization, and mortality.nnnRESULTSnTransplant-free survival to stage 2 was significantly higher in the preemptive group, but there were no significant differences in survival to discharge after stage 1, length of hospitalization, and weight-for-age z-score at discharge and at stage 2 palliation. In the conventional group, 27 of 43 underwent GT placement, all via laparotomy, 23 with Nissen fundoplication. In the preemptive group, all underwent GT placement (21 laparoscopic, 10 laparotomy), 7 with Nissen fundoplication. A second gastric intervention was performed in 11 of 21 with laparoscopic GT (7 conversion to gastrojejunostomy tube, 4 Nissen fundoplication).nnnCONCLUSIONnPreemptive GT placement is associated with improved survival to stage 2 after a Norwood operation but not with shorter hospitalization or better growth. A thorough gastrointestinal evaluation must be performed before GT placement to avoid additional surgery.

Long-term outcomes of intraoperative pulmonary artery stent placement for congenital heart disease

Objective:Our objective was to examine long‐term outcomes of intraoperative pulmonary artery stents and determine risk factors for reintervention Background:Short‐term outcomes of intraoperative pulmonary artery stents have been reported previously. However, long‐term results are unknown. Methods: We conducted a retrospective review of patients who underwent intraoperative pulmonary artery stent placement for branch pulmonary artery stenosis. Results: Ninety‐six stents were implanted intraoperatively in 67 patients. Twenty‐seven patients received two or more stents at initial intervention. Median patient age at initial stent placement was 1.8 years. Median post‐inflation diameter was 8 mm. At a mean follow‐up of 7.6 ± 4.5 years, 49% of stents required reintervention (balloon angioplasty at catheterization in 28 patients and surgical revision in 19 patients). Actuarial freedom from reintervention at 2, 5, and 10 years was 68%, 49%, and 40%, respectively. In univariate analysis of time to first reintervention, age at implantation < 2 yrs (P < 0.0009) and initial post‐inflation stent diameter < 10 mm (P < 0.0002) were associated with risk for reintervention. Multivariable Cox regression analysis showed age < 2 years (P < 0.005) and diagnosis of tetralogy of Fallot (p < 0.002) or truncus arteriosus (P < 0.007) to be significant risk factors for reintervention. Conclusion: Intraoperative placement of stents in the pulmonary arteries is an alternative to surgical angioplasty, but is associated with a high incidence of reintervention. Age < 2 years and the diagnosis of tetralogy of Fallot or truncus arteriosus are risk factors for reintervention.

Doppler tissue imaging and catheter-derived measures are not independent predictors of rejection in pediatric heart transplant recipients

The purpose of the study is to determine the association of Doppler Tissue Imaging (DTI) and catheter-derived measures with rejection in pediatric heart transplant (PHT) recipients and to determine any correlation between DTI and catheter-derived measurements. Sixty echocardiograms were prospectively performed in 37 PHT recipients at the time of surveillance cardiac biopsy. During right-heart cardiac catheterization, sequential pressures of the right heart and pulmonary capillary wedge pressures (PCWP) were measured. DTI was performed to obtain peak systolic (S’), early (E’) and late (A’) diastolic velocities (cm/s) at tricuspid annulus, septum and mitral annulus. Septal S’ and tricuspid annular A’ were associated with rejection, but had low sensitivity and specificity. Elevated lateral mitral E/E’ did not predict rejection. The mean pulmonary capillary wedge pressure (PCWP) and cardiac index were similar in those with and without rejection. The lateral mitral and septal E/E’ did not correlate with PCWP. Some DTI-derived measures were altered during rejection, but were not clinically useful predictors of rejection. Catheter-derived measures were not significantly altered during rejection and did not correlate with DTI-derived measures. None of these measures can replace the current practice of performing cardiac biopsy for surveillance of rejection.

Stenting for superior vena cava obstruction in pediatric heart transplant recipients

Superior vena cava (SVC) obstruction can be a complication in heart transplant recipients. We reviewed our experience with relief of SVC obstruction using endovascular stents in pediatric heart transplant recipients.

Echocardiographic Evaluation of Ventricular Assist Devices in Pediatric Patients

BACKGROUNDnThe use of ventricular assist devices (VADs) in children is challenging because of small patient size, frequent structural heart disease, and the need for biventricular assist devices. This report describes the role of echocardiography in the management of children supported by VADs.nnnMETHODSnA retrospective review of the records of all pediatric patients who underwent VAD placement between May 2005 and May 2011 was performed to collect demographics, cardiac diagnoses, details of VADs, and transthoracic and transesophageal echocardiographic findings from the time of initial diagnosis until VAD explantation.nnnRESULTSnThe study included 32 patients (median age, 3 years; age range, 20 days to 16 years; median weight, 12.3 kg; weight range, 3.5-60 kg), 20 with left ventricular assist devices and 12 with biventricular assist devices. Diagnoses included dilated cardiomyopathy or myocarditis (n = 27) and congenital heart disease (n = 5). The median duration of support was 12 days (range, 1-141 days). Patients with decreased right ventricular function were 8 times more likely to undergo biventricular assist device placement compared with those with normal right ventricular function (P = .026). Pre-VAD intracardiac shunts were identified in 11 patients and intracardiac thrombus in one patient. Cardiac chamber dimensions and mitral insufficiency were significantly reduced after VAD implantation. Postimplantation pericardial effusions were recognized in 16 patients and pericardial hematomas in 12 patients.nnnCONCLUSIONSnEchocardiography is invaluable in the management of pediatric patients receiving VADs. It is helpful in pre-VAD assessment, guiding intraoperative device placement, recognizing VAD dysfunction, and identifying postimplantation complications.

A Novel Paradigm for Providing Improved Care to Chronic Patients in Cardiac Intensive Care Unit

OBJECTIVEnEvaluate the impact of chronic cardiac care team (CCCT) on hospital course of patients, their families, and nursing staff.nnnDESIGNnRetrospective observational study in children with hospital stay of ≥6 weeks in a pediatric cardiac intensive care unit (CICU) at a tertiary care childrens hospital. Before and after care, survey of the nurses and patients family was also performed.nnnRESULTSnThe CCCT provided care for 68 patients of which 44 survived to discharge. Median age at admission was 19 days (range 0-20.6 years); 18 (26%) were admitted at birth. Cardiac diagnosis included single ventricle in 27, heart failure/cardiac transplantation in 37, others in 6. The CCCT was involved in follow-up for vitamin and endocrine deficiencies, updating immunization status, optimizing nutritional intake, growth parameters, assess feeding issues, and providing end-of-life discussions in all those who died. One year after implementation, 85% nurses indicated improved understanding of patient problems, 57% reported improved working relationship with families, and 87% reported improved team communication. Family survey indicated that implementation of the model led to significantly improved opinion of parents in their ability to participate in the plan of care (28% vs. 70%, P = 0.019) and better relationship with the CICU staff caring for their child (57% vs. 100%, P = 0.008).nnnCONCLUSIONnThe CCCT provides a new team-based paradigm for improving continuity of care in chronic CICU patients by supplementing medical care and facilitates end-of-life discussions. The CCCT bridges communication gap between CICU staff and families.

Early Detection of Cardiac Dysfunction by Strain and Strain Rate Imaging in Children and Young Adults With Marfan Syndrome

Strain and strain rate imaging have been reported to detect cardiac dysfunction more accurately than conventional methods in adults with Marfan syndrome, but their utility has not been proven in younger patients. We sought to determine whether strain and strain rate imaging would allow early detection of cardiac dysfunction in children and young adults with Marfan syndrome.

Transesophageal doppler measurement of renal arterial blood flow velocities and Indices in children

BACKGROUND: Doppler-derived renal blood flow indices have been used to assess renal pathologies. However, transesophageal ultrasonography (TEE) has not been previously used to assess these renal variables in pediatric patients. In this study, we (a) assessed whether TEE allows adequate visualization of the renal parenchyma and renal artery, and (b) evaluated the concordance of TEE Doppler-derived renal blood flow measurements/indices compared with a standard transabdominal renal ultrasound (TAU) in children. METHODS: This prospective cohort study enrolled 28 healthy children between the ages of 1 and 17 years without known renal dysfunction who were undergoing atrial septal defect device closure in the cardiac catheterization laboratory. TEE was used to obtain Doppler renal artery blood velocities (peak systolic velocity, end-diastolic velocity, mean diastolic velocity, resistive index, and pulsatility index), and these values were compared with measurements obtained by TAU. Concordance correlation coefficient (CCC) was used to determine clinically significant agreement between the 2 methods. The Bland-Altman plots were used to determine whether these 2 methods agree sufficiently to be used interchangeably. Statistical significance was accepted at P ⩽ 0.05. RESULTS: Obtaining 2-dimensional images of kidney parenchyma and Doppler-derived measurements using TEE in children is feasible. There was statistically significant agreement between the 2 methods for all measurements. The CCC between the 2 imaging techniques was 0.91 for the pulsatility index and 0.66 for the resistive index. These coefficients were sensitive to outliers. When the highest and lowest data points were removed from the analysis, the CCC between the 2 imaging techniques was 0.62 for the pulsatility index and 0.50 for the resistive index. The 95% confidence interval (CI) for pulsatility index was 0.35 to 0.98 and for resistive index was 0.21 to 0.89. The Bland-Altman plots indicate good agreement between the 2 methods; for the pulsatility index, the limits of agreement were −0.80 to 0.53. The correlation of the size of the measurement and the mean difference in methods (−0.14; 95% CI = −0.28, 0.01) was not statistically significant (r = 0.31, P = 0.17). For the resistive index, the limits of agreement were −0.22 to 0.12. The correlation of the size of the measurement and the mean difference in methods (−0.05; 95% CI = −0.09, −0.01) was not statistically significant (r = 0.10, P = 0.65). CONCLUSION: This study confirms the feasibility of obtaining 2-dimensional images of kidney parenchyma and Doppler-derived measurements using TEE in children. Angle-independent TEE Doppler-derived indices show significant concordance with those derived by TAU. Further studies are required to assess whether this correlation holds true in the presence of renal pathology. This technique has the potential to help modulate intraoperative interventions based on their impact on renal variables and may prove helpful in the perioperative period for children at risk of acute kidney injury.

Tricuspid Annular and Septal Doppler Tissue Velocities Are Reduced in Pediatric Heart Transplant Recipients Without Acute Rejection

BACKGROUNDnWe sought to determine any differences between myocardial velocities in healthy children and pediatric heart transplant recipients without acute allograft rejection and to study the clinical factors that could alter these velocities.nnnMETHODSnFifty-eight pediatric heart transplant recipients without rejection and 27 healthy controls were prospectively enrolled. Doppler tissue imaging (DTI) was performed at the tricuspid annulus, septum, and mitral annulus. The influence of the following factors on DTI was assessed: time since transplant, extracorporeal membrane oxygenation, systemic hypertension, graft atherosclerosis, pulmonary hypertension, donor heart ischemic time, and previous rejection.nnnRESULTSnThe mean tricuspid annular and septal tissue velocities were significantly reduced in the transplant group compared with controls. The mitral annular velocities were similar in the two groups. Donor heart ischemic time and previous rejection significantly altered DTI velocities.nnnCONCLUSIONnTricuspid annular and septal Doppler tissue velocities are significantly reduced in pediatric heart transplant recipients without allograft rejection and can be altered by prolonged donor heart ischemic time and previous rejection.

Idiopathic giant right atrial aneurysm.

A 2-year-old boy with an incidental finding of massive cardiomegaly on a chest X-ray was diagnosed with a giant right atrial aneurysm upon further investigation with echocardiography. The patient underwent successful surgical reduction of the right atrium and closure of the patent foramen ovale to prevent thromboembolic complications and to lower the risk of atrial arrhythmias. The resected atrium had paper-thin walls and pathological features of interstitial fibrosis with endocardial thickening.