Russell R. Cross

Echocardiographic Evaluation of Umbilical Venous Catheter Placement

OBJECTIVE: To compare techniques for guiding and confirming placement of umbilical venous catheters (UVCs) using two-dimensional echocardiography.STUDY DESIGN: Fifty-three newborns admitted to our neonatal intensive care unit who required an UVC or who were transferred within 24 hours of UVC placement at a referring hospital were studied. UVC position was assessed by antero-posterior (AP) chest radiography (CXR), lateral CXR, and oxygenation data. The accuracy of the above techniques was compared to echocardiography with saline contrast injection.RESULTS: Echocardiography revealed that UVCs were located ideally at the right atrial/inferior vena cava junction in only 12 (23%) of 53 patients. Twenty-four (45%) were incorrectly positioned in the left atrium. The sensitivity and specificity of AP CXR in evaluating inappropriate UVC position were 32% and 89%, respectively. Lateral CXR and thoracic level on AP CXR did not predict accurately catheter position. UVC pO2 data were not useful in excluding left atrial placement.CONCLUSION: Current methods to determine insertion length and confirm location of UVCs are not adequate. Echocardiography should be considered to confirm correct placement of UVCs.

Health Policy StatementACCF 2012 Health Policy Statement on Patient-Centered Care in Cardiovascular Medicine: A Report of the American College of Cardiology Foundation Clinical Quality Committee

Joseph P. Drozda, Jr, MD, FACC, Chair Joseph G. Cacchione, MD, FACC Blair D. Erb, Jr, MD, FACC Robert A. Harrington, MD, FACC Jerry D. Kennett, MD, FACC Harlan M. Krumholz, MD, SM, FACC Frederick A. Masoudi, MD, MSPH, FACC Eric D. Peterson, MD, MPH, FACC Athena Poppas, MD, FACC David J.

High rate of coronary artery abnormalities in adolescents and young adults infected with human immunodeficiency virus early in life.

We completed a cross-sectional study of individuals infected with human immunodeficiency virus in early childhood using cardiac magnetic resonance imaging and magnetic resonance angiography. Coronary artery abnormality (CAA) was defined by the presence of luminal narrowing and irregularity of the coronary vessel wall. More than 50% of participants (14/27) had evidence of CAA. Individuals had a high rate of CAA, suggesting possible early atherosclerosis.

Abnormal Cardiac Strain in Children and Young Adults with HIV Acquired in Early Life

BACKGROUND Traditional measures of cardiac function are now often normal in adolescents and young adults treated with antiretroviral therapy for human immunodeficiency virus (HIV) infection. There is, however, evidence of myocardial abnormalities in adults with HIV. Cardiac strain analysis may detect impairment in cardiac function that may be missed by conventional measurements in this population. METHODS This was a retrospective study in which echocardiograms of HIV-infected subjects (n = 28) aged 7 to 29 years who participate in a natural history study of HIV acquired early in life were analyzed and compared with matched controls. Standard echocardiographic measures, along with speckle tracking-derived strain and strain rate, were assessed. RESULTS Among the HIV-infected subjects, the median CD4 count was 667 cells/mm(3), and the mean duration of antiretroviral therapy was 14.6 years. Ejection fractions and fractional shortening were normal. There were no significant differences in measures of systolic or diastolic function between the groups. The HIV-infected group had borderline increased left ventricular mass indices. Global longitudinal and circumferential strain and strain rate, as well as global radial strain rate, were significantly impaired in the HIV-infected group compared with controls. There were no associations identified between left ventricular mass index or strain indices and current CD4 count, CD4 nadir, HIV viral load, or duration of antiretroviral therapy. CONCLUSIONS HIV-infected participants demonstrated impaired strain and strain rate despite having normal systolic function and ejection fractions. Strain and strain rate may prove to be prognostic factors for long-term myocardial dysfunction. Therefore, asymptomatic children and young adults with long-standing HIV infection may benefit from these more sensitive measures.

Impact of pharmacotherapy on interstage mortality and weight gain in children with single ventricle.

OBJECTIVE.: Infants with single ventricle physiology have a high mortality and poor somatic growth during the interstage period. We retrospectively assessed the impact of pharmacotherapy in this population using a multicenter database. DESIGN AND RESULTS.: Records for 395 patients (63.5% boys) with single ventricle were obtained from the National Pediatric Cardiology Quality Improvement Collaborative registry. Median of five medications were prescribed per patient at discharge after stage 1 palliation (interquartile range 3 to 6); the most common medications being aspirin (95.7%), diuretics (90.4%), angiotensin convertase enzyme inhibitors (37.7%), proton pump inhibitors (33.4%), H2 receptor blockers (30.6%), and digoxin (27.6%). Interstage mortality was 9.4%. Digoxin use was associated with lower risk of death (P =.03) on univariable analysis, however no single medication was an independent predictor on regression analysis. Change in weight-for-age z-score was studied as outcome of somatic growth with 36.3% patients showing a decrease during the interstage period. Total number of medications prescribed to a patient showed a negative correlation with the interstage change in z-score (r = -0.19, P =.002). On univariable comparisons, use of metoclopramide and lansoprazole were associated with decreased z-score (P =.004 and.041, respectively) although linear regression failed to identify any agent as independent predictor. CONCLUSIONS.: Children with single ventricle have high mortality and a profound medication burden. No individual medication is independently associated with better survival or weight gain during interstage period. Despite widespread use, proton pump inhibitors and prokinetic agents are not associated with better outcomes and may be associated with poor growth.

Single-ventricle palliation for high-risk neonates: examining the feasibility of an automated home monitoring system after stage I palliation.

Strategies to reduce interstage morbidity and mortality for patients with single ventricle following stage I palliation include, standardized care protocols, focused high-risk outpatient clinics, dedicated teams that focus on the unique needs of these fragile patients and use of home surveillance monitoring. Use of telemedicine devices for home monitoring has been shown to improve outcomes in adults. These devices allow for a more automated approach to home monitoring that have many advantages. We describe our program that utilizes a web-based telemedicine device to capture and transmit data from the homes of our patients during the interstage period. Our early data suggest that home telemedicine is feasible, provides a more systematic data review and analysis and supports the assertion that patients using home surveillance have significantly better nutritional status than those not using home monitoring.

Should Tricuspid Annuloplasty be Performed With Pulmonary Valve Replacement for Pulmonary Regurgitation in Repaired Tetralogy of Fallot

Indications for prophylactic tricuspid annuloplasty in patients with pulmonary regurgitation (PR) after tetralogy of Fallot (TOF) repair are unclear and often extrapolated from acquired functional tricuspid regurgitation (TR) data in adults, where despite correction of primary left heart pathology, progressive tricuspid annular dilation is noted beyond a threshold diameter >4 cm (21 mm/m(2)). We hypothesized that unlike in adult functional TR, in pure volume-overload conditions such as patients with PR after TOF, the tricuspid valve size is likely to regress after pulmonary valve replacement (PVR). A total of 43 consecutive patients who underwent PVR from 2005 until 2012 at a single institution were retrospectively reviewed. Absolute and indexed tricuspid annulus diameters (TADs), tricuspid annulus Z-scores, grade of TR along with right ventricular size, and function indices were recorded before and after PVR. Preoperative and postoperative echocardiographic data were available in all patients. A higher tricuspid valve Z-score correlated with greater TR both preoperatively (P = 0.005) and postoperatively (P = 0.02). Overall reductions in the absolute and indexed TAD and tricuspid valve Z-scores were seen postoperatively, with greater absolute as well as percentage reduction seen with larger preoperative TAD index (P = 0.007) and higher tricuspid annulus Z-scores (P = 0.06). In pure volume-overload conditions such as patients with PR after TOF, reduction in the tricuspid valve size is seen after PVR. Concomitant tricuspid annuloplasty should not be considered based on tricuspid annular dilation alone.

Image Fusion Guided Device Closure of Left Ventricle to Right Atrium Shunt

A 16-year-old boy with a double-outlet right ventricle, D-malposed great vessels, and a subpulmonary ventricular septal defect status-post surgical ventricular septal defect patch closure and arterial switch procedure at 2 months of age, reported progressive exercise intolerance. He was found to have moderate right atrial enlargement, mild dilation of right and left ventricles, and a persistent residual left ventricle to right atrium (LV-RA) intracardiac shunt on echocardiographic assessment (similar physiology to a Gerbode-type defect; Figure A and Movie I in the online-only Data Supplement). Cardiac MRI delineated the LV-RA shunt (steady-state free precession cine; Figure B and Movie I in the online-only Data Supplement), with an estimated Qp:Qs of 1.4:1 (velocity-encoded MRI). Cardiac MRI–derived left-ventricular end-diastolic volume was 132 mL/m2 ( z score …

Mesalamine-induced myopericarditis in a paediatric patient with Crohn's disease.

Mesalamine-containing products are considered first-line treatment for inflammatory bowel disease. Myocarditis is recognised as a very rare possible side effect of these medications, but has not often been described in the paediatric population. We present a case of an adolescent with Crohns disease who presented with myopericarditis after recent initiation of Pentasa. Once identified as the causative agent, the drug was discontinued, with subsequent normalisation of troponin and improvement of function. This case identifies the importance of prompt evaluation, diagnosis, and treatment of paediatric patients receiving mesalamine-containing medications that present with significant cardiovascular symptoms.

Radiation-free CMR diagnostic heart catheterization in children

BackgroundChildren with heart disease may require repeated X-Ray cardiac catheterization procedures, are more radiosensitive, and more likely to survive to experience oncologic risks of medical radiation. Cardiovascular magnetic resonance (CMR) is radiation-free and offers information about structure, function, and perfusion but not hemodynamics. We intend to perform complete radiation-free diagnostic right heart catheterization entirely using CMR fluoroscopy guidance in an unselected cohort of pediatric patients; we report the feasibility and safety.MethodsWe performed 50 CMR fluoroscopy guided comprehensive transfemoral right heart catheterizations in 39 pediatric (12.7 ± 4.7 years) subjects referred for clinically indicated cardiac catheterization. CMR guided catheterizations were assessed by completion (success/failure), procedure time, and safety events (catheterization, anesthesia). Pre and post CMR body temperature was recorded. Concurrent invasive hemodynamic and diagnostic CMR data were collected.ResultsDuring a twenty-two month period (3/2015 – 12/2016), enrolled subjects had the following clinical indications: post-heart transplant 33%, shunt 28%, pulmonary hypertension 18%, cardiomyopathy 15%, valvular heart disease 3%, and other 3%. Radiation-free CMR guided right heart catheterization attempts were all successful using passive catheters. In two subjects with septal defects, right and left heart catheterization were performed. There were no complications. One subject had six such procedures. Most subjects (51%) had undergone multiple (5.5 ± 5) previous X-Ray cardiac catheterizations. Retained thoracic surgical or transcatheter implants (36%) did not preclude successful CMR fluoroscopy heart catheterization. During the procedure, two subjects were receiving vasopressor infusions at baseline because of poor cardiac function, and in ten procedures, multiple hemodynamic conditions were tested.ConclusionsComprehensive CMR fluoroscopy guided right heart catheterization was feasible and safe in this small cohort of pediatric subjects. This includes subjects with previous metallic implants, those requiring continuous vasopressor medication infusions, and those requiring pharmacologic provocation. Children requiring multiple, serial X-Ray cardiac catheterizations may benefit most from radiation sparing. This is a step toward wholly CMR guided diagnostic (right and left heart) cardiac catheterization and future CMR guided cardiac intervention.Trial registrationClinicalTrials.gov NCT02739087 registered February 17, 2016