The Pulse – July 2019

The Pulse is a summary of relevant news and articles for Congenital Heart Professionals and highlights:

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Featured Science

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Featured Science

Congenital Heart Anesthesia and Intensive Care Featured Science 

Anesthesia for high-risk procedures in the catheterization laboratory.

Daaboul DG, DiNardo JA, Nasr VG.

Paediatr Anaesth. 2018 Dec 28. doi: 10.1111/pan.13571. [Epub ahead of print]

PMID: 30592354

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Take Home Points: Commentary by Laura A. Downey, a pediatric cardiac anesthesiologist at Children’s Healthcare of Atlanta/Emory University:

  • While reported adverse events in the catheterization lab range between 4-10%, the prevalence of adverse events (4.2%) and all cause-mortality (12%) during the hospital stay is highest for neonates. In addition to the risk of the procedure itself, young age, pulmonary artery hypertension, diastolic dysfunction, low cardiac-output, cyanosis, and low mixed venous saturation may further increase the risk.
  • Safe induction and maintenance of general anesthesia for high-risk cardiac catheterization require an understanding of the pathophysiology of each disease process, the planned procedure, its impact on the hemodynamics, the impact of the various anesthetic and pharmacologic interventions as well as experienced personnel and good communication between team members.

 

Positive Airway Pressure Versus High-Flow Nasal Cannula for Prevention of Extubation Failure in Infants After Congenital Heart Surgery.

Richter RP, Alten JA, King RW, Gans AD, Rahman AF, Kalra Y, Borasino S.

Pediatr Crit Care Med. 2019 Feb;20(2):149-157. doi: 10.1097/PCC.0000000000001783.

PMID: 30407954

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Take Home Points: Commentary from Dr. Sana Ullah, a pediatric cardiac anesthesiologist at UT Southwestern Medical Center in Dallas, Texas: 

  • Prevention of post-extubation failure after congenital cardiac surgery in neonates and infants should be a high priority as it is associated with significant morbidity and mortality.
  •   The optimal strategy for mitigating post-extubation failure [high flow nasal cannula (HFNC) versus non-invasive positive airway pressure (PAP)ventilation] is not well established.
  •  In this retrospective, single institution, propensity score matched cohort study comparing extubation to HFNC versus PAP, there was no difference in post-extubation failure rates. However, extubation to PAP was associated with greater resource utilization, longer times to transition to low-flow nasal cannula and then room air, and longer postsurgical hospital stay.

High-energy nutrition in paediatric cardiac critical care patients: a randomized controlled trial.

Zhang H, Gu Y, Mi Y, Jin Y, Fu W, Latour JM.

Nurs Crit Care. 2019 Mar;24(2):97-102. doi: 10.1111/nicc.12400. Epub 2018 Dec 9.

PMID: 30548121

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Take Home Points: Commentary from Dr. Anne Elisa Cossu, a practicing pediatric cardiac anesthesiologist at Riley Hospital for Children in Indianapolis, IN:

  • Infants with congenital heart disease are at high risk for malnutrition. The immediate postoperative period can worsen malnutrition and increase mortality in infants and children due to increased energy requirements, inadequate calorie intake, intestinal malabsorption, and fluid restriction.
  •  This study was aimed at assessing efficacy and safety of feeding high-energy formula (HF) to infants with congenital heart disease in the early postoperative period after cardiac surgery. The authors found that infants fed HF gained more weight but had higher rates of feeding intolerance. Feeding intolerance was relieved with medication and did not deter feed advancement.

 

Pediatric Cardiology Featured Science 

Non-invasive Hemodynamic CMR Parameters Predicting Maximal Exercise Capacity in 54 Patients with Ebstein’s Anomaly.

Meierhofer C, Kühn A, Müller J, Shehu N, Hager A, Martinoff S, Stern H, Ewert P, Vogt M.

Pediatr Cardiol. 2019 Apr;40(4):792-798. doi: 10.1007/s00246-019-02066-7. Epub 2019 Feb 6.

PMID: 30726509

Shelby White

Take Home Points: Comment from Dr. Shelby White (Tucson AZ), section editor of Pediatric Cardiology Journal Watch:

  • Exercise capacity is used to prognosticate in patients with Ebstein’s anomaly (EA) and cardiac magnetic resonance (CMR) is used to assess volumetric and functional parameters.
  • Functional parameters measured by CMR have been shown to correlate with exercise capacity and can be used in follow-up for patients with EA, possibly to predict the need for surgical intervention prior to development of symptoms

 

Congenital Heart Surgery Featured Science

Extracorporeal membrane oxygenation use in the first 24 hours following pediatric heart transplantation: Incidence, risk factors, and outcomes.

Godown J, Bearl DW, Thurm C, Hall M, Feingold B, Soslow JH, Mettler BA, Smith AH, Profita EL, Singh TP, Dodd DA.

Pediatr Transplant. 2019 Apr 11:e13414. doi: 10.1111/petr.13414. [Epub ahead of print]

PMID: 30973190

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Take Home Points: Commentary from Dr. Timothy Pirolli (Dallas), section editor of Congenital Heart Surgery Journal Watch: 

  • Primary graft dysfunction (requiring ECMO) after pediatric heart transplant is not uncommon and can lead to significant morbidity or mortality.
  •     This retrospective study was designed using large administrative databases to find the incidence of, risk factors for, and outcomes of primary graft dysfunction and ECMO utilization after heart transplant. The results indicate that primary dysfunction is not rare (7.9% of transplants) and that outcomes are strongly associated with the duration of ECMO.

 

ACHD Featured Science (sponsored by ISACHD)

Exercise Capacity After Repair of Ebstein Anomaly in Adults.

Morrical BD, Dearani JA, Bonnichsen CR, Taggart NW.

Pediatr Cardiol. 2019 Apr;40(4):726-732. doi: 10.1007/s00246-019-02056-9. Epub 2019 Jan 30.

PMID: 30701277

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Take Home Points: Commentary by Dr. Blanche Cupido (Cape Town), section editor of ACHD Journal Watch: 

  • Most patients reported symptomatic improvement after surgical repair of Ebstein anomaly – as assessed by NYHA class and self-reported symptoms.
  •    Formal exercise testing did not reveal objective evidence of functional improvement.
  •   Echo parameters showed improvement in terms of the degree of TR and RV size.
  •   Those on betablockers at ANY time had a reduced exercise capacity as measured by METs and VO2max.

 

Heart or heart-lung transplantation for patients with congenital heart disease in England.

Dimopoulos K, Muthiah K, Alonso-Gonzalez R, Banner NR, Wort SJ, Swan L, Constantine AH, Gatzoulis MA, Diller GP, Kempny A.

Heart. 2019 Apr;105(8):596-602. doi: 10.1136/heartjnl-2018-313984. Epub 2019 Jan 12.

PMID: 30636220

Take Home Points: Commentary by Dr. Damien Cullington (Liverpool, UK), section editor of ACHD Journal Watch: 

  •   Retrospective analysis of patients with congenital heart disease who underwent heart or heart-lung transplantation between 1997-2015 in England, UK.
  •     Over an 18 year period, in 444 patients, there were 469 transplants – 83% heart and the remainder heart-lung.
  •     The majority of first heart or heart lung transplants were performed in patients <18 yrs. old (53%). The median age at transplantation was 19.5 years (range 0-63.6 years)
  •     Just over half of all transplants (54%, n=239) were in patents with complex congenital heart disease.
  •     Of patients undergoing heart-lung transplantation, 92% had complex congenital heart disease. Comparatively, of those patients undergoing heart transplant alone, 46% were complex and the remainder mild or moderate.
  •     Older age and heart-lung transplant were strong predictors of death.
  •     Although there is an increasing need for transplantation in the congenital cardiac population there is a supply-demand mismatch, which is ever widening.

 

Congenital Heart and Pediatric EP Featured Science 

Catheter Ablation for Atrial Tachycardia in Adults With Congenital Heart Disease: Electrophysiological Predictors of Acute Procedural Success and Post-Procedure Atrial Tachycardia Recurrence.

Grubb CS, Lewis M, Whang W, Biviano A, Hickey K, Rosenbaum M, Garan H.

JACC Clin Electrophysiol. 2019 Apr;5(4):438-447. doi: 10.1016/j.jacep.2018.10.011. Epub 2019 Jan 30.

PMID: 31000097 Free Article

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Take Home Points: Comment from Dr. Akash Patel (San Francisco), section editor of Congenital Electrophysiology Journal Watch

 

  •     Atrial tachycardia is a common complication in adults with congenital heart disease leading to increased morbidity and mortality.
  •     The majority of atrial tachycardia is macro reentrant (93%) followed by focal (7%).
  •     Nearly half (45%) had typical cavo-tricuspid isthmus (CTI) flutter.
  •     Acute procedural success for CTI dependent flutter was high at 98.4% but success for > 1 arrhythmia mechanism or a single complex mechanism was only 80%.
  •     Only a single arrhythmia mechanism was associated with acute procedural success
  •     Recurrence after the first ablation procedure was common (44%) with a median time to recurrence of ~4 years. Recurrence after the second procedure was common (55%) with a median time to recurrence of ~4.7 years.
  •     Recurrence was often due to different atrial tachycardia (52%).
  •     Presence of prior maze and failed initial procedure were associated with recurrence of atrial tachycardia .
  •   Improvements in surgical and catheter-based ablation will likely improve acute and long-term outcomes in ACHD patients but there may be a continued need for repeat procedures to disease evolution over time.

 

ACHA Webinars for Patients and Families

Neurocognitive Issues in Adults with Congenital Heart Disease         

Wednesday, July 17, 2019, 7 p.m. – 8 p.m. EDT

Presented by Scott Klewer, MD

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On behalf of the CHiP Network, thank you for reading!
Sincerely,

Gary Webb, MD
CHiP Network