Canadian Pediatric Cardiology Association Research Articles

The Canadian Pediatric Cardiology Research Network: A Model National Data-Sharing Organization to Facilitate the Study of Pediatric Heart Diseases

BackgroundCommon hurdles to pediatric cardiology research include the heterogeneity and relative rarity of specific cardiac malformations, the potential for effect of residual lesions occurring decades after repair, and the scarcity of objective and easily measurable outcomes such as death and transplantation. MethodsTo help meet these challenges, the Canadian Pediatric Cardiology Research Network (CPCRN) was founded by the Canadian Pediatric Cardiology Association to link Canadian academic institutions to promote and facilitate multicollaborations for the benefit of pediatric and congenital cardiology research. The overarching goal of the CPCRN is to build a national framework that harnesses the strong desire for collaboration within the pediatric cardiology community and to identify solutions to barriers that impede multicentre partnerships. ResultsIn this report, the authors describe the approach and the components of the CPCRN. Specifically, we detail the rolling out of a pan-Canadian master agreement that covers current and future studies, the systematic banking of all project data, and the mechanisms developed to facilitate secondary use of data. ConclusionsThis experience could help guide the formation of other national research groups, particularly those focused on congenital or rare diseases.

Utility and Access to 3-Dimensional Printing in the Context of Congenital Heart Disease: An International Physician Survey Study

BackgroundThree-dimensional (3D) printing is a new technology capable of producing patient-specific 3D cardiac models. MethodsA cross-sectional survey of pediatric cardiologists was conducted. Members of the Canadian Pediatric Cardiology Association and Congenital Cardiac Interventional Study Consortium were invited to participate. A questionnaire was distributed using Research Electronic Data Capture between May and September 2019. Results were analyzed using descriptive statistics, Fisher exact test, and odds ratio. ResultsA total of 71 pediatric cardiologists responded. Some 85% (60/71) agreed that patient-specific 3D printed cardiac models are a beneficial tool in treating children with congenital heart disease (CHD); 80% of those (48/60) believe 3D models facilitate communication with colleagues; 49% (35/71) of respondents had access to 3D printing technology; and 77% (27/35) of those were using models for clinical care. Access differed according to geographic location (P = 0.004). Of respondents, Americans were 5.5 times more likely (confidence interval, 1.6-19.2) than Canadians to have access to 3D printing technology. The primary reason for lack of access was financial barriers (50%, 18/36). In clinical practice, surgical planning is the primary use of models (96%, 26/27), followed by interventional catheterization planning (52%, 14/27). Double outlet right ventricle was the most commonly modelled lesion (70%, 19/27). Conclusion3D printing is a new technology that is beneficial in the care of children with CHD. Access to 3D printing varies by geographic location. In pediatric cardiology, 3D models are primarily used for procedural planning for CHD lesions with complex 3D spatial relationships.

Pulse Oximetry.

Pulse Oximetry.

Recent Graduates Experience Difficulty in Finding Positions Despite Apparent Need for More Pediatric Cardiologists in Canada

There have been reports that pediatric cardiology is an increasingly competitive field and that it has become difficult for recent graduates to find employment. In Canada, empirical observations are consistent with these findings, but this has not been formally evaluated. The aim of this study was to survey pediatric cardiologists (PCs) on their perception of the current workforce in Canada. A survey was sent to PCs and trainee members of the Canadian Pediatric Cardiology Association in November 2017. Eligible nonmembers of the Canadian Pediatric Cardiology Association were also contacted with the help of Canadian program directors and division chiefs. A total of 68 of 83 PCs completed the survey (82%). The proportion of respondents reporting difficulties in finding a stable position in pediatric cardiology was 83% for those finishing training after 2014 compared with 33% between 2010 and 2014. There was a concomitant increase in the duration of additional subspecialization, which more than doubled after 2014. This contrasted with most PCs (57%) and division chiefs (86%) reporting being understaffed, and with a higher number of anticipated openings compared with available trainees. Division chiefs reporting being understaffed mostly attributed this to government regulations or institutional budgetary constraints. We observed a discrepancy between a perceived need for additional PCs and a reported increasing difficulty in finding employment by recent graduates. This coincided with an increasing number of additional subspecialization years by recent graduates. Institutional and government restrictions may contribute to this situation.

Practices and Attitudes of Canadian Cardiologists Caring for Patients With Trisomy 18

Trisomy 18 (T18) is a genetic disorder with cardiac lesions in up to 90% of patients. Cardiac surgery is not frequently offered because of the overall poor prognosis, although this has recently been challenged. Our study aimed to explore the practices and attitudes of Canadian pediatric cardiologists managing T18 patients. We administered a survey to pediatric cardiologists attending the Canadian Cardiovascular Congress, Canadian Pediatric Cardiology Association Business Meeting. There were 30 respondents. Most (67%) supported comfort care for affected patients with a heart lesion. None supported palliative surgery for those with complex heart lesions. Of 30 respondents, 16 (53%) counsel families prenatally, and none would present the option of a single ventricle surgical track for complex heart disease. In a hypothetical situation in which their own child was born with T18, 67% would choose comfort care with medical treatment of heart failure, and none would choose palliative surgery. Being a parent was associated with a higher likelihood of choosing termination (14 of 20 vs 6 of 9; P = 0.046) or comfort care (14 of 20 vs 6 of 9; P = 0.036). Qualitative data suggest support for comfort care, while recognizing the need for individualization and shared decision-making, within the context of institution-specific policies. Canadian pediatric cardiologists surveyed support comfort care and medical treatment but not surgical treatment for T18 patients with cardiac lesions. They place primacy on nonmaleficence, yet also recognize the emerging need for individualized shared decision-making in these cases.

49th Annual Meeting of the Association for European Paediatric and Congenital Cardiology, AEPC with joint sessions with the Japanese Society of Pediatric Cardiology and Cardiac Surgery, Asia-Pacific Pediatric Cardiology Society, European Association for Cardio-Thoracic Surgery and Canadian Pediatric Cardiology Association, Prague, Czech Republic, 20–23 May 2015

Background: This prospective study focuses on factors associated with arterial damage in children with type 1 diabetes (T1D). Materials and Methods: Eighty children and adolescents with T1D (mean age 15, range: 8-20 yrs; mean diabetes duration 7, range: 0.5 to 19 years) were investigated twice, approximately 2 years apart, for carotid artery intima-media thickness (cIMT) and compliance (CAC), flow-mediated dilatation (FMD) of the brachial artery, and plasma levels of matrix metalloproteinase (MMP)-8. HLA genotypes were determined in dried spots of peripheral blood by polymerase chain reaction followed by hybridization assay. The number of respiratory tract infections (RTI) during the past year was obtained by a questionnaire in 56 patients. Results: cIMT progression (% change of cIMT from baseline) correlated inversely with the % changes of both CAC (p = 0.04, r=−0.3, n=62) and FMD (p=0.03, r=−0.3, n=67). RTI frequency correlated significantly with cIMT progression irre- spective of age, diabetes duration, BMI, and HbA1c (p=0.03, r=0.3, in multivariate analysis). When patients were divided in relation to DQ2/8 genotype and RTI, the association of DQ2/8 with cIMT progression remained significant in patients with over three infections/year (p = 0.04, r = 0.3). During follow-up, the group of DQ2/8 patients with CRP > 1 mg/l showed significantly higher levels of plasma MMP-8 than the non-DQ2/8 group. Conclusions: Diabetes-risk genotype DQ2/8 and inflammation con- tribute to vascular changes in children and adolescents with T1D. (Less)

TRANSCATHETER AORTIC VALVE IMPLANTATION PROGRAM DEVELOPMENT: RISK STRATIFICATION AND CLINICAL PATHWAYS TO OPTIMIZE LENGTH OF STAY

BACKGROUND: Sustained transcatheter aortic valve implantation (TAVI) program success requires processes of care to support careful case selection, determine peri-procedural requirements, facilitate early recovery and decrease length of stay. The Vancouver Program initiated multidisciplinary and multimodality risk stratification to determine patients’ suitability for a transfemoral (TF) minimalist peri-procedural approach, and implemented risk-stratified clinical pathways to facilitate discharge and reduce length of stay. METHODS: Standardized and streamlined screening was implemented to conduct multimodality assessments, including cardiac catheterization, transthoracic echocardiography, computed tomography, functional assessment and medical consultations. Following multidisciplinary eligibility decision for TF TAVI by the Heart Team, additional risk stratification was discussed to determine individuals’ appropriateness for a peri-procedural minimalist approach and/or early discharge. Risk-stratified clinical pathways were developed to support the patient cohorts. RESULTS: In 2013, 144 consecutive patients were accepted for TF TAVI and assigned to risk-stratified protocols (see Table 1). The mean age was 82 7 years, with the proportion of women ranging from 37% to 42% in the four cohorts, and mean STS risk scores between 6.3 and 7.1. The burden of comorbidities and functional impairment was similar across groups. The overall in-hospital outcomes included 2.1% mortality, 0% myocardial infarction, 0.7% stroke, 2.1% life threatening bleeding, 0.7% new dialysis, and 4.2% conduction disturbances requiring a new permanent pacemaker. Risk-stratified outcomes are presented in Table 1. The median length of stay for all patients was 3 days (IQR 2-3), 2 days (IQR 1-3) in the Awake cohort and 2 (IQR 1-2) in the Early Discharge cohort; 95.8% of patients were discharged home. The 30-day all-cause hospital readmission rate was 11.1%, ranging from 7% and 8% in the Awake and Early Discharge cohorts respectively, to 13% in the GA/TEE and Regular Discharge cohorts; no new deaths occurred between discharge and 30 days. CONCLUSION: The refined understanding of TAVI risk profiles and their mitigation with improved case selection, imaging, procedural expertise and clinical pathways offer opportunities to improve outcomes while ensuring patient safety and the sustained success of TAVI programs. Early experience with TAVI risk stratification, individualized procedure planning and tailored clinical pathways supported by multimodality screening and multidisciplinary case selection and care results in excellent outcomes and optimized length of stay. Canadian Pediatric Cardiology Association (CPCA) Oral SURGERY AND INTERVENTIONAL CATHETERISM IN CONGENITAL HEART DISEASE Sunday, October 26, 2014

Auscultation: learning to listen

Tqeaching Heart Auscultation to Health Professionals: Methods for Improving the Practice of an Ancient but Critical Skill. John P. Finley, editor. Canadian Pediatric Cardiology Association; 2011 The stethoscope is perhaps the most recognizable totem of the modern-day physician. From its initial

Challenges for the Canadian Cardiovascular Society in the 1990s

During the 1990s, under the leadership of Dr Eldon R Smith, the first five-year strategic plan was created. Partly as a result of this plan, a review of the annual meeting of the Canadian Cardiovascular Society (CCS) was undertaken. I was fortunate enough to have been chosen to chair this review and the subsequent Annual Meeting Committee. The initial review revealed significant areas for improvement, including finances, location, partners, sponsors, threats and opportunities. Each issue was tackled systematically, with an emphasis on producing a high-quality learning and networking experience, eventually resulting in a joint partnership with the Heart and Stroke Foundation of Canada (HSFC) in creating the Canadian Cardiovascular Congress, which has since become the largest medical meeting in Canada. The success of the CCS annual general meeting and the Canadian Cardiovascular Congress resulted in significant revenue for the Society in the early years. Because of tax constraints, these residuals were placed in a separate charitable account, eventually morphing into the CCS Academy, and most recently, the CCS Foundation, whose focus is on recruiting and retaining outstanding young people into the clinical, teaching and research aspects of cardiovascular sciences. Bursaries are provided to support a number of young people each year to attend the Canadian Cardiovascular Congress and to support some other specific learning or research projects for the Society. During the 1990s, there was also an increasing emphasis on the need for evidence-based guidelines. The consensus conferences, ever-popular with members and nonmembers alike, became more focused on the evidence available for recommendations, and the consensus conferences became a regular feature of The Canadian Journal of Cardiology. For the first time in Canada, the issue of prevention and the role of the cardiovascular specialist in prevention were identified. The Harold N Segall Award of Merit was created and focused on prevention. Guidelines were created for adult congenital heart disease, as well as women and cardiovascular disease. Issues such as heart failure, atrial fibrillation, implantable cardiac defibrillators (and others) were analyzed from the Canadian perspective, and Canadian guidelines were created and disseminated. Also during this time, The Royal College of Physicians and Surgeons of Canada devolved specialty continuing professional development (CPD) to the specialty professional associations, and created CPD accreditation guidelines. The Society, which had always been strong in CPD, was the first of any specialty groups to be given accreditation assessor status, and created within the CCS a separate committee and staff position to further develop learning and knowledge translation capacity and opportunities for the Society. This too has spawned a trainee day at the congress, further support for adult cardiology and, now, pediatric cardiology fellowship examination review symposia on an annual basis. An award for the distinguished teacher was created to honour outstanding teachers in cardiovascular sciences and to complement the existing awards for research achievement and annual achievement awards. In addition, a new award for the paper with maximum impact for the preceding year was created: the Dr Robert E Beamish Award, which is supported by the Journal. Because of the focus on excellence and the recognition of excellence among the members of the cardiovascular community, the CCS partnered with the HSFC to create an awards reception. Others followed, including the Anemia Institute for Research and Education Award (supported by the Canadian Anesthesiologists’ Society), the Richard Rowe Research Prize (supported by the Canadian Pediatric Cardiology Association), the Dr Paul Cartier Cardiac Surgery Resident Research Award (supported by the Canadian Society of Cardiac Surgeons) and, of course, the many research awards sponsored by both the HSFC and Canadian Institutes of Health Research. The increasing activities of the Society have resulted in a more complex organization with an increasing staff, but also increasing membership and increasing visibility and political influence. The headquarters was relocated to Ottawa, Ontario, during this decade, and a full-time executive director was hired. There is no doubt that the CCS is viewed by other specialty associations as one of the premier professional specialty organizations in the country. Closer links were established with the American College of Cardiology, and the CCS began to play a more significant role in the InterAmerican Society of Cardiology, culminating in the InterAmerican Congress of Cardiology being held in Toronto, Ontario, hosted jointly by the CCS and the HSFC in 2001. In summary, the 1990s were, for the CCS, a ‘decade of doing’, and tribute should be given to the many members who freely gave their time and expertise to individual projects, manuscripts, research and organizational support and leadership. Without them, the Society would not be able to continue to focus on what members need to better serve their patients and on excellence in teaching and research.