Pediatric Cardiac Catheterization Procedures Research Articles

The effect of fluids flushed in pediatric cardiac catheterization procedures on lung ultrasound score

ABSTRACT Background Intravascular catheters used during cardiac catheterization require frequent flushing with heparinized solutions. Fluid overload is more common in pediatric patients with congenital heart diseases. This study aimed to determine the safe volume of fluids that can be used without congestion using the lung ultrasound score. Methodology A total of 42 patients aged from 1 month to 6 years undergoing diagnostic cardiac procedures were included in this study. The total volume of infused fluids, the volume of fluids used for flushing intravascular sheaths and catheters, the lung ultrasound score, and PaCO2 and PaO2 /FiO2 ratio were documented. Results There was a very strong positive relationship between the total fluid volume infused in ml/kg and the difference in the lung ultrasound score before and after fluid infusion (r = 0.841, P < 0.001). There was a very weak positive relationship between the total fluid volume infused in ml/kg and the difference in PaCO2 before and after fluid infusion (r = 0.217, P = 0.167). There was a weak negative relationship between the total fluid volume infused in ml/kg and the change in the PaO2 /FiO2 ratio (r = −0.21, P = 0.182). Conclusion A fluid flush volume of >11.3 ml/kg has a high probability of inducing volume load in pediatric patients undergoing cardiac catheterization. A flushing volume of 3.478 ml/kg affects the lung ultrasound score. Hence, we recommend reducing the volume of intravenous fluids if higher volumes are required for flushing.

The Perioperative Services Response at a Major Children's Hospital During the Peak of the COVID-19 Pandemic in New York City.

The Perioperative Services Response at a Major Children's Hospital During the Peak of the COVID-19 Pandemic in New York City.

Radiogenic risks to patients and staff from fluoro-assisted therapeutic cardiac catheterizations

Advances in sectional imaging have led to prolonged x-ray fluoro-assisted therapeutic cardiac catheterizations. Given the frequency of such procedures, limited data are available for patient and staff doses. For certain pediatric cardiac catheterization procedures we examine: (i) effective and organ doses, also the radiogenic and tissue reaction risks and; (ii) staff effective dose during cardiac interventions. At four cardiac catheterization centres, patient doses were measured with a calibrated kerma area product (KAP) meter; staff doses were measured using calibrated TLDs. The mean and range of age (years) and weight (kg) for patients were 4.3 (0.04–14.0) and 10.8 (3.0–46.0) respectively; the overall mean and range of fluoroscopic time (min) was 13.0 (1.4–54.8). For coronary angiography and pacemaker procedures the overall mean and range of cumulative kerma area product (CKAP, cGy.cm2) were 350 (12.0–510). The average annual staff dose of 9.0 (7.2–14.4) mSv is relatively low given the current workload. Some patients received high doses approaching the threshold for tissue reactions. Optimisation of radiation dose is required as is follow-up of patients receiving high doses to detect the possibility of tissue reactions.

Utility and Clinical Profile of Dexmedetomidine in Pediatric Cardiac Catheterization Procedures: A Matched Controlled Analysis.

Dexmedetomidine is increasingly used in children undergoing cardiac catheterization procedures. We compared the percentage of surgical time with hemodynamic instability and the incidence of postoperative agitation between pediatric cardiac catheterization patients who received dexmedetomidine infusion and those who did not and the incidence of postoperative agitation. We matched 653 pediatric patients scheduled for cardiac catheterization. Two separate multivariable linear mixed models were used to assess the association between dexmedetomidine use and intraoperative blood pressure and heart rate instability. A multivariate logistic regression was used for relationship between dexmedetomidine and postoperative agitation. No difference between the study groups was found in the duration of MAP ( P = .867) or heart rate (HR) instabilities ( P = .224). The relationship between dexmedetomidine use and the duration of negative hemodynamic effects does not depend on any of the considered CHD types (all P > .001) or intervention ( P = .453 for MAP and P = .023 for HR). No difference in postoperative agitation was found between the study groups ( P = .590). Our study demonstrated no benefit in using dexmedetomidine infusion compared with other general anesthesia techniques to maintain hemodynamic stability or decrease agitation in pediatric patients undergoing cardiac catheterization procedures.

Implementation of Methodology for Quality Improvement in Pediatric Cardiac Catheterization: A Multi-center Initiative by the Congenital Cardiac Catheterization Project on Outcomes-Quality Improvement (C3PO-QI).

The Congenital Cardiac Catheterization Project on Outcomes (C3PO) launched in 2007 as a multi-center collaborative to establish standardized and comparable metrics for pediatric cardiac catheterization procedures. The limitations of larger registries at the time led to the development of the next phase in 2013, C3PO-Quality Improvement (C3PO-QI), focusing on instituting QI initiatives within the field. The objective of this manuscript is to provide a detailed overview of C3PO-QI and report data on case characteristics and outcome metrics being explored. C3PO-QI was designed to cultivate institutional collaboration during implementation of its initiatives. A database and website were developed to support data entry and on-demand reporting. The registry prospectively captures pediatric cardiac catheterization data among 15 hospitals. The present study includes case demographic data (n) and quality metric reporting by case type, age, and radiation dose variables. This dataset includes 13,135 cases entered into the database between 1/1/2014 and 12/31/2015. Interventional cases make up the highest percentage by case mix distribution (48%), and patients <1years make up the highest percentage by age distribution (26%). The ratio of diagnostic and interventional procedures performed changes by age group. Application of QI metric shows all procedure types surpassing metric goals. Large volume data collection, such as in C3PO-QI, allows for meaningful interpretation of data. C3PO-QI is uniquely poised to deliver fast-paced changes in the field. Although the project initiatives are specific to pediatric cardiac catheterization, the implementation of the project and utilization of real-time reporting is generalizable to other specialties and multi-center collaboratives.

Informed consent in pediatric cardiology and cardiac surgery

A multidisciplinary study group was established to review and approve the informed consent froms in Pediatric Cardiology and Cardiac Surgery. The work was carried out in several stages, starting with an analysis of what was already in use in several Italian Centers. Subsequently, shared forms for pediatric cardiac surgery and interventional catheterization procedures were developed, pointing to clarity of information, prediction of therapeutic options, quantification for verbal categories of risk associated with cardiac surgery procedures, and provision of information also to young patients. Two versions of informed consent for pediatric cardiac surgery and pediatric interventional catheterization procedures were developed. The work oerformed by the multidisciplinary study group, under the supervision of the Italian Society of Pediatric Cardiology and the Section of Surgery for Congenital Heart Disease of the Italian Society for Cardiac Surgery, resulted in a clear and evolutionary summary of the relationship between available therapeutic options and the patient needs to understand and share the healthcare pathway in terms of risk and perspectives.

Characterization of MOSFET Dosimeter Angular Response Using a Spherical Phantom for Fluoroscopic Dosimetry.

Metal-Oxide Semiconductor Field-Effect Transistor (MOSFET) dosimeters, placed in anthropomorphic phantoms, are a standard method for organ dosimetry in medical x-ray imaging applications. However, many x-ray applications, particularly fluoroscopy procedures, use variable projection angles. During dosimetry, the MOSFET detector active area may not always be perpendicular to the x-ray beam. The goal of this study was to characterize the dosimeter's angular response in the fluoroscopic irradiation involved in pediatric cardiac catheterization procedures, during which a considerable amount of fluoroscopic x-ray irradiation is often applied from various projection angles. A biological x-ray irradiator was used to simulate the beam quality of a biplane fluoroscopy imaging system. A custom-designed acrylic spherical scatter phantom was fabricated to measure dosimeter response (in mV) in two rotational axes, axial (ψ) and normal-to-axial (θ), in 30° increments, as well as four common oblique angles used in cardiac catheterization: a) 90° Left Anterior Oblique (LAO); b) 70° LAO/ 20° Cranial; c) 20° LAO/ 15° Cranial; and d) 30° Right Anterior Oblique (RAO). All results were normalized to the angle where the dosimeter epoxy is perpendicular to the beam or the Posterior-Anterior projection angle in the clinical setup. The relative response in the axial rotation was isotropic (within ± 10% deviation); that in the normal-to-axial rotation was isotropic in all angles except the ψ = 270° angle, where the relative response was 83 ± 9%. No significant deviation in detector response was observed in the four common oblique angles, with their relative responses being: a) 102 ± 3%; b) 90 ± 3%; c) 92 ± 3%; and d) 95 ± 3%, respectively. These angular correction factors will be used in future dosimetry studies for fluoroscopy. The spherical phantom may be useful for other applications, as it allows the measurement of dosimeter response in virtually all angles in the 3-dimensional spherical coordinates.

CRISP: Catheterization RISk score for Pediatrics: A Report from the Congenital Cardiac Interventional Study Consortium (CCISC).

We sought to develop a scoring system that predicts the risk of serious adverse events (SAE's) for individual pediatric patients undergoing cardiac catheterization procedures. Systematic assessment of risk of SAE in pediatric catheterization can be challenging in view of a wide variation in procedure and patient complexity as well as rapidly evolving technology. A 10 component scoring system was originally developed based on expert consensus and review of the existing literature. Data from an international multi-institutional catheterization registry (CCISC) between 2008 and 2013 were used to validate this scoring system. In addition we used multivariate methods to further refine the original risk score to improve its predictive power of SAE's. Univariate analysis confirmed the strong correlation of each of the 10 components of the original risk score with SAE attributed to a pediatric cardiac catheterization (P < 0.001 for all variables). Multivariate analysis resulted in a modified risk score (CRISP) that corresponds to an increase in value of area under a receiver operating characteristic curve (AUC) from 0.715 to 0.741. The CRISP score predicts risk of occurrence of an SAE for individual patients undergoing pediatric cardiac catheterization procedures.

X-Ray Dose from Pediatric Cardiac Catheterization: A Comparison of Materials and Methods for Measurement or Calculation

Pediatric cardiac catheterization procedures have the potential to transmit high X-ray doses, which may lead to acute effects or latent skin reactions. Direct measurement of radiation dose was facilitated using nanodot dosimeters and radiochromic film. Direct measurement results were compared with vendor-listed dosimetry and calculation using phantom data. Vendor-listed data demonstrated a wide discrepancy with measured data, whereas the calculation reproducibly overestimated the actual dose. A simple formula was derived to calculate the dose using fluoroscopy time, cine frame quantity and average cine mA in a biplane environment.

34 Pediatric Interventional Catheterization: Development of a Risk Adjustment Model for Preventable Complications

Background: Development of a risk adjustment method is necessary to account for complexity of case mix in pediatric cardiac catheterization procedures so valid comparisons of outcomes can be determined. Methods: Using a prospective database, we identified patient and procedural characteristics predictive of preventable serious or somewhat serious complications. Creation of 2 diagnosis groups and 5 procedural risk groups allowed classification according to the complexity of the diagnosis and anticipated relative risk of the procedure. Hemodynamic vulnerability was determined by baseline characteristics. Significant variables that increased the area under the receiver operator characteristic (ROC) curve were chosen for the final model. Expected complication rates and standardized complication ratios (SCR) were then determined for individual practitioners. Results: Of 791 procedures, 26 (3.3%) had possibly or definitely preventable, serious or somewhat serious events. Event rates tended to increase as procedural risk category increased (0.5% in 1, 4.4% in 2, 4.2% in 3, 11.1% in 4, 8.0% in 5, p <0.001). Higher event rates were observed in younger patients (11.4% age < 1 month vs 2.9% 3 1 month, p<0.001) and those with physiologic vulnerability (4.7% vs 2.1%, p=0.04). These 3 factors remained independent predictors of higher event rate in multivariate analysis (area under ROC = 0.787). Among 7 cardiologists, significant case-mix differences were identified. Application of the risk adjustment yielded SCRs ranging from 0.5 to 1.7, and risk adjusted complication rates ranging from 1.6% to 5.6%. Although statistically significant differences in complication rates were not detected, there was a trend towards higher risk adjusted rates for less experienced interventionalists. Conclusions: Further development and future validation of this risk adjustment method for pediatric cardiac catheterization will allow valid assessment of risk-adjusted performance of both practitioners and institutions performing these complex procedures.

35 Adverse Event Rates for Pediatric Cardiac Catheterization Procedures: Identification of High-Risk Populations

Background: We sought to determine the rate of adverse events in pediatric cardiac catheterization procedures and determine patient and procedural characteristics predictive of events. Methods: A prospective database was created to record patient and procedural characteristics and adverse events. Procedures were grouped into 5 categories based on anticipated risk. Results: In 9 months, 791 procedures were performed and most involved at least one intervention (81%). Ages at procedures were: < 1 mo (4%); 1mo to 1 yr (16%); 1 to 2 yrs (14%); and > 3 yrs (66%). Procedures were electively scheduled in 78%. An indicator of vulnerable hemodynamics was present in 38% of cases including elevated pulmonary or right ventricular pressures > systemic, cyanosis (saturation <75%), or low CI (< 2.0 L/min/m2). The lowest anticipated procedural risk group comprised the largest proportion of procedures (group 1, 47%; 2, 32%; 3, 9%; 4, 9%; 5, 3%). At least 1 adverse event occurred in 22.8% of procedures: serious life threatening events (2%), events requiring significant intervention (6 %), and minor events (17 %). Adverse events were significantly more likely to occur in younger patients (37% < 3 yrs vs. 15% > 3yrs, p<0.001) and in those with an indicator of physiologic vulnerability (33% vs 14%, p <0.001). Adverse events were less common in outpatient procedures than inpatient and emergent procedures (8% vs 25% and 33%, p <0.001). Interventional procedures (25% vs 15%, p = 0.01) and higher procedural risk group were associated with increasing complication rates (11% in 1, 26% in 2, 39% in 3, 50% in 4, 44% in 5, p <0.001). Conclusion: These data provide current estimates of adverse event rates in pediatric catheterization and identify high risk patient and procedural characteristics.

Quantifying and Minimizing Radiation Exposure During Pediatric Cardiac Catheterization

This study reports findings from evaluations of new technologies to measure radiation exposure during pediatric cardiac catheterization procedures. A strategy of pulsed fluoroscopy and low power settings resulted in significantly lower patient radiation exposure compared to conventional 60 frames/sec, high-power settings during fluoroscopy. During radiofrequency ablation procedures, thyroid and thoracic skin sites outside the direct fluoroscopic field received minimal radiation exposure. Intrathoracic radiation exposure was measured with the use of an esophageal dosimeter. In conclusion, strategies to reduce total radiation exposure should be employed, radiation dose should be measured, and assessment of radiation skin injury should be included in post-catheterization assessment.

Use of miniature biplane transesophageal echocardiography during pediatric atrial catheter interventional procedures

We reported the use of a new miniature biplane TEE probe during pediatric cardiac interventional catheterization procedures. Use of this imaging modality provided significant advantages during dilation of obstructed venous pathways and closure of interatrial defects. Procedural characteristics and specific congenital heart lesion—related advantages were discussed.

A thermodilution method for quantification of bidirectional shunts

A method for measurement of bidirectional cardiovascular shunt fractions from single indicator dilution curves is presented. Linear system models corresponding to four basic shunt configurations are devised to represent the indicator dilution response of the cardiopulmonary circulation. The congenital heart defects in which bidirectional shunts exist are discussed in terms of the four anatomic configurations. Computer algorithms and digital processing techniques used for analyses of the indicator dilution curves are presented in detail. Forty-one thermodilution curves recorded during 13 pediatric cardiac catheterization procedures were analyzed and the results compared to simultaneous oximetric determinations. Comparison of L-R shunts, expressed as fractions of pulmonary plus R-L shunt flows, calculated by the two methods gave a standard error of 0.083 and a maximum difference of 0.15. Error analysis of the indicator dilution method predicted a standard deviation of 0.06. Multiple determinations were reproducible within a standard deviation of 0.051. Comparison of the right-to-left shunts, expressed as fractions of systemic plus left-to-right shunt flows gave a standard error of 0.083 and a maximum difference of 0.13. The standard deviation of multiple determinations was 0.029.