Pediatric Cardiac Catheterization Research Articles

Radiation dose benchmarks in pediatric cardiac catheterization: A prospective multi-center C3PO-QI study.

This study sought to update benchmark values to use a quality measure prospectively. Congenital Cardiac Catheterization Outcomes Project - Quality Improvement (C3PO-QI), a multi-center registry, defined initial radiation dose benchmarks retrospectively across common interventional procedures. These data facilitated a dose metric endorsed by the American College of Cardiology in 2014. Data was collected prospectively by 9 C3PO-QI institutions with complete case capture between 1/1/2014 and 6/30/2015. Radiation was measured in total air kerma (mGy), dose area product (DAP) (µGy*M2 ), DAP per body weight, and fluoroscopy time (min), and reported by age group as median, 75th and 95th %ile for the following six interventional procedures: (1) atrial septal defect closure; (2) aortic valvuloplasty; (3) treatment of coarctation of the aorta; (4) patent ductus arteriosus closure; (5) pulmonary valvuloplasty; and (6) transcatheter pulmonary valve implantation. The study was comprised of 1,680 unique cases meeting inclusion criteria. Radiation doses were lowest for pulmonary valvuloplasty (age <1 yrs, median mGy: 59, DAP: 249) and highest in transcatheter pulmonary valve implantation (age >15 yrs, median mGy: 1835, DAP: 17990). DAP/kg standardized outcome measures across weights within an age group and procedure type significantly more than DAP alone. Radiation doses decreased for all procedures compared to those reported previously by both median and median weight-based percentile curves. These differences in radiation exposure were observed without changes in median fluoroscopy time. This study updates previously established benchmarks to reflect QI efforts over time. These thresholds can be applied for quality measurement and comparison. © 2017 Wiley Periodicals, Inc.

Cerebral High-Intensity Transient Signals during Pediatric Cardiac Catheterization: A Pilot Study Using Transcranial Doppler Ultrasonography.

Cerebral emboli are one potential cause of acute brain injury in children with congenital heart disease (CHD) undergoing cardiac catheterization. In this pilot study using transcranial Doppler (TCD) ultrasonography, we sought to evaluate the incidence, burden, and circumstances of cerebral high-intensity transient signals (HITS), presumably representing emboli, during pediatric cardiac catheterization. Emboli monitoring of the right middle cerebral artery was performed in five children. HITS, counted offline, were defined as unidirectional signals associated with audible "chirp" and sinusoidal correlation. HITS were grouped as single, >10 HITS ("cluster"), or HITS "with curtain effect" per 3-5 cardiac cycles. Cerebral blood flow velocity (CBFV) and pulsatility index (PI) were recorded after anesthetic induction (baseline). Total HITS in the cohort was 1,697 (790 single HITS, 606 HITS within clusters, and 301 HITS within curtains). HITS in clusters and curtains comprised 53% (907/1,697) of total HITS, and occurred in 44 clusters/curtains. Events associated with clusters/curtains included left ventricular angiography (39%; 17/44), right ventricular angiography (16%; 7/44), device placement (16%; 7/44), heparin bolus (9%; 4/44), pulmonary artery angiography (9%; 4/44), venous access (5%; 2/44), right atrial angiography (2%; 1/44), arterial access (2%; 1/44), and hemodynamic measurements (2%; 1/44). No patient had clinically detectable neurologic injury. HITS are common during pediatric cardiac catheterization, and associated with procedural factors. Whether curtains/clusters are worse than single, repetitive HITS is unknown. Larger studies are needed to determine whether HITS are a marker of risk of neurologic injury from emboli during pediatric cardiac catheterization.

Effectiveness of an Educational Program on Nurse's knowledge concerning Complications of Cardiac Catheterization among Children at Al-Nassirhya Heart Center

OBJECTIVE: To assess nurses' knowledge concerning complications of cardiac catheterization among children and to find out the relationships between the nurses' knowledge concerning complications of cardiac catheterization among children and socio-demographic information. METHODOLOGY: a descriptive study was carried out at Al-Nassirhya Heart Center During the period in November 8th -2015 to the Wednesday June -2016. A non-probability (purposive) sample of (25) nurses, who worked at congenital heart anomalies department which include pediatric wards and cardiac catheterization unit. specialized in pediatric cardiac diseases in AL Nasiriyah Heart Center. The tool of the study included a questionnaire, which has six main parts. The Reliability of questionnaire was determined through internal consistency and through a pilot study, and the content validity of the questionnaire was determined through an expert panel. The data were analyzed through the application of descriptive frequencies, percentages, mean of score and the inferential statistical analysis: F test. RESULTS: The study revealed that there is no statistical significant association between nurses' age and their knowledge concerning the complications of cardiac catheterization at (pre test, post-1 and post-2) of educational program follow up (p value &gt; 0.05). There is no statistical significant association between nurses' gender, nurses' level of education, monthly income, residential area, years of service in nursing field, nurses' years of experience in heart centers and training course about cardiac catheterization and their knowledge concerning the complications of cardiac catheterization. The present study concluded that high percentage of staff nurses were graduated of Nursing Institute and most of them did not participate in training courses about cardiac catheterization. CONCLUSIONS : (1) Most study sample was males. (2) Mostly the ages of study sample were (25-29) Year. (3) A High percentage of the sample did not participate in training courses concerning to cardiac catheterization. (4)Highly significant differences between the two periods (pre and post-1 tests) of study sample in all domains of (nurses' information about cardiac catheterization and its complication in pediatric KUFA JOURNAL FOR NURSING SCIENCES RECOMMENDATION: (1) The study recommended the necessity to develop the nurses' skills. (2) Giving chance to nurses to participate in training courses to improve nursing care provided to the child and his family during cardiac catheterization procedure.

Pediatric cardiovascular care in Uganda: Current status, challenges, and opportunities for the future.

In many developing countries, concerted action against common childhood infectious diseases has resulted in remarkable reduction in infant and under-five mortality. As a result, pediatric cardiovascular diseases are emerging as a major contributor to childhood morbidity and mortality. Pediatric cardiac surgery and cardiac catheterization interventions are available in only a few of Sub-Saharan African countries. In Uganda, open heart surgeries (OHSs) and interventional procedures for pediatric cardiovascular disease are only possible at the Uganda Heart Institute (UHI), having been started with the help of expatriate teams from the years 2007 and 2012, respectively. Thereafter, independent OHS and cardiac catheterization have been possible by the local team at the UHI since the year 2009 and 2013, respectively. The number of OHSs independently performed by the UHI team has progressively increased from 10 in 2010 to 35 in 2015, with mortality rates ranging from 0% to 4.1% over the years. The UHI pediatric catheterization team has independently performed an increasing number of procedures each year from 3 in 2013 to 55 in 2015. We herein describe the evolution and current status of pediatric cardiovascular care in Uganda, highlighting the unique aspects of its establishment, existing constraints, and future plans.

The impact of femoral arterial thrombosis in paediatric cardiac catheterisation: a national study.

Previous studies have identified risk factors for femoral arterial thrombosis after paediatric cardiac catheterisation, but none of them have evaluated the clinical and economic significance of this complication at the population level. Therefore, we examined the national prevalence and economic impact of femoral arterial thrombosis after cardiac catheterisation in children. Patients⩽18 years of age who underwent cardiac catheterisation were identified in the 2003-2009 Kids' Inpatient Database. Patients were stratified by age as follows: <1 year of age or 1-18 years of age. The primary outcome was arterial thrombosis of the lower extremity during the same hospitalisation as cardiac catheterisation. Propensity score matching was used to determine the impact of femoral arterial thrombosis on hospital length of stay, cost, and mortality. Among the 11,497 paediatric cardiac catheterisations identified, 4558 catheterisations (39.6%) were performed in children <1 year of age. This age group experienced a higher prevalence of reported femoral arterial thrombosis, compared with children aged 1-18 years (1.3 versus 0.3%, p<0.001). After matching, femoral arterial thrombosis in children <1 year of age was associated with similar mortality (5.4 versus 1.8%, p=0.28), length of stay (8 versus 5 days, p=0.11), and total hospital cost ($27,135 versus $28,311, p=0.61), compared with absence of thrombosis. Femoral arterial thrombosis is especially prevalent in children <1 year of age undergoing cardiac catheterisation. Clinicians should be vigilant in monitoring femoral arterial patency in neonates and infants after cardiac catheterisation.

SCAI/CCAS/SPA Expert Consensus Statement for Anesthesia and Sedation Practice: Recommendations for Patients Undergoing Diagnostic and Therapeutic Procedures in the Pediatric and Congenital Cardiac Catheterization Laboratory.

Current practice of sedation and anesthesia for patients undergoing pediatric and congenital cardiac catheterization laboratory (PCCCL) procedures is known to vary among institutions, a multi-society expert panel with representatives from the Congenital Heart Disease Council of the Society for Cardiovascular Angiography and Interventions, the Society for Pediatric Anesthesia and the Congenital Cardiac Anesthesia Society was convened to evaluate the types of sedation and personnel necessary for procedures performed in the PCCCL. The goal of this panel was to provide practitioners and institutions performing these procedures with guidance consistent with national standards and to provide clinicians and institutions with consensus-based recommendations and the supporting references to encourage their application in quality improvement programs. Recommendations can neither encompass all clinical circumstances nor replace the judgment of individual clinicians in the management of each patient. The science of medicine is rooted in evidence, and the art of medicine is based on the application of this evidence to the individual patient. This expert consensus statement has adhered to these principles for optimal management of patients requiring sedation and anesthesia. What follows are recommendations for patient monitoring in the PCCCL regardless of whether minimal or no sedation is being used or general anesthesia is being provided by an anesthesiologist.

SCAI/CCAS/SPA expert consensus statement for anesthesia and sedation practice: Recommendations for patients undergoing diagnostic and therapeutic procedures in the pediatric and congenital cardiac catheterization laboratory.

Current practice of sedation and anesthesia for patients undergoing pediatric congenital cardiac catheterization laboratory (PCCCL) procedures is known to vary among institutions, a multi-society expert panel with representatives from the Congenital Heart Disease Council of the Society for Cardiovascular Angiography and Interventions (SCAI), the Society for Pediatric Anesthesia (SPA) and the Congenital Cardiac Anesthesia Society (CCAS) was convened to evaluate the types of sedation and personnel necessary for procedures performed in the PCCCL. The goal of this panel was to provide practitioners and institutions performing these procedures with guidance consistent with national standards and to provide clinicians and institutions with consensus-based recommendations and the supporting references to encourage their application in quality improvement programs. Recommendations can neither encompass all clinical circumstances nor replace the judgment of individual clinicians in the management of each patient. The science of medicine is rooted in evidence, and the art of medicine is based on the application of this evidence to the individual patient. This expert consensus statement has adhered to these principles for optimal management of patients requiring sedation and anesthesia. What follows are recommendations for patient monitoring in the PCCCL regardless of whether minimal or no sedation is being used or general anesthesia is being provided by an anesthesiologist. © 2016 Wiley Periodicals Inc.

Therapeutic Utilities of Pediatric Cardiac Catheterization.

In an era when less invasive techniques are favored, therapeutic cardiac catheterization constantly evolves and widens its spectrum of usage in the pediatric population. The advent of sophisticated devices and well-designed equipment has made the management of many congenital cardiac lesions more efficient and safer, while providing more comfort to the patient. Nowadays, a large variety of heart diseases are managed with transcatheter techniques, such as patent foramen ovale, atrial and ventricular septal defects, valve stenosis, patent ductus arteriosus, aortic coarctation, pulmonary artery and vein stenosis and arteriovenous malformations. Moreover, hybrid procedures and catheter ablation have opened new paths in the treatment of complex cardiac lesions and arrhythmias, respectively. In this article, the main therapeutic utilities of cardiac catheterization in children are discussed.

Optimization of CT patient dose: First results from a dose management project

Purpose The goal of this study is to demonstrate the impact and benefits of the implementation of a dose management project in a radiological protection department to analyse the results after three years collecting dose data. Materials and methods In mid-2013 our hospital decided to implement the dose monitoring tool of General Electric (DoseWatch™). A dose management team was created, including two radiologists and two physicists, one of them as the team leader. The project began with a dedicated CT for pediatrics (Philips Brilliance) and a RF device (Philips DigitalDiagnost). In 2015, the project was extended to 2 more CT’s (GE Lightspeed and Toshiba Aquilion) and a dedicated pediatric cardiac catheterization device (Siemens ArtisZee). A dose alert threshold based on statistical approaches was established for each protocol to control and compare the dose with the european dose reference levels. Results CT analysis has been done, segmenting in different age ranges [0–5, 6–10, 11–15, 16–20, >21]. Study has been focused on Abdomen, Thorax and Head practices. Median CTDIvol were compiled in tables for each protocol. For example for skull and age ranges above the values obtained were: 4.1 mGy; 4.2 mGy; 4.1 mGy; 4.06 mGy; 30.4 mGy. Conclusion The implementation of a dose management project is really important for the hospital to minimize the radiation risks. The creation of a dose team and the use of a dose monitoring tool are crucial to control and optimize the dose. Implementation of the DoseWatch™ tool eases to the dose team to analyse and compare dose values in different devices, protocols and modalities. Disclosure There is no bias in this work and no relationships with influence on the results.

Ultrasound‐guided femoral arterial access in pediatric cardiac catheterizations: A prospective evaluation of the prevalence, risk factors, and mechanism for acute loss of arterial pulse

The objectives of this study were to describe the prevalence, mechanisms, and identify risk factors for acute loss of arterial pulse (LOP) in children who had ultrasound-guided femoral arterial access (UGFAA) during cardiac catheterization. LOP is a known complication in children following femoral arterial (FA) access for cardiac catheterization. The prevalence of LOP requiring treatment ranges between 4% and 8%. A prospective study was performed including 486 cardiac catheterizations using UGFAA in children ≤18 years over a 3 years period. Ultrasound and Doppler evaluations were performed prior to and at the end of the procedure. LOP was identified in 33 cases (6.8%) with 23 (4.7%) requiring treatment. For children ≤6 months, the prevalence of LOP requiring treatment was 13.6%. FA diameter <3mm was the only significant independent predictor for LOP (OR: 8.44, 95% CI: 2.07-34.5, P < 0.001). Smaller patient size, number of access attempts, time required for access, operator experience, sheath size, and length of procedure were not found to be significant predictors. Children with LOP had a greater percentage decrease in vessel diameter (median 62% vs 18%, P < 0.001) compared to those without LOP. FA thrombus was diagnosed only in 9 patients (27% of those with LOP). The prevalence of LOP requiring treatment is 4.7% when UGFAA is used during pediatric cardiac catheterizations. Arterial spasm was more common than thrombus as a cause of LOP. FA diameter <3mm was the only independent predictor for LOP in this carefully designed prospective study. © 2016 Wiley Periodicals, Inc.

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.

Radiation Exposure by Three-Dimensional Rotational Angiography (3DRA) During Trans-catheter Melody Pulmonary Valve Procedures (TMPV) in a Pediatric Cardiac Catheterization Laboratory.

This retrospective study aims to evaluate radiation exposure by three-dimensional rotational angiography (3DRA) during trans-catheter Melody pulmonary valve (TMPV) procedures. 3DRA has been reported to have added value in the management of complex congenital heart disease aiding in the performance of interventional procedures albeit with concerns of higher radiation exposure. We test the hypothesis that 3DRA does not cause additional radiation exposure during TMPV procedures. We analyzed all 81 TMPV procedures performed at St. Louis Children's Hospital, MO, USA, from January 1, 2011 to December 31, 2014. Dose-area product (DAP), DAP indexed to body weight (DAP/BW), fluoroscopy time (FT), and weight-fluoroscopy time product of each procedure were recorded. We reviewed each procedure's images to determine whether additional interventions were performed (e.g., pulmonary artery angioplasty or treatment of conduit pseudo-aneurysm). 3DRA was used in 36% of the procedures. 3DRA group had a higher number of additional procedures performed. The 3DRA group did not differ from the non-3DRA group in DAP, DAP/BW, and weight-fluoroscopy time product. 3DRA does not cause greater radiation exposure during TMPV procedures.

Ketofol versus sevoflurane for maintenance of aesthesia in paediatric cardiac catheterization: A prospective double blind study

BackgroundPediatric cardiac anesthesia involves anaesthetizing very small children with complex congenital heart disease. Sevoflurane provides the advantage of rapid induction of anesthesia with short recovery time. Ketofol is a neologism coined to refer to the combination of ketamine and propofol mixed together in one syringe. Ketamine and propofol have opposing influences on blood pressure, heart rate, and SVR.Aim of the workTo compare the effectiveness and side effects of ketofol versus sevoflurane for maintenance of aesthesia in pediatric cardiac catheterization.MethodsThis double blinded randomized study was carried on 90 pediatric patients ASA II and III undergoing cardiac catheterization. Induction was accomplished with titration of 3–5% sevoflurane. Patients were randomly assigned to one of the two study groups. Group K received ketofol mixture (propofol, 4 mg/mL, and ketamine, 2 mg/mL) infusion rate propofol 25–50 mic/kg/min and ketamine 12.5–25 mic/kg/min for maintenance. Group S received sevoflurane 0.5–1 MAC. Changes in recovery time, hemodynamic variables and the incidence of adverse effects were measured.ResultsDiastolic blood pressure showed significant difference between the study groups at induction p (0.001), 5 min after induction p(0.04), on recovery 0.037, 5 min postoperatively p(0.016), and 10 min postoperatively. The need for vasopressor and MAP decrease >20% compared with baseline did not show significant difference p(0.832). Recovery time was shorter in group S p(.000). The incidence of nausea and vomiting was significantly more in group S p(.000). Emergence agitation was observed in group S in 12(26.6) patients. Watcha scale was significantly lower in group K at 10 min postoperatively p(.001).ConclusionsBoth propofol–ketamine and sevoflurane provided effective sedation and analgesia during pediatric cardiac catheterization. But propofol–ketamine combination was superior to sevoflurane because the incidence of agitation, nausea and vomiting in patients given sevoflurane was significantly higher than in ketofol group.

Diagnostic Utility of Three-Dimensional Rotational Angiography in Congenital Cardiac Catheterization.

We evaluated the diagnostic utility of the three modalities of three-dimensional rotational angiography (3DRA): rotational angiography (RA), multiplanar reformat (MPR) and three-dimensional angiographic reconstruction (3D-R) in pediatric cardiac catheterization. The 3DRA studies were classified by anatomy of interest based on our injection protocol: pulmonary arteries (PA), aorta, cavopulmonary connection (CPC), and others. Retrospective review of 3DRA images by two reviewers for each modality was conducted with grading as inferior, similar, or superior in comparison with the diagnostic quality of fixed-plane angiography (FPA). The percentages of grades for each modality were averaged. Weighted kappa statistic was used to evaluate inter-rater reliability. In total, 114 3DRA studies were performed on 87 patients between August 2010 and March 2012. Median age was 2.7years (1day-48.4years) and median weight 12.1kg (3.6-106.5kg). For RA: 79.4% of the studies were of diagnostic quality and 52.2% were superior; 3D-R: 82% were of diagnostic quality and 65.8% were superior; and MPR: 83.5% were of diagnostic quality and 63% were superior. Overall 3DRA technologies (RA, 3D-R, MPR) were of diagnostic quality or better in 111/114 (97.4%) studies and 103/114 (90.4%) were judged superior. Most common reasons for inferior grading were limited opacification and metallic artifact. In pediatric cardiac catheterization, 3DRA imaging was of diagnostic quality and frequently provided additional clinically relevant data when compared to FPA.

PT208 Pathway to Independent Interventional Practice: Uganda Heart Institute Pediatric Cardiac Catheterization Program

PT208 Pathway to Independent Interventional Practice: Uganda Heart Institute Pediatric Cardiac Catheterization Program

Transient Pulmonary Atelectasis after Ketamine Sedation during Cardiac Catheterization in Spontaneously Breathing Children with Congenital Heart Disease

Background: Ketamine is applied widely for sedation during cardiac catheterization in spontaneously breathing children with congenital heart disease (CHD). However, a rare and unreported respiratory complication, transient and reversible atelectasis of lungs (TRAL), was identified. Purpose: The study was performed to investigate retrospectively the prevalence and clinical characteristics of TRAL after ketamine sedation in pediatric cardiac catheterization. Methods: Four thousand four hundred and seventy-four sick children were sedated with ketamine, and pediatric cardiac catheterization was carried out under spontaneous breathing. TRAL was detected in 33 children (17 M/16 F, age was 2.1±1.7 years) by retrospective analysis. The clinical and radiographic characteristics were recorded before, during and after TRAL. Results: In pediatric cardiac catheterization, the prevalence of TRAL was 0.74% after ketamine sedation. TRAL occurred in 23 children with cyanotic CHD, and 10 with acyanotic CHD. All TRALs had common clinical and radiographic features: the diffuse opacity of bilateral lungs developed rapidly (identified under X-ray fluoroscopy), associated with decrease in lung volume, and then the decrease in SpO2 (94.2±9.2% vs. 59.4±2.2%, P&lt;0.05), and heart rates (143.5±14.3 bpm vs. 58.3±9.7 bpm, P&lt;0.05) followed quickly. TRAL was relieved by supportive oxygen in 32 children (23 with face mask, and 9 with endotracheal intubation), and the duration of TRAL was 1.6±0.5 minutes. However, TRAL caused the death of one child. Conclusions: TRAL is a rare and urgent respiratory complication after ketamine sedation, and the mechanism is unclear. Rapid and diffuse opacity of bilateral lungs is the earliest sign of TRAL in pediatric cardiac catheterization, and the immediate supportive oxygen is crucial.

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.

Percutaneous Common Carotid Artery Access for Pediatric Interventional Cardiac Catheterization.

Surgical cutdown for access to the common carotid artery provides a more direct route for certain pediatric cardiac interventions and avoids femoral artery injury in small infants. The safety of percutaneous carotid access (PCA) in children is unknown. Retrospective review of PCA at Texas Children's Hospital and Children's Healthcare of Atlanta. From July 2006 to November 2014, 42 patients underwent 47 attempts at catheterization via PCA. Median (range) age was 20 days (0 days-2.9 years) and weight was 3.2 kg (1.1-12.2). Two patients had failed PCA with no sequelae. Of the 45 catheterizations with successful PCA and sheath placement, 44 interventions were performed, the most common being stenting or stent redilation of the ductus arteriosus, balloon aortic valvuloplasty, and stenting or angioplasty of Blalock-Taussig shunts. After sheath withdrawal, hemostasis was achieved with manual compression, with no need for surgical control of bleeding. Follow-up carotid imaging was performed in all. Acutely, 3 patients developed carotid thrombosis with resolution in 1 and mild residual narrowing in 2 after anticoagulation therapy. At follow-up, 40 of 42 patients (95%) had a normal carotid artery, with 2 instances of mild stenosis. There were no neurological sequelae attributable to PCA. PCA is safe even in small infants, and hemostasis can be achieved without surgical repair, with a carotid patency rate superior to published data after surgical cutdown. Surgical cutdown is not routinely required for pediatric cardiac catheterization via the carotid artery.

CONTEMPORARY AUSTRALIAN DOSE AREA PRODUCT LEVELS IN THE FLUOROSCOPIC INVESTIGATION OF PAEDIATRIC CONGENITAL HEART DISEASE.

This study examines radiation dose levels delivered to children from birth to 15 y of age in the investigation of congenital heart disease (CHD) at a major Sydney children's hospital. The aims are to compare values with those derived from similar studies, to provide a template for more consistent dose reporting, to establish local and national diagnostic reference levels and to contribute to the worldwide paediatric dosimetry database. A retrospective review of 1007 paediatric procedural records was undertaken. The cohort consisted of 795 patients over a period from January 2007 to December 2012 who have undergone cardiac catheterisation for the investigation of CHD. The age range included was from the day of birth to 15 y. Archived dose area product (DAP) and fluoroscopy time (FT) readings were retrieved and analysed. The mean, median, 25th and 75th percentile DAP levels were calculated for six specific age groupings. The 75th percentile DAP values for the specific age categories were as follows: 0-30 d-1.9 Gy cm2, 1-12 months-2.9 Gy cm2, 1-3 y-5.3 Gy cm2, 3-5 y-6.2 Gy cm2, 5-10 y-7.5 Gy cm2 and 10-15 y-17.3 Gy cm2. These levels were found to be lower than the values reported in comparable overseas studies. Individual year-specific levels were determined, and it is proposed that these are more useful than the common grouping method. The age-specific 75th percentile DAP levels outlined in this study can be used as baseline local diagnostic reference levels. The needs for the standardisation of DAP reporting and for a greater range of age-specific diagnostic reference levels have been highlighted. For the first time, Australian dose values for paediatric cardiac catheterisation are presented.

Comparative study between the effect of sevoflurane and ketamine-midazolam on the cardiac troponin I level and hemodynamic variables in pediatric therapeutic cardiac catheterization for pulmonic stenosis

Introduction Congenital pulmonary stenosis is considered one of the most common cardiac anomalies in pediatrics. Percutaneous balloon dilatation is one method for its treatment, but it is usually associated with an increase in the cardiac troponin level. Aims and objectives The study was carried out to compare between the effect of sevoflurane and ketamine-midazolam on the level of cardiac troponin I as a specific marker for myocardial injury in children before and after therapeutic cardiac catheterization for pulmonic stenosis. Patients and methods Forty patients, up to 13 years old, undergoing cardiac catheterization were divided randomly into two groups: sevoflurane group (Gs) and ketamin-midazolam group (Gk-m). The standardized protocol for cardiac catheterization was maintained for all the patients. Serum samples were withdrawn at the start of - and 6 h subsequent to - the procedure for analysis of cardiac troponin I. Hemodynamic and oxygenation parameters were recorded at induction, T10, T20, and T30 minutes after induction. After recovery, sedation was assessed using the Ramsay Sedation Score. Results Hemodynamic parameters, mean arterial blood pressure, heart rate, and cardiac index were significantly increased in Gk-m as compared with its basal values and with Gs. The serum cardiac troponin I was significantly increased after the procedure in both groups as compared with its basal value before the procedure. The increase in the cardiac troponin I was significantly higher in Gk-m than Gs ( P < 0.001). The Ramsay Sedation Score showed a significant increase in Gk-m than Gs at all times postoperatively. Conclusion The use of sevoflurane as an anesthetic regimen for pediatric therapeutic cardiac catheterization for pulmonic stenosis is superior to the ketamine-midazolam combination as it is associated with a lower troponin I level, less myocardial injury, and greater hemodynamic stability.