Pediatric Electrophysiology Research Articles

Children's Heartbeat: A Web-Based Program to Spread Knowledge on Arrhythmias in Children.

Expertise in pediatric arrhythmia management is lacking in most low- and middle- income countries (LMIC). Strategies to disseminate education in pediatric electrophysiology are essential to meet this need. Children's Heartbeat was created to meet the growing demand for pediatric electrophysiologic consultation in LMIC. Children's Heartbeat is a virtual video-conferencing program that uses the Extension for Community Healthcare Outcomes model to disseminate knowledge about pediatric arrhythmia management from pediatric electrophysiologists to clinicians in medically under-resourced regions worldwide. Monthly virtual case-based sessions are held with pediatric electrophysiologists and clinicians in medically under-resourced settings to discuss pediatric electrophysiology management. Since its inception, Children's Heartbeat viewership has grown exponentially to include 181 total registrants, 64 average monthly participants, and an additional 121 average viewers of recorded sessions. Attendees have expressed increased confidence in pediatric arrhythmia management. Children's Heartbeat has successfully provided pediatric electrophysiology consultation to medically under-resourced regions globally and have increased clinicians' confidence in caring for children with arrhythmias. Future directions include spreading the program to general pediatric and pediatric cardiology trainees and practicing pediatricians in rural parts of high-income countries and evaluating the direct impact of Children's Heartbeat on the management of arrhythmias in pediatric patients in LMIC.

Assessment of current pediatric electrocardiogram (ECG) interpretation practices

BackgroundDespite improvements in digital electrocardiograms (ECGs), current standard of care requires physician confirmation. Mismatched expectations between ordering providers and ECG readers, often pediatric cardiologists and electrophysiologists (EPs), are common, especially since there are no standardized practices for pediatric ECG reading. ObjectivesThe aim of this study was to understand current practices in pediatric ECG reading. MethodsAn electronic survey was sent to members of the Pediatric and Congenital Electrophysiology Society (PACES). Participation was optional; results were recorded from 12/19/22–1/9/23. Only complete and non-duplicate entries were included. ResultsA total of 127 responses were received, 93 were analyzed. Most responses were from centers in North America (n = 65, 70 %), including the US (n = 58, 62 %), Canada (n = 6, 6 %), and Mexico (n = 1, 1 %). The remaining were from Europe (n = 18, 19 %), Asia (n = 7, 8 %), Australia (n = 2, 2 %), and South America (n = 1, 1 %). Most (n = 46, 49 %) were from small centers (0–25 ECGs read per day), 27 respondents (29 %) were from medium centers (26–50 ECGs read per day), 20 respondents (22 %) were from large centers (>50 ECGs read per day). The majority (n = 65, 70 %) reported >3 readers/day for inpatient and emergency department ECGs. 49 % (n = 46) of centers read ECGs >2 times/day on weekdays with more variable practice on weekends. For critical/time sensitive findings, most centers (n = 90, 97 %) used verbal communication +/− the EMR. There was consensus (≥50 % agreement) that the following findings are critical/time sensitive: QTc >500 ms, T-wave alternans, narrow complex tachycardia, wide complex tachycardia, pre-excited atrial fibrillation, focal ischemic changes, second degree heart block type II, complete heart block, and pacemaker malfunction. ConclusionReading practices are variable. Critical/time sensitive findings are most often communicated verbally, however, there is no agreed upon standard. There was consensus in critical/time-sensitive findings. Improved understanding of common practices and resource allocation may lead to increased consistency in pediatric ECG reading.

Mobile ECG devices in pediatric cardiology: efficacy and accuracy of smart watch and hand-held device in healthy children

Abstract Background and Aim Pediatric arrhythmias require accurate electrocardiogram (ECG) assessment for diagnosis and management. Mobile ECG devices, such as smart watch based and hand-held devices, offer potential advantages in terms of portability and accessibility. This study aimed to compare the efficancy and diagnostic accuracy of ECG tracings obtained using a smart watch and a hand-held device with standard 12-lead ECG tracings in healthy children. Methods ECG data were acquired from healthy pediatric subjects (n=30) aged 4 to 18 years using the smart watch, hand-held device, and standard 12-lead ECG. Single leads were acquired sequentially. The time required for ECG acquisition was recorded for each device. Subsequently, ECG leads were analyzed for voltage, duration, and morphology of waves and intervals, as well as ST segments. Qualitative assessment of leads included morphology comparison of waves and complexes to standard 12-lead ECG and using a physician based quality rating scale. Assessment was performed by two blinded pediatric electrophysiologists. Results We found significant differences in the time required to acquire ECG tracings between the smart watch, standard 12-lead ECG, and hand-held device, with the smart watch being notably slower (median 15 min, 4 min, 1 min, respectively). ECG leads obtained with the smart watch and hand-held device demonstrated comparability to standard 12-lead ECG tracings in terms of quantitative key parameters, including voltage (mV) and duration (ms) of waves and intervals. Qualitative assessment revealed good correlation of the hand-held device with standard 12-lead ECG, while the smart watch performed less well. Conclusions This study suggests that mobile ECG devices offer a diagnostic accuracy comparable to that of standard 12-lead ECGs in healthy children. While the smart watch may be slower in ECG acquisition, acquisition of all 12 standard ECG leads is feasible in this population. The potential of both included mobile devices for pediatric usage in specific clinical scenarios, such as remote monitoring or emergencies, is promising.Graphical Abstract

X-ray Doses in Relation to Body Mass, Indication, and Substrate During Pediatric Electrophysiological Procedures on the Heart.

The main goal of this study is to determine typical values of dose area product (DAP) and difference in the effective dose (ED) for pediatric electrophysiological procedures on the heart in relation to patient body mass. This paper also shows DAP and ED in relation to the indication, the arrhythmia substrate determined during the procedure, and in relation to the reason for using radiation. Organ doses are described as well. The subjects were children who have had an electrophysiological study done with a 3D mapping system and X-rays in two healthcare institutions. Children with congenital heart defects were excluded. There were 347 children included. Significant difference was noted between mass groups, while heavier children had higher values of DAP and ED. Median DAP in different mass groups was between 4.00 (IQR 1.00-14.00) to 26.33 (IQR 8.77-140.84) cGycm2. ED median was between 23.18 (IQR 5.21-67.70) to 60.96 (IQR 20.64-394.04) µSv. The highest DAP and ED in relation to indication were noted for premature ventricular contractions and ventricular tachycardia-27.65 (IQR 12.91-75.0) cGycm2 and 100.73 (IQR 53.31-258.10) µSv, respectively. In arrhythmia substrate groups, results were similar, and the highest doses were in ventricular substrates with DAP 29.62 (IQR 13.81-76.0) cGycm2 and ED 103.15 (IQR 60.78-266.99) µSv. Pediatric electrophysiology can be done with very low doses of X-rays when using 3D mapping systems compared to X-rays-based electrophysiology, or when compared to pediatric interventional cardiology or adult electrophysiology.

Long-Term Outcomes of Cardiac Resynchronization Therapy in Patients With Repaired Tetralogy of Fallot: A Multicenter Study.

A growing number of patients with tetralogy of Fallot develop left ventricular systolic dysfunction and heart failure, in addition to right ventricular dysfunction. Although cardiac resynchronization therapy (CRT) is an established treatment option, the effect of CRT in this population is still not well defined. This study aimed to investigate the early and late efficacy, survival, and safety of CRT in patients with tetralogy of Fallot. Data were analyzed from an observational, retrospective, multicenter cohort, initiated jointly by the Pediatric and Congenital Electrophysiology Society and the International Society of Adult Congenital Heart Disease. Twelve centers contributed baseline and longitudinal data, including vital status, left ventricular ejection fraction (LVEF), QRS duration, and NYHA functional class. Outcomes were analyzed at early (3 months), intermediate (1 year), and late follow-up (≥2 years) after CRT implantation. A total of 44 patients (40.3±19.2 years) with tetralogy of Fallot and CRT were enrolled. Twenty-nine (65.9%) patients had right ventricular pacing before CRT upgrade. The left ventricular ejection fraction improved from 32% [24%-44%] at baseline to 42% [32%-50%] at early follow-up (P<0.001) and remained improved from baseline thereafter (P≤0.002). The QRS duration decreased from 180 [160-205] ms at baseline to 152 [133-182] ms at early follow-up (P<0.001) and remained decreased at intermediate and late follow-up (P≤0.001). Patients with upgraded CRT had consistent improvement in left ventricular ejection fraction and QRS duration at each time point (P≤0.004). Patients had a significantly improved New York Heart Association functional class after CRT implantation at each time point compared with baseline (P≤0.002). The transplant-free survival rates at 3, 5, and 8 years after CRT implantation were 85%, 79%, and 73%. In patients with tetralogy of Fallot treated with CRT consistent improvement in QRS duration, left ventricular ejection fraction, New York Heart Association functional class, and reasonable long-term survival were observed. The findings from this multicenter study support the consideration of CRT in this unique population.

Pharmacological Management of Cardiac Arrhythmias in the Fetal and Neonatal Periods: A Scientific Statement From the American Heart Association: Endorsed by the Pediatric & Congenital Electrophysiology Society (PACES).

Disorders of the cardiac rhythm may occur in both the fetus and neonate. Because of the immature myocardium, the hemodynamic consequences of either bradyarrhythmias or tachyarrhythmias may be far more significant than in mature physiological states. Treatment options are limited in the fetus and neonate because of limited vascular access, patient size, and the significant risk/benefit ratio of any intervention. In addition, exposure of the fetus or neonate to either persistent arrhythmias or antiarrhythmic medications may have yet-to-be-determined long-term developmental consequences. This scientific statement discusses the mechanism of arrhythmias, pharmacological treatment options, and distinct aspects of pharmacokinetics for the fetus and neonate. From the available current data, subjects of apparent consistency/consensus are presented, as well as future directions for research in terms of aspects of care for which evidence has not been established.

“But for the blind spot”: Accuracy and diagnostic performance of smart watch cardiac features in pediatric patients

BackgroundThe Apple Watch™ (AW) offers heart rate (HR) tracking by photoplethysmography (PPG) and single-lead electrocardiographic (ECG) recordings. The accuracy of AW-HR and diagnostic performance of AW-ECGs among children during both sinus rhythm and arrhythmias have not been explored. ObjectiveThe purposes of this study were to assess the accuracy of AW-HR measurements compared to gold standard modalities in children during sinus rhythm and arrhythmias and to identify non–sinus rhythms using AW-ECGs. MethodsSubjects ≤18 years wore an AW during (1) telemetry admission, (2) electrophysiological study (EPS), or (3) exercise stress test (EST). AW-HRs were compared to gold standard modality values. Recorded AW-ECGs were reviewed by 3 blinded pediatric electrophysiologists. ResultsEighty subjects (median age 13 years; interquartile range 1.0–16.0 years; 50% female) wore AW (telemetry 41% [n = 33]; EPS 34% [n = 27]; EST 25% [n = 20]). A total of 1090 AW-HR measurements were compared to time-synchronized gold standard modality HR values. Intraclass correlation coefficient (ICC) was high 0.99 (0.98–0.99) for AW-HR during sinus rhythm compared to gold standard modalities. ICC was poor comparing AW-HR to gold standard modality HR in tachyarrhythmias (ICC 0.24–0.27) due to systematic undercounting of AW-HR values. A total of 126 AW-ECGs were reviewed. Identification of non–sinus rhythm by AW-ECG showed sensitivity of 89%–96% and specificity of 78%–87%. ConclusionsWe found high levels of agreement for AW-HR values with gold standard modalities during sinus rhythm and poor agreement during tachyarrhythmias, likely due to hemodynamic effects of tachyarrhythmias on PPG-based measurements. AW-ECGs had good sensitivity and moderate specificity in identification of non–sinus rhythm in children.

Thromboembolism prophylaxis practices of pediatric and congenital electrophysiologists during invasive electrophysiology studies: A PACES survey.

Thromboembolic events related to invasive electrophysiology studies, while rare, can have devastating consequences. Use of systemic anticoagulation for a pediatric or adult-congenital invasive electrophysiology study is recommended, however there is no established standard of practice in this population. To report on procedural practices for thromboembolism prophylaxis during invasive electrophysiology studies for pediatric patients and adults with congenital heart disease. An anonymous web-based survey was sent to the members of the Pediatric and Congenital Electrophysiology Society. The survey focused on pre-procedural, intra-procedural, and post-procedural thromboembolism prophylaxis practices during invasive electrophysiology studies. Significant practice variation was defined as <90% concordance among respondents. Survey was completed by 73 members; 52 (71%) practicing in the United States, 65 (89%) practicing in an academic institution, and 14 (19%) in an institution that performs more than 200 invasive electrophysiology procedures annually. Responses showed significant variation in practice. Prior to an invasive electrophysiology procedure, 25% discontinue aspirin while 47% discontinue anticoagulants. Heparin is given for all procedures by 32%. When heparin is administered, the first dose is given by 32% after sheaths are placed, 42% after crossing into the systemic atrium, and 26% just prior to systemic-side ablation. Most target an activated clotting time between 200-300 seconds. Post systemic-side ablation, 58% do not initiate a heparin infusion. Post-procedural oral agents were initiated on day of procedure by 34% of respondents and on post-procedure day 1 by 53%. If treating with aspirin, 74% use low-dose (3-5mg/kg or 81mg daily), and 68% treat for 4-6weeks. There is significant variation in thromboembolism prophylaxis for invasive EP studies among pediatric and congenital electrophysiologists. Further studies are needed to optimize the management of thromboembolism prophylaxis in this population.

New insights from paediatric electrophysiology

Visual electrophysiology is uniquely valuable in paediatric practice because it provides objective measures of visual pathway function. The combination of electroretinograms and visual evoked potentials to flashes and patterns enables a functional assessment of the entire pathway, from photoreceptors to striate cortex. This information can be impossible to obtain from children by other means. Electrophysiology complements structural information, often highlighting discrepant structure function relationships.Objective functional electrophysiology facilitates early diagnosis and can delineate potential treatment windows from the youngest ages. Thus visual electrophysiology findings in children contribute to natural history and deep phenotyping studies that inform clinical trials of new treatments not only for ocular disease, but also systemic diseases that involve the eye.This talk will describe ways in which ISCEV tests can be adapted and optimized for young children in clinical practice without loss of diagnostic accuracy, and how electrophysiology can distinguish phenotypes and inform genetic analysis. Examples of the value and limitations of electrophysiology in potential gene trials and other ameliorating treatments will be presented and discussed; including inherited retinal disease such as RPE65, neurodegenerations that affecting the eye such as CLN2 and iron brain disorders such as PKAN and ciliopathies such as BBS.Key words: visual electrophysiology, children, ERG, VEP, ISCEV.

Current State of Cardiac Implantable Electronic Device Remote Monitoring in Pediatrics and Congenital Heart Disease: A PACES-Sponsored Quality Improvement Initiative.

Cardiac implantable electronic device (CIED) remote transmissions are an integral part of longitudinal follow-up in pediatric and adult congenital heart disease (ACHD) patients. To evaluate baseline CIED remote monitoring(RM) data among pediatric and ACHD centers prior to implementation ofa Pediatric and Congenital Electrophysiology Society (PACES)-sponsored quality improvement (QI) project. This is a cross-sectional study of baseline CIED RM. Centers self-reported baseline data: individual center RM compliance was defined as high if there was > 80% achievement and low if < 50%. A total of 22 pediatric centers in the USA and Australia submitted baseline data. Non-physicians were responsible for management of the RM program in most centers: registered nurse (36%), advanced practice provider (27%), combination (23%), and third party (9%). Fifteen centers (68%) reported that > 80% of their CIED patients are enrolled in RM and only two centers reported < 50% participation. 36% reported high compliance of device transmission within 14 days of implant and 77% of centers reported high compliance of CIED patients enrolled in RM. The number of centers achieving high compliance differed by device type: 36% for pacemakers, 50% for ICDs, and 55% for Implantable Cardiac Monitors(ICM). All centers reported at least 50% adherence to recommended follow-up for PM and ICD, with 23% low compliance rate for ICMs. Based on this cross-sectional survey of pediatric and ACHD centers, compliance with CIED RM is sub-optimal. The PACES-sponsored QI initiative will provide resources and support to participating centers and repeat data will be evaluated after PDSA cycles.

Electrocardiograms Do Not Detect Myocardial Ischemia in Patients With Williams Syndrome and Nonsyndromic Elastin Arteriopathy With Coronary Artery Stenosis

Coronary artery stenosis (CAS) may affect up to 27% of patients with Williams syndrome (WS), which may lead to myocardial ischemia. Patients with WS face a 25- to 100-fold greater risk of sudden cardiac death, frequently linked to anesthesia. Assessing CAS requires either imaging while under general anesthesia or intraoperative assessment, with the latter considered the gold standard. Our study aimed to identify electrocardiogram (ECG) markers of myocardial ischemia in patients with WS or nonsyndromic elastin arteriopathy and documented CAS. We retrospectively reviewed patients with WS/elastin arteriopathy who underwent supravalvar aortic stenosis surgery and CAS assessment from January 1, 2006 to April 30, 2021. A pediatric electrophysiologist, not aware of the patients' CAS status, reviewed their preoperative ECGs for markers of ischemia. We assessed associations of study parameters using Wilcoxon rank-sum and Fisher's exact tests. Of 34 patients, 62% were male, with a median age of 20 months (interquartile range: 8 to 34). CAS was present in 62% (21 of 34), 76% of whom (16 of 21) were male. There were no ECG indicators of myocardial ischemia in patients with CAS. In conclusion, CAS was present in >1/2 the children with WS/elastin arteriopathy who underwent repair of supravalvar aortic stenosis. CAS in WS/nonsyndromic elastin arteriopathy does not appear to exhibit typical ECG-detectable myocardial ischemia. ECGs are not a useful screening tool for CAS in WS/elastin arteriopathy. Given the high anesthesia-related cardiac arrest risk, other noninvasive indicators of CAS are needed.

Virtual Reality-based Methods for Training Novice Electrophysiology Trainees-A Pilot Study.

Developing an accurate and detailed 3-dimensional (3D) mental model of cardiac anatomy is critical for electrophysiology (EP) trainees. Due to its immersive nature, virtual reality (VR) may provide a better learning environment than traditional teaching methods for assimilating 3D cardiac anatomy. The purpose of this pilot study was to evaluate the technical feasibility of an interactive, remote VR-based method for teaching cardiac anatomy to novice EP trainees. We created a shared, remote VR environment that allows the shared viewing of high-resolution 3D cardiac models. Eighteen trainees accepted for pediatric and adult EP fellowships were recruited. We performed a cohort study comparing the traditional teaching methods with the VR learning environment. Participants completed a demographic questionnaire and a satisfaction survey. The adult EP trainees were given a multiple-choice pre- and post-test exam to assess their anatomical knowledge. Both the adult and pediatric EP trainee cohorts rated the VR experience positively and preferred the VR environment to the more traditional teaching method. All the participants expressed interest in incorporating the VR learning environment into the EP fellowship curriculum. The usability of the system was relatively low, with approximately one-third of participants rating the system as hard to use. The impact of the VR session on exam performance was mixed among the adult cohort. We demonstrated the feasibility of gathering geographically dispersed EP fellows in training with a shared VR-based environment to teach cardiac anatomy. Although we were not able to demonstrate a learning benefit over the traditional lecture format in the adult cohort, the training environment was favorably received by all the participants.

Editorial introductions.

Editorial introductions.

Single-lead ECGs: the future of home-monitoring in neonatal supraventricular tachycardias

Abstract Funding Acknowledgements Type of funding sources: None. Background Supraventricular tachycardia (SVT) is the most common tachyarrhythmia in the neonatal period. Prevalence has not been fully established (up to 1 in 1000 children) and incidence is reported as 1-5% during the first days of life. To date several studies have evaluated in adult population the efficacy and quality of single-lead ECG compared to standard 12-lead ECG. Limited studies are reported in literature in pediatric settings and even less in newborns population. Purpose Primary outcomes of this study are to describe the clinical follow-up of neonatal tachyarrhythmias and to assess parents’ perception of usefulness of single-lead ECG devices. Methods This is a descriptive, cross-sectional and observational study enrolled neonates aged less than 28 days of life with prenatal or postnatal diagnosis of tachyarrhythmia with single-lead ECG home-monitoring, with at least one tracing obtained during follow-up and whose caregiver completed a telephone survey between January 2017 and September 2022 in a Pediatric third-level-Centre. Clinical data and single-lead ECG tracings submitted by parents have been reviewed by two pediatric electrophysiologists. Perception of the usefulness of the device has been assessed through telephone surveys of caregivers. Results Thirty neonates were recruited (57% male, 43% female): 18 (60%) with postnatal and 12 (40%) with prenatal diagnosis. The most reported type of tachycardia was supraventricular in 25 patients (83%), half of them were atrioventricular reentrant tachycardias (AVRT) with 4 cases of Coumel tachycardia and only 2 ventricular tachycardias (VT). Parents submitted a total of 248 single-lead ECG tracings (7% unreadable and 15% with artefacts that didn’t affect the evaluation). 13% (4/30) of the neonates had tachyarrhythmia during home-monitoring: all of these were supraventricular (for a total of 14 tracings evaluated) and were admitted to the Emergency Department (ED) without evidence of hemodynamic decompensation. A variation in medical management (increasing doses of pharmacological treatment or adding another drug) has been needed. 17% (5/30) received accessory pathway ablation during clinical follow-up (2 cases of Coumel tachycardia, 2 cases of AVRT and 1 case of WPW. In the parents’ telephone surveys 72.4% of the them indicated that it was easy to obtain the tracings with the single-lead ECG and 100% to transmit them. 90% perceived a reduction in the need to go to ED and 90% showed increased comfort in managing the arrhythmia. Conclusions Home-monitoring with single-lead ECG is a useful tool for the follow-up of newborns. It allows rapid and reliable recording of heart rhythm and heart rate. It facilitates early diagnosis of tachyarrhythmias in neonates and early therapeutic decisions, provides comfort and reassurance to parents during clinical follow-up. We trust that in the future all neonatal tachyarrhythmias will benefit from this type of home-monitoring.

PO-03-124 DEVELOPMENT AND VALIDATION OF A DEEP NEURAL NETWORK TO MEASURE QTC ON PEDIATRIC ELECTROCARDIOGRAMS

A prolonged Bazett corrected QT (QTcB) either congenital or acquired is one of the primary risk factors in the development of ventricular arrhythmias and sudden cardiac death in children. QTcB determination is notoriously problematic for non-pediatric cardiologists and currently available automatic electrocardiogram (ECG) interpreters. We set out to develop and validate a deep neural network (DNN) to measure QTcB and diagnose prolonged QTc on pediatric ECGs. All resting ECGs from both inpatient and outpatient settings at a quaternary freestanding children’s hospital performed on children 0-18 years of age and read by a pediatric electrophysiologist (PEP) for which the QTcB was manually measured between January 2010 and December 2020 were included. Using the manual QTcB measurements as labels and matrices of all 15 lead voltages as features a convolutional DNN with residuals blocks was trained to measure the QTcB (unweighted DNN) and a dynamic bias was added to optimize the false negative rate and make the model more conservative (dynamically-weighted DNN). The QTcBs on a prospective sample of 200 randomly selected ECGs from 2021 were manually measured by each of 3 PEPs. The ECGs were further classified as pathologically prolonged if the QTcB >=460 ms, and the diagnostic accuracy of the algorithms and the PEPs validated against the PEP consensus estimate of the QTcB. The DNN was trained on a sample of 65,370 ECGs from 37,992 patients. The mean absolute error (MAE) of the PEPs against the consensus of all others was 17.3 (16.2-18.4) ms. Both the unweighted DNN (MAE 10.9 (10.3-11.5) ms) and the dynamically-weighted DNN (MAE 12.8 (12.0-13.6) ms) outperformed the PEPs. The sensitivity of individual PEPs to detect a prolonged QTc (>=460 ms) was 72.7% which was significantly better than the unweighted DNN (64.3%, p=0.045) but significantly worse than the dynamic DNN (92.8%, p<0.001). The positive likelihood ratio of the PEPs was lower than the uneweighted model (p=0.006) but higher than the dynamic model (p=0.002). The negative likelihood ratio of the dynamic DNN (1:12.8) outperformed both the unweighted DNN (1:2.7) and the PEPs (1:3.5). A dynamically-weighted DNN can serve as an automatic screening test to accurately detect pathologically prolonged QTc’s on pediatric ECGs given a higher sensitivity and lower negative likelihood ratio than pediatric electrophysiologists while achieving more accurate estimates of the QTc itself.

PO-03-147 EVALUATION OF A PEDIATRIC ELECTROPHYSIOLOGY CASE COMPLEXITY PREDICTION MODEL TO OPTIMIZE PROCEDURAL SCHEDULING

While operational efficiency has been evaluated in adult interventional and surgical specialties, limited data exist regarding the prediction of case complexity in the pediatric and congenital electrophysiology (EP) laboratory. To identify pre-procedural variables that predict prolonged case durations among pediatric and adult congenital patients presenting for diagnostic EP study and catheter ablation. A retrospective cross-sectional study was performed of all EP studies performed at Boston Children’s Hospital between 1/1/2015-1/1/2020 including pediatric and adult congenital heart disease patients of all ages. The primary outcome was case duration ≥180 minutes. Univariate and multivariate analyses were performed for the primary outcome using logistic regression, with a sub-analysis repeated for pediatric patients <20 years of age. During the 5-year period, 1025 patients underwent EP study and 292 (28.5%) had a case duration ≥180 minutes. Factors associated with the primary outcome on multivariate analysis were: age ≥20 years at EP study (OR 1.95, 95% CI 1.24-3.07, p 0.004), arrhythmia diagnosis of premature ventricular contractions/ventricular tachycardia (PVC/VT, OR 3.70, 95% CI 2.10-6.55, p <0.001), Fontan (OR 3.74, 95% CI 1.69-8.30, p=0.001) or Mustard/Senning physiology (OR 4.13, 95% CI 1.48-11.60, p=0.007), and the presence of non-cardiac comorbidities (OR 2.47, 95% CI 1.29-4.73, p 0.006). Restricting the analysis to pediatric patients <20 years old, factors associated with the primary outcome on multivariate analysis were an arrhythmia diagnosis of PVC/VT (OR 3.04, 95% CI 1.64-5.63, p <0.001), Fontan physiology (OR 3.13, 95% CI 1.10-8.92, p 0.033), non-cardiac comorbidities (OR 4.32, 95% CI 2.07-9.01, p <0.001), and prior ablation (OR 1.58, 95% CI 1.03-2.41, p 0.035). Intra-atrial reentrant tachycardia was not associated with prolonged case duration in either multivariate model. A weighted risk score using factors identified on multivariate analyses correctly classified procedures with prolonged case duration with reasonable accuracy (c-statistic 0.70). Age-dependent anatomic, electrophysiologic, and comorbid factors are associated with prolonged case duration in the pediatric and congenital EP laboratory. Applying a simple risk score using pre-procedural variables can discriminate cases with and without prolonged duration, and may aid in efficient procedural scheduling practices.

Transcatheter Leadless Pacing in Children: A PACES Collaborative Study in the Real-World Setting.

Transcatheter Leadless Pacemakers (TLP) are a safe and effective option for adults with pacing indications. These devices may be an alternative in pediatric patients and patients with congenital heart disease for whom repeated sternotomies, thoracotomies, or transvenous systems are unfavorable. However, exemption of children from clinical trials has created uncertainty over the indications, efficacy, and safety of TLP in the pediatric population. The objectives of this study are to evaluate clinical indications, procedural characteristics, electrical performance, and outcomes of TLP implantation in children. Retrospective data were collected from patients enrolled in the Pediatric and Congenital Electrophysiology Society TLP registry involving 15 centers. Patients ≤21 years of age who underwent Micra (Medtronic Inc, Minneapolis, MN) TLP implantation and had follow-up of ≥1 week were included in the study. The device was successfully implanted in 62 of 63 registry patients (98%) at a mean age of 15±4.1 years and included 20 (32%) patients with congenital heart disease. The mean body weight at TLP implantation was 55±19 kg and included 8 patients ≤8 years of age and ≤30 kg in weight. TLP was implanted by femoral (n=55, 87%) and internal jugular (n=8, 12.6%) venous approaches. During a mean follow-up period of 9.5±5.3 months, there were 10 (16%) complications including one cardiac perforation/pericardial effusion, one nonocclusive femoral venous thrombus, and one retrieval and replacement of TLP due to high thresholds. There were no deaths, TLP infections, or device embolizations. Electrical parameters, including capture thresholds, R wave sensing, and pacing impedances, remained stable. Initial results from the Pediatric and Congenital Electrophysiology Society TLP registry demonstrated a high level of successful Micra device implants via femoral and internal venous jugular approaches with stable electrical parameters and infrequent major complications. Long-term prospective data are needed to confirm the reproducibility of these initial findings.

New frontiers in taking care of children with heart rhythm disorders and pediatric electrophysiology publications

New frontiers in taking care of children with heart rhythm disorders and pediatric electrophysiology publications

Nurse Practitioner Delivered Virtual Care in a Pediatric Specialty Clinic

Virtual care in pediatric specialty practice has become widely used to increase access to care, one in which nurse practitioners (NPs) can play a vital role. We sought to evaluate the outcomes of virtual care provided by pediatric cardiology and electrophysiology (EP) NPs for pediatric and congenital heart disease patients. Retrospective review of all virtual care visits performed by pediatric EP NPs between October 2019 and October 2021 at a single tertiary care center. NPs delivered virtual care for 287 pediatric EP evaluations for 276 patients; 132 (45%) independently, with the remaining 155 collaborating with an electrophysiologist as a shared visit. The mean age was 15.2 ± 8.9 years. NPs performed a significant subset of these visits independently and were a vital part of all visits in this study. The role of the NP in specialty pediatric virtual care should continue to be supported and advanced.

A Global Look to the Future of Pediatric Electrophysiology

A Global Look to the Future of Pediatric Electrophysiology