Publications by authors named "Naomi J Kertesz"

43 Publications

Management of rhythm disorders in Duchenne muscular dystrophy: Is sudden death a cardiac or pulmonary problem?

Pediatr Pulmonol 2021 Apr 2;56(4):760-765. Epub 2021 Mar 2.

The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA.

Dystrophin deficiency results in the cardiomyopathy of variable onset and deficiency. Myocardial scarring commonly results in cardiac dysfunction, with both atrial and ventricular dysrhythmias. Heart failure, rather than arrhythmia burden, remains the strongest cardiac predictor of mortality in this patient population. Current data suggest the overall rate of sudden cardiac death in pediatric dilated cardiomyopathy is significantly lower than in adults. Specifically, in the Duchenne cardiomyopathy population, sudden death from an arrhythmic cause appears to be rare, even in patients with previously diagnosed arrhythmias. Despite this, recommendations for implantable cardioverter-defibrillator (ICD) placement in patients with Duchenne cardiomyopathy has traditionally been extrapolated from adult heart failure recommendations based on decreased left ventricular ejection fraction <35%. Early involvement of the cardiologist in the care for patients with dystrophin-deficient cardiomyopathy is recommended for this reason. The indications for ICD placement to prevent sudden death in patients with Duchenne cardiomyopathy are not well defined. There is little evidence to suggest that placement meaningfully prolongs life in this population, and should be carefully considered in accordance with the care goals of the patient and his family.
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http://dx.doi.org/10.1002/ppul.25205DOI Listing
April 2021

Loss of ventricular preexcitation during noninvasive testing does not exclude high-risk accessory pathways: A multicenter study of WPW in children.

Heart Rhythm 2020 10 1;17(10):1729-1737. Epub 2020 Jun 1.

Division of Pediatric Cardiology, The Children's Hospital at Montefiore Medical Center, Bronx, New York.

Background: Abrupt loss of ventricular preexcitation on noninvasive evaluation, or nonpersistent preexcitation, in Wolff-Parkinson-White syndrome (WPW) is thought to indicate a low risk of life-threatening events.

Objective: The purpose of this study was to compare accessory pathway (AP) characteristics and occurrences of sudden cardiac arrest (SCA) and rapidly conducted preexcited atrial fibrillation (RC-AF) in patients with nonpersistent and persistent preexcitation.

Methods: Patients 21 years or younger with WPW and invasive electrophysiology study (EPS) data, SCA, or RC-AF were identified from multicenter databases. Nonpersistent preexcitation was defined as absence/sudden loss of preexcitation on electrocardiogram, Holter monitoring, or exercise stress test. RC-AF was defined as clinical preexcited atrial fibrillation with shortest preexcited R-R interval (SPERRI) ≤ 250 ms. AP effective refractory period (APERP), SPERRI at EPS , and shortest preexcited paced cycle length (SPPCL) were collected. High-risk APs were defined as APERP, SPERRI, or SPPCL ≤ 250 ms.

Results: Of 1589 patients, 244 (15%) had nonpersistent preexcitation and 1345 (85%) had persistent preexcitation. There were no differences in sex (58% vs 60% male; P=.49) or age (13.3±3.6 years vs 13.1±3.9 years; P=.43) between groups. Although APERP (344±76 ms vs 312±61 ms; P<.001) and SPPCL (394±123 ms vs 317±82 ms; P<.001) were longer in nonpersistent vs persistent preexcitation, there was no difference in SPERRI at EPS (331±71 ms vs 316±73 ms; P=.15). Nonpersistent preexcitation was associated with fewer high-risk APs (13% vs 23%; P<.001) than persistent preexcitation. Of 61 patients with SCA or RC-AF, 6 (10%) had nonpersistent preexcitation (3 SCA, 3 RC-AF).

Conclusion: Nonpersistent preexcitation was associated with fewer high-risk APs, though it did not exclude the risk of SCA or RC-AF in children with WPW.
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http://dx.doi.org/10.1016/j.hrthm.2020.05.035DOI Listing
October 2020

Reclassification of Variants of Uncertain Significance in Children with Inherited Arrhythmia Syndromes is Predicted by Clinical Factors.

Pediatr Cardiol 2019 Dec 18;40(8):1679-1687. Epub 2019 Sep 18.

Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.

Genetic testing is important to augment clinical diagnosis and inform management of inherited arrhythmias syndromes (IAS), but variants of uncertain significance (VUS) are common and remain a challenge in clinical practice. In 2015, American College of Medical Genetics (ACMG) published updated guidelines for interpretation of genetic results. Despite increasing understanding of human genomic variation, there are no guidelines for reinterpretation of prior genetic test results. Patients at a single tertiary children's hospital with genetic testing for an IAS that demonstrated a VUS were re-evaluated using 2015 ACMG guidelines, clinical information, and publically available databases. Search of the electronic medical record identified 116 patients with genetic testing results available, and 24/116 (21%) harbored a VUS for an IAS. 23 unique VUS were evaluated from 12 genes. Over half of the VUS (12/23 (52%)) were reclassified using 2015 criteria, and 8 (35%) changed to pathogenic and 4 (17%) to benign. Relative risk of reclassification of VUS to a pathogenic variant in a patient with confirmed clinical diagnosis was 4.1 (95% CI 1.23-15.4). Reclassification was not associated with initial testing year. These data demonstrate 52% of VUS in children with IAS are reclassified with application of 2015 ACMG guidelines. Strength of phenotyping is associated with eventual pathogenic classification of genetic variants and periodic re-evaluation of VUS identified on genetic testing for IAS is warranted.
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http://dx.doi.org/10.1007/s00246-019-02203-2DOI Listing
December 2019

Impact of Obesity on Left Ventricular Thickness in Children with Hypertrophic Cardiomyopathy.

Pediatr Cardiol 2019 Aug 1;40(6):1253-1257. Epub 2019 Jul 1.

Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Obesity is associated with additional left ventricular hypertrophy (LVH) in adults with hypertrophic cardiomyopathy (HCM). It is not known whether obesity can lead to further LVH in children with HCM. Echocardiographic LV dimensions were determined in 504 children with HCM. Measurements of interventricular septal thickness (IVST) and posterior wall thickness (PWT), and patients' weight and height were recorded. Obesity was defined as a body mass index (BMI) ≥ 99th percentile for age and sex. IVST data was available for 498 and PWT data for 484 patients. Patient age ranged from 2 to 20 years (mean ± SD, 12.5 ± 3.9) and 340 (68%) were males. Overall, patient BMI ranged from 7 to 50 (22.7 ± 6.1). Obesity (BMI 18-50, mean 29.1) was present in 140 children aged 2-19.6 (11.3 ± 4.1). The overall mean IVST was 20.5 ± 9.6 mm and the overall mean PWT was 11.0 ± 8.4 mm. The mean IVST in the obese patients was 21.6 ± 10.0 mm and mean PWT was 13.3 ± 14.7 mm. The mean IVST in the non-obese patients was 20.1 ± 9.5 mm and mean PWT was 10.4 ± 4.3 mm. Obesity was not significantly associated with IVST (p = 0.12), but was associated with increased PWT (0.0011). Obesity is associated with increased PWT but not IVST in children with HCM. Whether obesity and its impact on LVH influences clinical outcomes in children with HCM needs to be studied.
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http://dx.doi.org/10.1007/s00246-019-02145-9DOI Listing
August 2019

Risk factors for lethal arrhythmic events in children and adolescents with hypertrophic cardiomyopathy and an implantable defibrillator: An international multicenter study.

Heart Rhythm 2019 10 23;16(10):1462-1467. Epub 2019 Apr 23.

Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

Background: Predictors of risk of lethal arrhythmic events (LAE) is poorly understood and may differ from adults in children with hypertrophic cardiomyopathy (HCM).

Objective: The purpose of this study was to determine predictors of LAE in children with HCM.

Methods: A retrospective data collection was performed on 446 children and teenagers 20 years and younger (290 [65%] male; mean age 10.1 ± 5.7 years) with idiopathic HCM from 35 centers. Patients were classified as group 1 (HCM with LAE) if having a secondary prevention implantable cardioverter-defibrillator (ICD) or primary prevention ICD with appropriate interventions or group 2 (HCM without LAE) if having a primary prevention ICD without appropriate interventions.

Results: There were 152 children (34%) in group 1 and 294 (66%) in group 2. Risk factors for group 1 by univariate analysis were septal thickness, posterior left ventricular (LV) wall thickness, lower LV outflow gradient, and Q wave > 3 mm in inferior electrocardiographic leads. Factors not associated with LAE were family history of SCD, abnormal blood pressure response to exercise, and ventricular tachycardia on ambulatory electrocardiographic monitoring. Risk factors for SCD by multivariate analysis were age at ICD placement (hazard ratio [HR] 0.9; P = .0025), LV posterior wall thickness z score (HR 1.02; P < .005), and LV outflow gradient < 30 mm Hg (HR 2.0; P < .006). LV posterior wall thickness z score ≥ 5 was associated with LAE.

Conclusion: Risk factors for LAE appear different in children compared to adults. Conventional adult risk factors were not significant in children. Further prospective studies are needed to improve risk stratification for LAE in children with HCM.
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http://dx.doi.org/10.1016/j.hrthm.2019.04.040DOI Listing
October 2019

Life-Threatening Event Risk in Children With Wolff-Parkinson-White Syndrome: A Multicenter International Study.

JACC Clin Electrophysiol 2018 04 15;4(4):433-444. Epub 2017 Nov 15.

Division of Cardiology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada.

Objectives: This study sought to characterize risk in children with Wolff-Parkinson-White (WPW) syndrome by comparing those who had experienced a life-threatening event (LTE) with a control population.

Background: Children with WPW syndrome are at risk of sudden death.

Methods: This retrospective multicenter pediatric study identified 912 subjects ≤21 years of age with WPW syndrome, using electrophysiology (EPS) studies. Case subjects had a history of LTE: sudden death, aborted sudden death, or atrial fibrillation (shortest pre-excited RR interval in atrial fibrillation [SPERRI] of ≤250 ms or with hemodynamic compromise); whereas subjects did not. We compared clinical and EPS data between cases and subjects.

Results: Case subjects (n = 96) were older and less likely than subjects (n = 816) to have symptoms or documented tachycardia. Mean age at LTE was 14.1 ± 3.9 years of age. The LTE was the sentinel symptom in 65%, consisting of rapidly conducted pre-excited atrial fibrillation (49%), aborted sudden death (45%), and sudden death (6%). Three risk components were considered at EPS: SPERRI, accessory pathway effective refractory period (APERP), and shortest paced cycle length with pre-excitation during atrial pacing (SPPCL), and all were shorter in cases than in control subjects. In multivariate analysis, risk factors for LTE included male sex, Ebstein malformation, rapid anterograde conduction (APERP, SPERRI, or SPPCL ≤250 ms), multiple pathways, and inducible atrial fibrillation. Of case subjects, 60 of 86 (69%) had ≥2 EPS risk stratification components performed; 22 of 60 (37%) did not have EPS-determined high-risk characteristics, and 15 of 60 (25%) had neither concerning pathway characteristics nor inducible atrioventricular reciprocating tachycardia.

Conclusions: Young patients may experience LTE from WPW syndrome without prior symptoms or markers of high-risk on EPS.
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http://dx.doi.org/10.1016/j.jacep.2017.10.009DOI Listing
April 2018

Efficacy of Flecainide in the Treatment of Catecholaminergic Polymorphic Ventricular Tachycardia: A Randomized Clinical Trial.

JAMA Cardiol 2017 07;2(7):759-766

Thomas P. Graham Jr Division of Pediatric Cardiology, Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt Center for Arrhythmia Research and Therapeutics, Vanderbilt University Medical Center, Nashville, Tennessee14Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee17Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee.

Importance: Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a potentially lethal genetic arrhythmia syndrome characterized by polymorphic ventricular tachycardia with physical or emotional stress, for which current therapy with β-blockers is incompletely effective. Flecainide acetate directly suppresses sarcoplasmic reticulum calcium release-the cellular mechanism responsible for triggering ventricular arrhythmias in CPVT-but has never been assessed prospectively.

Objective: To determine whether flecainide dosed to therapeutic levels and added to β-blocker therapy is superior to β-blocker therapy alone for the prevention of exercise-induced arrhythmias in CPVT.

Design, Setting, And Participants: This investigator-initiated, multicenter, single-blind, placebo-controlled crossover clinical trial was conducted from December 19, 2011, through December 29, 2015, with a midtrial protocol change at 10 US sites. Patients with a clinical diagnosis of CPVT and an implantable cardioverter-defibrillator underwent a baseline exercise test while receiving maximally tolerated β-blocker therapy that was continued throughout the trial. Patients were then randomized to treatment A (flecainide or placebo) for 3 months, followed by exercise testing. After a 1-week washout period, patients crossed over to treatment B (placebo or flecainide) for 3 months, followed by exercise testing.

Interventions: Patients received oral flecainide or placebo twice daily, with the dosage guided by trough serum levels.

Main Outcomes And Measures: The primary end point of ventricular arrhythmias during exercise was compared between the flecainide and placebo arms. Exercise tests were scored on an ordinal scale of worst ventricular arrhythmia observed (0 indicates no ectopy; 1, isolated premature ventricular beats; 2, bigeminy; 3, couplets; and 4, nonsustained ventricular tachycardia).

Results: Of 14 patients (7 males and 7 females; median age, 16 years [interquartile range, 15.0-22.5 years]) randomized, 13 completed the study. The median baseline exercise test score was 3.0 (range, 0-4), with no difference noted between the baseline and placebo (median, 2.5; range, 0-4) exercise scores. The median ventricular arrhythmia score during exercise was significantly reduced by flecainide (0 [range, 0-2] vs 2.5 [range, 0-4] for placebo; P < .01), with complete suppression observed in 11 of 13 patients (85%). Overall and serious adverse events did not differ between the flecainide and placebo arms.

Conclusions And Relevance: In this randomized clinical trial of patients with CPVT, flecainide plus β-blocker significantly reduced ventricular ectopy during exercise compared with placebo plus β-blocker and β-blocker alone.

Trial Registration: clinicaltrials.gov Identifier: NCT01117454.
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http://dx.doi.org/10.1001/jamacardio.2017.1320DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5548393PMC
July 2017

Effectiveness of Early Invasive Therapy for Atrial Tachycardia in Adult Atrial-Baffle Survivors.

Tex Heart Inst J 2017 Feb 1;44(1):16-21. Epub 2017 Feb 1.

Adults who underwent complex atrial baffling as children via Mustard or Senning procedures are at heightened risk for atrial arrhythmias. Antiarrhythmic therapies are typically ineffective in this population. Accordingly, our team of pediatric and adult electrophysiologists investigated the effectiveness of early invasive transbaffle-access techniques to perform early radiofrequency ablation at the source of these clinically significant arrhythmias. For this retrospective study, we selected 11 adult survivors of atrial baffling (mean age, 34 ± 9 yr) who underwent clinically indicated electrophysiologic study after no more than one trial of antiarrhythmic therapy. Using transbaffle-access techniques and 3-dimensional mapping of the venous atria, we found 12 inducible arrhythmias in 10 patients: intra-atrial reentrant tachycardia (n=6), atrioventricular nodal reentrant tachycardia (n=3), focal atrial tachycardia (n=2), and repetitive double firing of the atrioventricular node (n=1). Defining success as short- and midterm freedom from arrhythmia, we analyzed outcomes of radiofrequency ablation at 1 and 6 months. At 1 month, ablation was 100% successful. At 6 months, after 11 ablations in 9 patients, 5 patients had no clinical recurrence, 2 had improved arrhythmia control from minimal medical therapy, and 2 were to undergo repeat study for recurrent tachycardia. In the recurrence-free patients, arrhythmias during electrophysiology study matched the types found clinically before the study. To our knowledge, this is the largest one-year cohort of adult survivors of atrial baffling to have undergone study by a combined pediatric-adult electrophysiology team. We conclude that early invasive transbaffle access for ablating diverse atrial tachyarrhythmias was effective in these patients.
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http://dx.doi.org/10.14503/THIJ-15-5470DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5317354PMC
February 2017

Arrhythmias After Stage I Hybrid Palliation in Single-Ventricle Patients.

Pediatr Cardiol 2016 Dec 18;37(8):1416-1421. Epub 2016 Jul 18.

Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH, 43205-2664, USA.

The hybrid procedure is an alternative palliative strategy for patients with single-ventricle physiology. No data exist documenting the incidence of arrhythmias after the hybrid procedure. Goal of this study was to determine the incidence and type of arrhythmias in patients undergoing the hybrid procedure. A retrospective chart review was performed including all patients undergoing the hybrid procedure between January of 2010 through December of 2013. Sixty-five patients underwent the hybrid procedure during this time period (43 HLHS, 22 other). Average gestational age at admission was 37.7 weeks. Average age at time of procedure was 7.6 days. Five patients had documented arrhythmias (7.7 %). Four were supraventricular tachycardias, and 1 was a sinus bradycardia. One patient with arrhythmia died during hospitalization, and another patient with arrhythmia died during the interstage period. Hybrid palliation for patients with single-ventricle physiology has a low incidence of arrhythmias. In this cohort of patients, arrhythmias did not contribute to mortality. There was a trend toward association between arrhythmias and longer total length of hospital stay.
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http://dx.doi.org/10.1007/s00246-016-1450-3DOI Listing
December 2016

Outcomes following the implantation of cardioverter-defibrillator for primary prevention in transposition of the great arteries after intra-atrial baffle repair: a single-centre experience.

Europace 2016 Jul 23;18(7):1016-22. Epub 2015 Dec 23.

The Heart Center, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43215, USA.

Aims: Patients with D-loop transposition of the great arteries (D-TGA) status post intra-atrial baffling are at an increased risk for sudden cardiac arrest. The benefit of primary implantable cardioverter-defibrillator (ICD) implantation in these patients is questionable due to high burden of adverse events. We aimed to evaluate the incidence and causes of all types of device shocks, as well as of device-related complications among patients with D-TGA implanted with ICDs for primary prevention.

Methods And Results: Retrospective analysis of all patients with D-TGA who underwent atrial switch procedure and ICD implantation for primary prevention. Eighteen patients (83% males) were identified. Average age at atrial switch was 2.5 years (range 0.1-17) and at ICD implantation 26 years (15-41). During a median follow-up of 4 years, 10 patients (55%) received shocks for non-ventricular arrhythmic events, whereas 1 patient was shocked for ventricular tachycardia, for an annual rate of shock delivery of 7.1%. The most common cause for shock delivery was the occurrence of atrial arrhythmias, mostly in the form of atrial flutter. Elevated systemic ventricular end-diastolic pressures were found to be associated with an increased risk for inappropriate shocks. Five patients (28%) required lead extraction and three required generator change due to device recalls during follow-up.

Conclusion: Atrial arrhythmias were the most common cause for ICD shocks in a primary prevention population, while ventricular tachycardia was infrequent. The association between elevated end-diastolic pressures and the occurrence of arrhythmias demonstrates the close mechano-electrical relationship in D-TGA and may be an important predictor of arrhythmic events.
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http://dx.doi.org/10.1093/europace/euv297DOI Listing
July 2016

Arrhythmias Following Comprehensive Stage II Surgical Palliation in Single Ventricle Patients.

Pediatr Cardiol 2016 Mar 14;37(3):552-7. Epub 2015 Dec 14.

The Heart Center, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.

Post-operative arrhythmias are common in pediatric patients following cardiac surgery. Following hybrid palliation in single ventricle patients, a comprehensive stage II palliation is performed. The incidence of arrhythmias in patients following comprehensive stage II palliation is unknown. The purpose of this study is to determine the incidence of arrhythmias following comprehensive stage II palliation. A single-center retrospective chart review was performed on all single ventricle patients undergoing a comprehensive stage II palliation from January 2010 to May 2014. Pre-operative, operative, and post-operative data were collected. A clinically significant arrhythmia was defined as an arrhythmia which led to cardiopulmonary resuscitation or required treatment with either pacing or antiarrhythmic medication. Statistical analysis was performed with Wilcoxon rank-sum test and Fisher's exact test with p < 0.05 significant. Forty-eight single ventricle patients were reviewed (32 hypoplastic left heart syndrome, 16 other single ventricle variants). Age at surgery was 185 ± 56 days. Cardiopulmonary bypass time was 259 ± 45 min. Average vasoactive-inotropic score was 5.97 ± 7.58. Six patients (12.5 %) had clinically significant arrhythmias: four sinus bradycardia, one 2:1 atrioventricular block, and one slow junctional rhythm. No tachyarrhythmias were documented for this patient population. Presence of arrhythmia was associated with elevated lactate (p = 0.04) and cardiac arrest (p = 0.002). Following comprehensive stage II palliation, single ventricle patients are at low risk for development of tachyarrhythmias. The most frequent arrhythmia seen in these patients was sinus bradycardia associated with respiratory compromise.
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http://dx.doi.org/10.1007/s00246-015-1314-2DOI Listing
March 2016

Experience with Holter monitoring during propranolol therapy for infantile hemangiomas.

J Am Acad Dermatol 2015 Aug 6;73(2):255-7. Epub 2015 Jun 6.

Nationwide Children's Hospital, Columbus, Ohio. Electronic address:

Background: Although adverse events in children treated with propranolol have proven rare, the appropriate methods of assessing cardiovascular risk and monitoring for toxicity when the medication is used for infantile hemangiomas remain unclear.

Objective: We sought to analyze Holter monitor reports of otherwise healthy patients on propranolol for infantile hemangiomas to determine the incidence of sustained arrhythmias and to evaluate the utility of Holter monitoring in the outpatient setting.

Methods: We retrospectively reviewed the charts of patients with infantile hemangioma who underwent 24-hour Holter monitoring after initiation or dose escalation of propranolol between 2011 and 2014.

Results: In all, 43 patients aged 1.8 to 36.2 months, with 44 Holter monitor reports, were included in the study. No sustained arrhythmias were revealed. The treatment plan was not altered in any patient based on the Holter monitor report.

Limitations: This was a retrospective study design.

Conclusion: Our study suggests that Holter monitoring may be unnecessary in otherwise healthy patients with infantile hemangioma older than 12 weeks who are treated with propranolol in the outpatient setting.
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http://dx.doi.org/10.1016/j.jaad.2015.05.015DOI Listing
August 2015

Magnetic versus manual catheter navigation for ablation of free wall accessory pathways in children.

Circ Arrhythm Electrophysiol 2012 Aug 24;5(4):804-8. Epub 2012 May 24.

Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA.

Background: Transcatheter ablation of accessory pathway (AP)-mediated tachycardia is routinely performed in children. Little data exist regarding the use of magnetic navigation (MN) and its potential benefits for ablation of AP-mediated tachycardia in this population.

Methods And Results: We performed a retrospective review of prospectively gathered data in children undergoing radiofrequency ablation at our institution since the installation of MN (Stereotaxis Inc, St. Louis, MO) in March 2009. The efficacy and safety between an MN-guided approach and standard manual techniques for mapping and ablation of AP-mediated tachycardia were compared. During the 26-month study period, 145 patients underwent radiofrequency ablation for AP-mediated tachycardia. Seventy-three patients were ablated with MN and 72 with a standard manual approach. There were no significant differences in demographic factors between the 2 groups with a mean cohort age of 13.1±4.0 years. Acute success rates were equivalent with 68 of 73 (93.2%) patients in the MN group being successfully ablated versus 68 of 72 (94.4%) patients in the manual group (P=0.889). During a median follow-up of 21.4 months, there were no recurrences in the MN group and 2 recurrences in the manual group (P=0.388). There were no differences in time to effect, number of lesions delivered, or average ablation power. There was also no difference in total procedure time, but fluoroscopy time was significantly reduced in the MN group at 14.0 (interquartile range, 3.8-23.9) minutes compared with the manual group at 28.1 (interquartile range, 15.3-47.3) minutes (P<0.001). There were no complications in either group.

Conclusions: MN is a safe and effective approach to ablate AP-mediated tachycardia in children.
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http://dx.doi.org/10.1161/CIRCEP.111.969485DOI Listing
August 2012

Impact of the American Heart Association scientific statement on screening electrocardiograms and stimulant medications.

Arch Pediatr Adolesc Med 2011 Feb;165(2):166-70

Lillie Frank Abercrombie Section of Pediatric Cardiology, Department of Cardiology, Texas Children's Hospital, 6621 Fannin, Houston, TX 77030, USA.

Objective: To evaluate the impact of the American Heart Association (AHA) scientific statement regarding electrocardiograms (ECGs) and stimulant medications on the practice of community pediatricians.

Design: Retrospective evaluation and survey analysis.

Setting: Academic tertiary care center.

Participants: Patients with ECGs referred to our institution by pediatricians with an indication of stimulant medication screening in the year after the AHA statement.

Intervention: We compared the ECG ordering practices of community pediatricians and the outcomes of further evaluation and estimated the associated cost before and after the AHA scientific statement.

Main Outcome Measures: Abnormal ECG findings, further workup, and change in clinical practice.

Results: In the year after publication of the 2008 AHA scientific statement, 372 ECGs were ordered with an indication of stimulant medication screening. Before publication of this statement, a mean (SD) of 6.9 (3.2) ECGs per month were referred for this indication. Despite continuing controversy, this number increased 4-fold to 31.2 (9.5) ECGs per month in the subsequent year. Twenty-four ECGs (6.4%) had abnormal findings. Eighteen patients were referred for further evaluation, and, at last follow-up, none had been found to have definitive disease. Six of 24 patients with abnormal ECG findings (25.0%) had a perceived significant delay in therapy because of the process. In responding pediatricians, 34.6% reported that the scientific statement had clearly affected their practice.

Conclusions: The clinical practice of community pediatricians in regard to screening ECGs and stimulant medications has been affected by the recent AHA scientific statement. The yield of performing ECGs with an indication of stimulant medication screening is very low.
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http://dx.doi.org/10.1001/archpediatrics.2010.278DOI Listing
February 2011

Use of a cardioselective beta-blocker for pediatric patients with prolonged QT syndrome.

Pediatr Cardiol 2011 Jan 20;32(1):63-6. Epub 2010 Oct 20.

Section of Pediatric Cardiology, Fundacion contra las enfermedades Neurologicas de la Infancia, Buenos Aires, Argentina.

The data on the efficacy of atenolol for long-QT syndrome (LQTS) are controversial. This study aimed to evaluate the efficacy of atenolol for pediatric patients with LQTS. A retrospective observational study investigating all patients who had LQTS treated with atenolol at two institutions was performed. The study identified 57 patients (23 boys and 34 girls) with a mean QT corrected for heart rate (QTc) of 521 ± 54 ms. The mean age of these patients at diagnosis was 9 ± 6 years. Their clinical manifestations included no symptoms (n = 33, 58%), ventricular tachycardia (n = 10, 18%), syncope (n = 6, 10%), resuscitated sudden cardiac death (n = 4, 7%), atrioventricular block (n = 2, 4%), and bradycardia or presyncope (n = 2, 3%). Of the 57 patients, 13 (22%) had a family history of sudden death. The follow-up period was 5.4 ± 4.5 years. Atenolol at a mean dose of 1.4 ± 0.5 mg/kg/day was administered twice a day for all the patients. The mean maximum heart rate was 132 ± 27 bpm on Holter monitors and 155 ± 16 bpm on exercise treadmill tests, with medication doses titrated up to achieve a maximum heart rate lower than 150 bpm on both tests. During the follow-up period, one patient died (noncompliant with atenolol at the time of death), and the remaining patients had no sudden cardiac death events. Four patients (8%) had recurrent ventricular arrhythmias, three of whom received an implantable cardioverter defibrillator (all symptomatic at the time of diagnosis). For three patients (6%), it was necessary to rotate to a different beta-blocker because of side effects or inadequate heart rate control. Atenolol administered twice daily constitutes a valid and effective alternative for the treatment of pediatric patients with LQTS.
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http://dx.doi.org/10.1007/s00246-010-9819-1DOI Listing
January 2011

Frequency of cardiac death in children with idiopathic dilated cardiomyopathy.

Am J Cardiol 2009 Dec 14;104(11):1574-7. Epub 2009 Oct 14.

Department of Pediatrics, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA.

The prognosis in children with idiopathic dilated cardiomyopathy (IDC) is guarded, with the 5-year mortality rate ranging from 14% to 50%, owing to sudden cardiac death (SCD) or pump failure. The risk factors for SCD in adults with IDC include asymptomatic nonsustained ventricular tachycardia and poor left ventricular function. It is unclear whether these findings can be extrapolated to the pediatric population. A retrospective review of all patients with the diagnosis of IDC seen at a single institution from 1990 to 2004 was performed. A total of 85 patients (46 males), with a median age of 3.8 years (0 days to 17.3 years) were studied. The mean left ventricular ejection fraction was 25 +/- 12% (median 23%, range 45% to 45%) at presentation. The following arrhythmias occurred at presentation or during the initial hospitalization: nonsustained ventricular tachycardia in 6, sustained ventricular tachycardia or fibrillation in 1, supraventricular arrhythmias in 6, and both atrial and ventricular arrhythmias in 1. During a subsequent hospitalization or outpatient follow-up, 7 patients had the following arrhythmias: supraventricular arrhythmias in 2, nonsustained ventricular tachycardia in 4, and both atrial and ventricular arrhythmias in 1. The cumulative survival rate was 40% at a mean follow-up of 6.2 years (95% confidence interval 4.4 to 8.1). One single episode of SCD occurred in 1 patient without a history of sustained arrhythmias. In conclusion, in children with IDC, despite the low left ventricular ejection fraction and presence of ventricular arrhythmias, only one episode of SCD occurred in this group of patients. Given the 1% incidence of SCD in this cohort, the use of implantable cardioverter-defibrillators as primary prevention in children with IDC might not be indicated.
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http://dx.doi.org/10.1016/j.amjcard.2009.07.034DOI Listing
December 2009

Radiofrequency ablation of nonautomatic focal atrial tachycardia in children with structurally normal hearts.

J Interv Card Electrophysiol 2009 Dec;26(3):225-9

Section of Pediatric Cardiology, FLENI, Buenos Aires, Argentina.

Introduction: The majority of children presenting with paroxysmal supraventricular tachycardia (SVT) have either accessory-pathway-mediated tachycardia or AV node reentry tachycardia. The purpose of this study is to report an unusual mechanism of SVT found in children with structurally normal hearts.

Methods And Results: Records of all patients undergoing an electrophysiology study (EPS) at our institution between 2000 and 2004 were reviewed to identify those with nonautomatic focal atrial tachycardia (NAFAT). Five patients (three males) with an average age of 13.8 years (median 15 years, range 7-18 years) were identified. All presented with paroxysmal palpitations. They all had structurally normal hearts. At EPS, SVT was reproducibly induced with programmed atrial stimulation (single, double, or triple extrastimuli) in all patients. The average cycle length was 276 +/- 9 ms. Adenosine terminated SVT in 2. A 3-D electro-anatomical system mapping was used in all cases. The right atrium (RA) was mapped in all and the left in two. Foci were mapped to the posterior high RA, lateral RA, lower mid RA septum, inferior to the sinus node, and in the right and left posteroseptal areas. Average number of radiofrequency lesions placed was 8.6 +/- 5. The success rate was 80%; there was one late recurrence. No procedural complications were observed.

Conclusions: NAFAT is a rare form of tachycardia that should be considered in the differential diagnosis of children presenting with SVT. It is amenable to mapping and radiofrequency ablation.
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http://dx.doi.org/10.1007/s10840-009-9430-7DOI Listing
December 2009

Pediatric nonpost-operative junctional ectopic tachycardia medical management and interventional therapies.

J Am Coll Cardiol 2009 Feb;53(8):690-7

Department of Pediatrics, Division of Cardiology, The Children's Hospital, 13123 E. 16th Avenue, Aurora, CO 80045, USA.

Objectives: To determine the outcomes of medical management, pacing, and catheter ablation for the treatment of nonpost-operative junctional ectopic tachycardia (JET) in a pediatric population.

Background: Nonpost-operative JET is a rare tachyarrhythmia that is associated with a high rate of morbidity and mortality. Most reports of clinical outcomes were published before the routine use of amiodarone or ablation therapies.

Methods: This is an international, multicenter retrospective outcome study of pediatric patients treated for nonpost-operative JET.

Results: A total of 94 patients with JET and 5 patients with accelerated junctional rhythm (age 0.8 year, range fetus to 16 years) from 22 institutions were identified. JET patients presenting at age < or =6 months were more likely to have incessant JET and to have faster JET rates. Antiarrhythmic medications were utilized in a majority of JET patients (89%), and of those, amiodarone was the most commonly reported effective agent (60%). Radiofrequency ablation was conducted in 17 patients and cryoablation in 27, with comparable success rates (82% radiofrequency vs. 85% cryoablation, p = 1.0). Atrioventricular junction ablation was required in 3% and pacemaker implantation in 14%. There were 4 (4%) deaths, all in patients presenting at age < or =6 months.

Conclusions: Patients with nonpost-operative JET have a wide range of clinical presentations, with younger patients demonstrating higher morbidity and mortality. With current medical, ablative, and device therapies, the majority of patients have a good clinical outcome.
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http://dx.doi.org/10.1016/j.jacc.2008.11.019DOI Listing
February 2009

Cross-stimulation: a rare complication of chronic epicardial leads.

J Cardiovasc Electrophysiol 2009 Sep 2;20(9):1065-7. Epub 2009 Feb 2.

Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas 77030, USA.

Cross-stimulation is a rare phenomenon that occurs during dual-chamber pacing when the pacing stimulus to one chamber results in the inadvertent capture of the other. Most cases are attributable to intrinsic design features of particular device models or lead malpositioning, and only occur early postimplantation with subsequent spontaneous resolution. We report a case of cross-stimulation occurring in a patient with chronic epicardial leads without loss of lead integrity.
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http://dx.doi.org/10.1111/j.1540-8167.2008.01421.xDOI Listing
September 2009

Results of a multicenter retrospective implantable cardioverter-defibrillator registry of pediatric and congenital heart disease patients.

J Am Coll Cardiol 2008 Apr;51(17):1685-91

Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts 02115, USA.

Objectives: We sought to determine the implications of implantable cardioverter-defibrillator (ICD) placement in children and patients with congenital heart disease (CHD).

Background: There is increasing frequency of ICD use in pediatric and CHD patients. Until recently, prospective registry enrollment of ICD patients was not available, and children and CHD patients account for only a small percentage of ICD recipients. Therefore, we retrospectively obtained collaborative data from 4 pediatric centers, aiming to identify implant characteristics, shock frequency, and complications in this unique population.

Methods: Databases from 4 centers were collated in a blinded fashion. Demographic information, implant electrical parameters, appropriate and inappropriate shock data, and complications were recorded for all implants from 1992 to 2004.

Results: A total of 443 patients were included, with a median age of 16 years (range 0 to 54 years) and median weight of 61 kg (range 2 to 130 kg), with 69% having structural heart disease. The most common diagnoses were tetralogy of Fallot (19%) and hypertrophic cardiomyopathy (14%). Implant indication was primary prevention in 52%. Shock data were available on 409 patients, of whom 105 (26%) received appropriate shocks (mean 4 shocks/patient, range 1 to 29 shocks/patient). Inappropriate shocks occurred in 87 of 409 patients (21%), with a mean of 6 per patient (range 1 to 60), mainly attributable to lead failure (14%), sinus or atrial tachycardias (9%), and/or oversensing (4%).

Conclusions: Children and CHD ICD recipients have significant appropriate and inappropriate shock frequencies. Optimizing programming, medical management, and compliance may diminish inappropriate shocks. Despite concerns regarding generator recalls, lead failure remains the major cause of inappropriate shocks, complications, and system malfunction in children. Prospective assessment of ICD usage in this population may identify additional important factors in pediatric and CHD patients.
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http://dx.doi.org/10.1016/j.jacc.2008.01.033DOI Listing
April 2008

Isolated junctional tachycardia in a patient with pheochromocytoma: an unusual presentation of an uncommon disease.

Pediatr Cardiol 2008 Sep 8;29(5):986-8. Epub 2007 Nov 8.

Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.

Pheochromocytoma is a rare disease, which often presents a diagnostic challenge due to a variable symptom presentation complex. We report the case of a child who presented with isolated symptoms of palpitations and was found to have junctional tachycardia with subsequent development of cardiomyopathy. Further evaluation revealed that she had an extra-adrenal pheochromocytoma, which was the cause of her arrhythmia and subsequent symptomatology.
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http://dx.doi.org/10.1007/s00246-007-9134-7DOI Listing
September 2008

Maintenance of AV synchrony in a small child utilizing two pacemakers and the triggered VVT mode: triggered pacing in small children.

Pacing Clin Electrophysiol 2007 Nov;30(11):1404-7

Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas 77030, USA.

Infants and small children with atrioventricular (AV) nodal disease frequently require pacing in order to maintain an adequate heart rate. The maintenance of AV synchrony is physiologically optimal in this setting. Unfortunately, small size and congenital anomalies often preclude the placement of standard transvenous dual chamber pacing systems. We report the case of a small child with a pre-existing dual chamber epicardial pacing system and subsequent ventricular lead dysfunction who underwent implantation of a new single chamber transvenous system which was programmed in VVT (triggered) mode in order to maintain AV synchrony.
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http://dx.doi.org/10.1111/j.1540-8159.2007.00880.xDOI Listing
November 2007

Isolated sinus node dysfunction in an infant with developmental delay.

Pediatr Cardiol 2008 Nov 22;29(6):1101-3. Epub 2007 Sep 22.

Department of Pediatrics, Baylor College of Medicine, The Lillie Frank Abercrombie Section of Cardiology, Houston, TX, USA.

We present a case of an infant with developmental delay, a structurally normal heart, and prolonged sinus pauses that suffered an unmonitored cardiac arrest while in the hospital. An investigation into the etiology of her sinus pauses did not reveal a definitive cause, and she continued to have pauses up to 15 s in duration. Her history of the cardiac arrest and the duration of the pauses guided the physicians' recommendations and the family's decision to undergo pacemaker implantation prior to discharge from the hospital.
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http://dx.doi.org/10.1007/s00246-007-9033-yDOI Listing
November 2008

Ventricular function and long-term pacing in children with congenital complete atrioventricular block.

J Cardiovasc Electrophysiol 2007 Apr;18(4):373-7

Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas 77030, USA.

Objective: To determine the sequela of right ventricular pacing in children with congenital complete atrioventricular block.

Background: Pacing is a well-accepted therapy for patients with congenital complete atrioventricular block. The long-term sequela of right ventricular pacing in this population has not been well described.

Methods: We performed a cohort study on all patients with congenital complete atrioventricular block who underwent pacemaker implantation at our institution from 1972 to 2004. Patients with associated congenital heart disease or ventricular dysfunction prior to pacemaker implantation were excluded.

Results: A total of 63 patients were included in the study. The median age at pacemaker implantation was 6.5 years, with an average follow-up of 9.9 years. The cumulative dysfunction free survival at 20 years was 92%. In total, four patients (6%) were noted to develop LV dysfunction an average of 15.1 years after pacemaker implantation. Of 30 patients who were paced for >10 years, only three (10%) developed echocardiographic evidence of LV dysfunction. Right ventricular apex pacing and prolonged QRS duration were found to be predictive of decreased long-term LV systolic function (P < 0.05).

Conclusions: Left ventricular dysfunction in patients with congenital complete atrioventricular block is a rare finding, even in those who have been paced for more than 10 years. Right ventricular apex pacing and prolonged QRS duration may be associated with decreased ventricular function over time. At this time, with such a low incidence of cardiac dysfunction, right ventricular pacing should be considered an acceptable first-line therapy in this population.
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http://dx.doi.org/10.1111/j.1540-8167.2006.00741.xDOI Listing
April 2007

Transient complete atrioventricular block after placement of a central venous catheter in a neonate.

Pediatr Crit Care Med 2007 Jan;8(1):64-6

Texas Children's Hospital, Lillie Frank Abercrombie Section of Pediatric Cardiology, Houston, TX, USA.

Objective: We present a case of trauma-induced complete atrioventricular block (transient) after placement of a central venous catheter.

Design: Case report.

Setting: Neonatal intensive care unit in a tertiary care children's hospital.

Patient: Review of the medical record and clinical course of a single premature infant.

Interventions: Removal of central venous catheter, monitoring of the cardiac output exam, and serial monitoring of the arrhythmia profile.

Measurements And Main Results: Trauma-induced complete atrioventricular block from placement of the central venous catheter resolved in 9 days, obviating the need for pacemaker placement.

Conclusions: Complete atrioventricular block is an infrequent complication of central venous catheter placement and may require several days to resolve.
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http://dx.doi.org/10.1097/01.pcc.0000256618.78382.daDOI Listing
January 2007

Therapeutic levels of intravenous procainamide in neonates: a retrospective assessment.

Pharmacotherapy 2006 Dec;26(12):1687-93

Department of Pharmacy, Texas Children's Hospital, Houston, Texas 77030.

Study Objectives: To evaluate dosing and pharmacokinetic parameters of intravenous continuous-infusion procainamide in neonates, and to identify dosage regimens and factors leading to therapeutic procainamide levels and minimal adverse events.

Design: Retrospective, observational study.

Setting: Pediatric hospital.

Patients: . Twenty-one patients (seven preterm, 14 full term) younger than 30 days who received continuous-infusion procainamide therapy for more than 15 hours or had two consecutive therapeutic procainamide levels obtained while receiving therapy between June 1, 2002, and December 31, 2005.

Measurements And Main Results: Data on demographics, dosing, drug levels, and adverse effects were collected. Doses that achieved therapeutic levels were documented, and procainamide clearance was calculated and evaluated with regard to renal function and gestational age in patients who were at steady state. Mean clearance and mean N-acetylprocainamide (NAPA):procainamide ratios were compared between preterm and term neonates. No patients experienced hemodynamic instability or other adverse effects due to procainamide. Procainamide was given as a mean +/- SD 9.6 +/- 1.5-mg/kg bolus in 20 of 21 patients before continuous infusion. The mean +/- SD dose at which two therapeutic levels were achieved was 37.56 +/- 13.52 microg/kg/minute. Procainamide clearance was 6.36 +/- 8.85 ml/kg/minute and correlated with creatinine clearance (r=0.78, p<0.00001) and age at day of sampling (r=0.49, p<0.00001). The NAPA:procainamide ratio at steady state was 0.84 +/- 0.53; two patients were determined to be fast acetylators (ratio > 1). Preterm infants had lower mean clearance rates (p<0.001) but higher NAPA:procainamide ratios (p<0.01) than those of term infants. Five patients experienced seven supratherapeutic levels while receiving therapy; four of these patients were preterm, and all had creatinine clearances less than 30 ml/minute/1.73 m(2). Three patients had four pairs of levels obtained after discontinuation of procainamide, and elimination rate constant and half-life were calculated.

Conclusion: Procainamide can be safely used in neonates, with no short-term adverse effects. The dosage regimen for intravenous procainamide required to achieve therapeutic levels in neonates is similar to that of older infants and children. Doses may need to be reduced in premature infants and in those with renal dysfunction.
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http://dx.doi.org/10.1592/phco.26.12.1687DOI Listing
December 2006

Atrial flutter in infants.

J Am Coll Cardiol 2006 Sep 17;48(5):1040-6. Epub 2006 Aug 17.

Department of Pediatrics, Division of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA.

Objectives: We sought to characterize the clinical nature of atrial flutter (AFL) in a large cohort of infants.

Background: There are no large studies describing the natural history of AFL in infants. Previous studies vary in the therapy used and expected prognosis.

Methods: We reviewed the records of all children younger than 1 year of age who were diagnosed with AFL at our hospital during the past 25 years, excluding those with previous cardiac surgery.

Results: We identified 50 infants with AFL. Most, 36 (72%), presented within the first 48 h of life. Congestive heart failure was evident in 10 infants, with 6 presenting at 1 day of age, and 4 presenting beyond 1 month of age. The remainder were asymptomatic. A large atrial septal defect was the only structural heart disease. Spontaneous conversion to sinus rhythm occurred in 13 (26%) infants. Sinus rhythm was restored in 20 of 23 (87%) attempts at direct current cardioversion and 7 of 22 (32%) attempts at transesophegeal pacing; 7 required antiarrhythmic therapy. An additional arrhythmia, all supraventricular, appeared in 11 (22%) infants. The recurrence of AFL developed in 6 infants; 5 of 6 of these incidents occurred within 24 h of the first episode. All patients with recurrence had an additional arrhythmia.

Conclusions: Infants with AFL usually present within the first 2 days of life. No association was found with structural heart disease. Direct current cardioversion appears to be most effective at establishing sinus rhythm. Chronic AFL has the potential to cause cardiovascular compromise. Atrial flutter in the absence of other arrhythmias has a low risk of recurrence. Once in sinus rhythm, infants with AFL have an excellent prognosis and may not require chronic antiarrhythmic therapy.
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http://dx.doi.org/10.1016/j.jacc.2006.04.091DOI Listing
September 2006

Outpatient continuous parenteral inotropic therapy as bridge to transplantation in children with advanced heart failure.

J Card Fail 2006 Mar;12(2):139-43

Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Baylor College of Medicine; Texas Children's Hospital, 6621 Fannin, MC 19345-C, Houston, TX 77030, USA.

Background: Advanced heart failure in children is associated with high morbidity and mortality and is often refractory to standard medical therapy. The purpose of this study was to review our institutional experience with the use of outpatient parenteral inotropic therapy (PIT) for advanced chronic heart failure in children.

Methods And Results: We reviewed the medical records of all patients treated with PIT as outpatients. Seven patients received outpatient PIT from 2/99 to 1/05 (mean age was 14.6 years +/- 3.7). Median duration of therapy was 10 weeks (range 4-84 weeks). The mean number of emergency department visits per patient was greater before starting PIT than after starting PIT (2.3 +/- 1.8 versus 1.1 +/- 2.2, P < .05). The mean number of hospital admissions from exacerbation of heart failure symptoms decreased after starting PIT (2.1 +/- 1.3 versus 0.6 +/- 0.8, P < .05). Mean EF% in patients with systolic dysfunction improved while on therapy (30 +/- 14% before versus 39 +/- 16% after, P < .05). There was 1 death and 5 complications in 2 patients. Six patients were successfully bridged to transplantation.

Conclusion: Outpatient continuous parenteral inotropic therapy may serve as a successful bridge to cardiac transplantation in selected pediatric outpatients.
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http://dx.doi.org/10.1016/j.cardfail.2005.11.001DOI Listing
March 2006

Innovative techniques for placement of implantable cardioverter-defibrillator leads in patients with limited venous access to the heart.

Pacing Clin Electrophysiol 2006 Feb;29(2):181-7

Division of Pediatrics, Section of Cardiology, Baylor College of Medicine, Texas Childrens Hospital, Houston, Texas, USA.

Background: Because of venous occlusion, intracardiac shunting, previous surgery, or small size placement of implantable cardioverter-defibrillator (ICD) leads may not be possible using traditional methods. The purpose of this study was to evaluate and describe innovative methods of placing ICD leads.

Methods: The records of all patients undergoing ICD implantation at our institution were reviewed to identify patients with nontraditional lead placement. Indications for ICD, method of lead and coil placement, defibrillation thresholds, complications, and follow-up results were reviewed retrospectively.

Results: Eight patients (aged 11 months to 29 years) were identified. Six patients with limited venous access to the heart (four extracardiac Fontan, one bidirectional Glenn, one 8 kg 11-month-old) underwent surgical placement of an ICD coil directly into the pericardial sac. A second bipolar lead was placed on the ventricle for sensing and pacing. Two patients with difficult venous access had a standard transvenous ICD lead inserted directly into the right atrium (transatrial approach) and then positioned into the ventricle. All patients had a defibrillation threshold of <20 J, although one patient required placement of a second coil due to an elevated threshold. There have been no complications and two successful appropriate ICD discharges at follow-up (median 22 months, range 5-42 months).

Conclusions: Many factors may prohibit transvenous ICD lead placement. Nontraditional surgical placement of subcutaneous ICD leads on the pericardium or the use of a transatrial approach can be effective techniques in these patients. These procedures can be performed at low risk to the patient with excellent defibrillation thresholds.
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http://dx.doi.org/10.1111/j.1540-8159.2006.00314.xDOI Listing
February 2006