Day 1 :
Keynote Forum
Keith J Strauss
University of Cincinnati, USA
Keynote: Comparison of patient dose and vessel visibility between grid removal and lower radiation dose settings for pediatric imaging in the cath lab
Time : 09:40-10:30
Biography:
Keith J Strauss has completed his Master’s degree in Radiological Physics from the University of Chicago. He worked as an Imaging Physicist for 8 years prior to working in the top three pediatric hospitals of USA. He has published more than 100 papers in various imaging journals and currently serves as an Editorial Board Member of Pediatric Radiology.
Abstract:
Purpose: The aim was to define an alternative to anti-scatter grid (ASG) removal which achieves similar patient radiation dose reduction as ASG removal without degrading image quality during pediatric imaging.
Materials & Methods: This study was approved by the local institution animal care and use committee (IACUC). Six different digital subtraction angiography settings were evaluated that altered the mAs, (100, 70, 50, 35, 25 and 17.5% of reference mAs) with and without ASG. Three pigs of 5, 15, and 20 kg (9, 15, and 17 cm abdominal thickness; newborn, average 3 year old, and average 10 year old human, respectively) were imaged using the six dose settings with and without ASG. Image quality was defined as the order of vessel branch that is visible relative to the injected vessel. Five interventional radiologists evaluated all images. Image quality and patient dose were statistically compared using analysis of variance and receiver operating curve (ROC) analysis to define the preferred dose level and use of ASG for a minimum visibility of 2nd or 3rd order branches of vessel visibility.
Results: ASG grid removal reduces dose by 26% with similar image quality loss. Only with the ASG present 3rd order branches can be visualized; 100% mAs are required for 9 cm pig while 70% mAs are adequate for the larger pigs. 2nd order branches can be visualized with ASG at 17.5% mAs for all three pig sizes. Without the ASG, 50%, 35% and 35% mAs is required for smallest to largest pig, respectively.
Conclusion: Removing ASG reduces patient dose and image quality. Hence, it can be concluded that image quality can be improved with the ASG present while further reducing patient dose.
Keynote Forum
Ricardo Munoz
University of Pittsburgh, USA
Keynote: Telemedicine in pediatric cardiac critical care
Time : 10:30-11:20
Biography:
Ricardo Munoz is the Chief of the Cardiac Intensive Care Division and Medical Director for Global Business and Telemedicine at Children’s Hospital of Pittsburgh of UPMC, and Professor of Critical Care Medicine, Pediatrics and Surgery at the University of Pittsburgh School of Medicine. He has done his training in pediatrics, pediatric critical care and pediatric cardiology at Massachusetts General Hospital and Children’s Hospital Boston/Harvard Medical School. He is the Editor of four books in the field of pediatric cardiac intensive care and is Board Certified in pediatrics, pediatric cardiology and pediatric critical care medicine. He is a Member and Counselor of Cardiac Intensive Care of the European Association of Pediatric Cardiology, and fellow of the American Board of Pediatrics, Society of Critical Care Medicine and the American College of Cardiology.
Abstract:
Concurrent changes in demography, world-health trends, and society and information technology/social networks present a significant challenge in anticipated global health care needs in the immediate future. Hence, a new paradigm needs to be developed. Telemedicine can alleviate many of these needs and shows promising way to deliver clinical care and medical education at a distance, in both the intensive care and pediatric cardiology settings, regionally or even across international borders. In pediatric cardiac critical care in particular, telemedicine models of care need to be tailored in accordance to the different characteristics of remote hospitals, and the best ones incorporate a systematic approach during the implementation of quality improvement initiatives. When used in this way, telemedicine can accelerate the process of collective learning, empowering remote teams and allowing for significant improvement in their patient outcomes. Our intuitional experience with telemedicine in pediatric cardiac critical care is presented here with 3310 teleconsultations provided to 6 international hospitals in Latin America in the last 5 years and more than 2000 quality interventions including ECHO telementoring, ECMO-related adjustments, adverse trend detections and surgery-related recommendations. We postulate that telemedicine is an excellent tool helping to improve performance and accelerate the collective learning curve in medical teams treating pediatric patients with critical congenital heart disease.
- Pediatric Cardiology
Child Interventional Cardiology
Pediatric Atherosclerosis
Session Introduction
Djindjic Boris
University in Nis, Serbia
Title: The impact of fasting and postprandial blood glucose increments on atherosclerosis via lipid composition and oxidative stress in patients with type 2 diabetes mellitus and coronary heart disease
Time : 11:40-12:10
Biography:
Djindjic Boris has completed his PhD from the University of Nis. He is an Associate Professor at the Institute of Pathophysiology, Medical Faculty, University of Nis and work as a Cardiologist at the Clinic of Cardiology, Clinical Center Nis. He has published more than 25 papers in reputed journals and has been serving as an Executive Editor of medical journal Acta Medica Mediane and Editorial Board Member of few national and international journals. He is the Leader of scientific subproject founded by Ministry of Science Republic of Serbia.
Abstract:
Objectives: Impact of fasting and postprandial blood glucose increments on atherosclerosis through changes of apolipoproteins and oxidative stress in patients with diabetes mellitus (T2DM) and coronary heart disease (CHD) was evaluated.
Methodology: Ninety T2DM patients (60 with CHD and 30 without CHD) treated with metformin and/or sulphonylureas were enrolled in cross-sectional nested case-control clinical study. The areas under the six-point daily glucose curve above the fasting glucose concentrations (AUCpp) and over 5.5 mmol/L (AUCbg) were calculated to determine postprandial (AUCpp) and fasting (AUCbg-AUCpp) glucose increments. Apolipoproteins AII and B (ApoAII and ApoB), serum lipids and malondialdehyde (MDA) were determined.
Results: AUCbg-AUCpp 58.2 (95% CI 40.6-75.8) was higher in CHD group compared to non-CHD 36.9 (95% CI 23.5-50.2) mmol*h/L. They had similar Apo AII (mean±SD) 1.630±0.69 vs. 1.55±0.55 mg/dl and Apo B 1.48±0.48 vs. 1.43±0.62 mg/dl (CHD vs. non-CHD). The MDA was significantly higher in CHD 16.47±4.5 compared to non-CHD patients 13.42±4.01 μmol/g plasma proteins. The values of PCO were similar in booth groups as well as serum lipids (HDL, LDL, total cholesterol and triglycerides). AUCpp positively correlates with MDA (r=0.45) and Apo B (r=0.49) in presence of CHD, AUCbg-AUCpp negatively correlate with Apo AII (r=-0.44) in absence of CHD. The analysis revealed that AUCpp over turning point of 0 mmol*h/L was associated with high MDA and Apo B in CHD.
Conclusion: In T2DM patients with stable CHD, AUCpp at any point significantly contributes to increasing of Apo B and MDA. Serum lipids did not show significant difference according to presence of CHD.
Nurul Islam
The Mission Hospital, India
Title: Minimal radiation exposure transcatheter patent ductus arteriosus closure using only venous access: A novel technique
Biography:
Nurul Islam has completed his graduation in Medical Science from Calcutta National Medical College, India. He has done his Post-graduation in Pediatrics from Vivekananda Institute of Medical Sciences under the West Bengal University of Health Sciences in 2010. He completed his Fellowship in Pediatric Cardiology under Diplomate National Board (DNB) from Indraprastha Apollo Hospitals, Delhi and has done his training in Advanced Pediatric Cardiac Intervention from Evelina Children Hospital, Guys and St Thomas Trust in UK. Currently, he is working as a Consultant Interventional Pediatric Cardiologist at the Mission Hospital.
Abstract:
Objective: The transcatheter closure of patent ductus arteriosus (PDA), as well as other pediatric cardiac interventions has raised the concerns regarding radiation exposure, particularly relevant while treating children. The purpose of this study is to show how to perform the transcatheter closure of PDA in children while giving less ionized radiation exposure and to prove that the amount of radiation can be reduced by using pressure trace during catheter manipulation. This is a prospective analysis of feasibility, safety and advantages of doing PDA device closure using only venous access under minimal radiation.
Background: Taking an arterial access for transcatheter device closure has been a standard practice but has some inherent complications. The use of radiation or fluoroscopy is necessary but it has some ill effects on tissues, especially in children because of their greater sensitivity compared to adults and also for health care providers inside catheterization laboratory for continuous exposure.
Method: As per our departmental policy, we decided to go for PDA device closure only through venous access in the beginning of March 2016 till date. We decided to reduce the radiation time during the procedure by different techniques; most important was entry into right ventricle and sometime till pulmonary artery under pressure tracing guidance. Echocardiography was used for patient selection and assessment for sizing of device and procedural outcome.
Result: 112 out of 145 patients underwent PDA device closure from March 2016 over 10 months with only venous access and under minimal radiation technique, weighing 3.8-42 kg with half of them <10 kg. Fluoroscopic time ranged from 0.04 to 2.12 minutes. Twelve patients had difficulty in entering right ventricle from right atrium and required fluoroscopic guidance. Immediate closure was achieved in 105 patients. Two syndromic babies had mild flow acceleration across left pulmonary artery and two patients had small intra-device shunt at 3 months of follow up.
Conclusion: PDA device closure can be comfortably done without an arterial access. Patients can be exposed to significant less radiation if catheter manipulation was done under pressure tracing compared to conventional procedure of fluoroscopic guidance.
Muneer Amanullah
Aga Khan University, Pakistan
Title: Minimally invasive technique of placing a dual chamber permanent pacemaker in children
Biography:
Muneer Amanullah has done his FRCS in the field of General Surgery at Edinburgh (UK). He was a Fellow Researcher in the Department of Congenital and Pediatric Cardiac Surgery in UK London. Currently, he is an Interim Associate Dean and also an Associate Professor for Congenital and Pediatric Cardiothoracic Surgery at Aga Khan University, Pakistan.
Abstract:
Background & Purpose: Dual chamber permanent pacing in pediatric population can be challenging with consideration of issues such as body growth, patient’s size, lifestyle, presence of coexisting congenital heart disease and intracardiac shunts. There are different approaches in the literature for permanent pacemaker implantation which includes thoracotomy, sternotomy or VATS guided placement, we present another technique for dual chamber pacemaker implantation via the xiphisternal approach.
Materials & Methods: The patient is placed in supine position. A 4-6 centimeter vertical midline incision over the xiphoid process is made to gain entry into the pericardial cavity. A pericardial well is created. The right atrium is held with soft clamps and delivered into the wound. Atrial pacing leads are attached to the body of the right atrium with 5/0 polypropylene. Ventricular pacing leads are implanted on the diaphragmatic surface of the right ventricle using 5/0 polypropylene sutures. For placement of pacemaker generator a pocket is created beneath the rectus abdominis muscle via an incision in the left lumber region. The pacing leads are connected to the generator using a subcutaneous tunnel. After maintaining a satisfactory pacing threshold by an electro-physiologist the anterior rectus sheath, subcutaneous tissue and skin are closed. The pericardium is left open and the xiphoid incision is closed in three layers. Mediastinal drains were not required.
Results: We have used this technique successfully in 15 patients with various indications and had no reported morbidity. Successful atrioventricular synchrony was established along with excellent pacing and sensing thresholds. Compared with thoracotomy and sternotomy this technique is associated with minimal surgical trauma, pain and next day discharge.
Conclusion: This minimally invasive technique of implanting a dual chamber pacemaker is easily reproducible and associated with minimal morbidity.
Mary Niu
University of Oklahoma, USA
Title: Autonomic denervation of neuromodulator for the treatment of ventricular tachyarrhythmias
Biography:
Mary Niu is a Doctor and has 13 years of experience working at Oklahoma City. Her expertise include Pediatrics. Currently, she is working at the OU Medical Center-Everett Tower, Oklahoma. Till now she published many of the articles in the reputed journals.
Abstract:
It is known that hyperactivity of the sympathetic nervous activity plays a critical role in the initiation and maintenance of ventricular tachyarrhythmias in diseases such as long-QT syndrome, catecholaminergic polymorphic ventricular tachycardia (CPVT) as well as electrical storms resulting from any etiology. On the contrary, vagal activity is widely considered to be anti-arrhythmic and anti-inflammatory as well. It has been proposed that therapies aimed at reducing the sympathetic tone and enhancing the vagal tone should provide clinical benefits. However, recent clinical trials of spinal cord stimulation, baroreceptor activation therapy and cervical vagal stimulation, designed to test this hypothesis, have produced conflicting results in patients with heart failure. Low-level transcutaneous vagal stimulation is another promising autonomic neuromodulation showing strong anti-arrhythmic effects on both atrial and ventricular tachyarrhythmias in preclinical studies. Clinical studies are underway to investigate its effects on patients with a propensity for ventricular tachyarrhythmias. The left stellate ganglion (LSG) is viewed as the gateway of the sympathetic innervation to the heart. Various interventions targeting the LSG have been developed, including video-assisted resection of the LSG, epidural anesthesia of the C7-T3 level, and application of local anesthetics to block the LSG. Recent clinical studies demonstrate that sympathetic denervation targeting the LSG is capable of improving the survival in patients with long QT syndrome, reducing the ventricular tachyarrhythmia in CPVT patients and alleviating the arrhythmia burden during electrical storms.
Faisal O Alatawi
Taibah University, Saudi Arabia
Title: The ROSHDAP (Registry of Saudi heart diseases and pregnancy) study: Rationale and design of a plan for heart diseases during pregnancy in Saudi Arabia
Biography:
Faisal O Alatawi he is affiliated form Taibah University, Saudi Arabia he currently working for the department of medicine and he published many of the research papers in reputed journals.
Abstract:
Background: The incidence of heart disease in pregnancy (HDP) is 0.2% to 4% in Western countries but is unknown in the Kingdom of Saudi Arabia (KSA). Most valvular diseases in pregnancy are due to rheumatic heart disease, which still is common in KSA. Improvements in neonatal and pediatric cardiac surgery in KSA have resulted in children born with complex congenital heart disease reaching reproductive age and becoming pregnant. Congenital heart disease is common in KSA due to widespread practice of consanguineous marriages. Knowledge and experience in HDP are important for health care providers to deliver proper counseling and treatment. We report a proposal to establish the Registry of Saudi Heart Diseases and Pregnancy (ROSHDAP) a national registry program for HDP.
Methods: All pregnant women in KSA who have heart disease will be eligible to enroll in the program. Patients who do not consent to participate will be excluded. Prospective information about demographic, clinical, and social characteristics; laboratory tests, electrocardiography, and echocardiography; gestation; delivery; and maternal, fetal, and neonatal outcomes will be collected confidentially and electronically and transmitted from participating centers to a central coordinating office for data management and analysis.
Results: A 5-phase program plan was developed, including initiation, development, prelude, nationwide, and conclusion phases. A proposal has been submitted for registry funding.
Conclusion: The ROSHDAP will provide information for epidemiology, resource planning for intervention, and clinical research, and will improve health care for patients who have HDP and their children.
Cristina Cruz
Saint John Hospital, Portugal
Title: Echocardiographic assessment of the proximal aorta after tetralogy of fallot repair
Biography:
Cristina Cruz she is affiliated form Saint John Hospital, Portugal, her research interest mainly focus her research interest mainly focus on tetralogy of fallot repair, and she belongs to department pediatric Cardiology. Till now she published many of the articles in reputed journals.
Abstract:
Background: An intrinsic aortopathy can lead to aortic (Ao) dilatation late after tetralogy of fallot (ToF) repair. Its extension and prevalence is not clearly defined.
Objectives: We aimed to compare the proximal aorta dimensions and elasticity assessed by transthoracic echocardiography in ToF and normal controls, and to find possible predictors of Ao dilatation.
Methods: We included 127 consecutive adults after ToF repair and 63 sex- and age-matched healthy controls. We estimated the Ao z-score at the level of the sinuses of Valsalva (SoV) and ascending aorta (AAo) and defined Ao dilation for a z-score >2. We assessed Ao strain, distensibility and stiffness index by transthoracic echocardiography using accepted formula.
Results: One hundred-twenty seven patients (pts) (mean age 30±9 years; 52% males) had a mean follow-up time since ToF repair of 23±7 years. In 59 cases, an aortopulmonary shunt was done prior to repair, with a median interval of 3 years. In 57 patients complete repair used a transannular patch. A right Ao arch coexisted in 29 cases. The prevalence of SoV and AAo dilatation were 29.9% and 23.8%, respectively. No differences were found between ToF pts and controls regarding systolic blood pressure and pulse pressure. ToF pts had a bigger Ao z-score (1.4±1.2 vs. -0.6±1.2, P<0.01 and 1.2±1.1 vs. -0.7±0.7, P<0.01, at the level of SoV and AAo, respectively), lower Ao strain [6.9 (2.6-61.5) vs. 15.4 (3.7-45.0), P<0.01] and distensibility [1.4 (0.4-1.4) vs. 3.7 (0.1-1.4) KPa-110-3, P<0.01], and a higher Ao stiffness index [7.4 (0.8-23.6) vs. 3.1 (0.9-14.1); P<0.01]. There was a significant positive correlation between the Ao z-score and left ventricular (LV) mass and volumes indexed to body surface area (AAo z-score and LV mass index in Pearson’s correlation (r)=0.26, P<0.01), Ao stiffness index and SAo (r=-0.21; P=0.007). By multivariate analysis, the sinotubular junction effacement was an independent predictor of AAo dilatation [odds ratio 4.1, 95% confidence interval (CI) 1.4-12.3, P=0.01].
Conclusion: It can be concluded that tetralogy of fallot patients have a bigger and stiffer ascending aorta, and transthoracic echocardiography can be used as a screening tool for this aortopathy.
Sadaf Chaudhry
Addenbrooke’s Hospital, UK
Title: Infant with suspected septic shock not responding to antibiotics
Biography:
Sadaf Chaudhry has obtained her MBBS from Leiden University in Netherlands. After her experience as a SHO Neonatology at John Radcliffe Hospital in Oxford, she started her Pediatric training at Health Education East of England. During her training, she has participated in small research projects and presented at international conferences. Currently, she is a Senior SpR at the Neonatal Unit at Addenbrooke’s Hospital in Cambridge. She is in her final year of Pediatric training and focusing on Pediatric Cardiology.
Abstract:
Sepsis in infants is a well-recognized entity with clear-cut treatment. However, what if the presenting infant does not respond to antibiotics and fluid treatment? What if the symptoms persist? When does one start thinking about alternative diagnoses? A pediatric team at a small DGH faced this problem. With this case report we would like to share our thought process and the challenges our team faced considering the atypical presentation of Kawasaki disease. Kawasaki disease is an acute febrile systemic vasculitis. Being the most common cause of acquired heart disease in the UK, early diagnosis and treatment is essential. Kawasaki disease remains a clinical diagnosis based on clinical criteria. Some patients do not fully meet these criteria, forming an incomplete form of the disease. This subtype still poses a significant risk of cardiac consequences; hence forming a challenging group of patients. In our case, a five month old boy initially seemed to present with septic shock. Despite appropriate antibiotic treatment his temperature did not settle. In addition the inflammatory markers only increased. He remained extremely irritable and had an extensive maculopapular rash. On day five of his illness, he was suspected to have incomplete Kawasaki disease. ECHO confirmed the presence of cardiac sequelae. This clinically septic child responded remarkably well to intravenous immunoglobulins and high dose aspirin.
Biography:
O Graupner has completed his MD from the Philipps University Marburg. He is an Assistant Doctor in the Department of Obstetrics and Gynecology at the Right the Isar Hospital, Technical University Munich. He has done his Doctoral degree under the supervision of Professor Axt-Fliedner.
Abstract:
Introduction & Purpose: Myocardial function (MF) of the systemic right ventricle (RV) determines the postnatal course of neonates with hypoplastic left heart syndrome (HLHS). Our study examines, whether the presence of endocardial fibroelastosis of the left ventricle (LV EFE) influences MF of the RV in HLHS fetuses.
Materials & Methods: A prospective study was conducted including 10 controls (group 1), 10 HLHS fetuses with (group 2) and 10 without LV EFE (group 3)-all matched for gestational age. M-mode was used to assess tricuspid plane systolic excursion (TAPSE) and the shortening fraction (SF). PW-Doppler and PW-TDI derived velocities were assessed. E/A, E/e', e'/a' ratios and the myocardial performance index (MPI) were calculated.
Results: The examination of MF revealed significantly lowers’ the velocities (p<0.05) and higher values for SF in group 2 compared to group 3. ET (ejection time), E wave velocity, E/e’ and SF showed significantly higher values in group 2 compared to group 1. In group 2 a’ velocity increased significantly over gestational age. TAPSE increased during gestation in group 3 but not in group 2.
Conclusion: These significant differences in MF between the groups might lend support to the notion of negative ventricular-ventricular interaction in case of HLHS with LV EFE possibly influencing surgical outcomes.
Rama Kumari
Nizam's Institute of Medical Sciences, India
Title: Prevalence of rheumatic and congenital heart diseases in school children of Andhra Pradesh, South India
Biography:
Rama Kumari has completed her DM in Cardiology from Andhra Medical College and currently working as a Faculty at Nizam's Institute of Medical Sciences, Hyderabad. She has published more than 25 papers in reputed journals and has been serving as an Editorial Board Member of repute.
Abstract:
Objective: To determine the prevalence of rheumatic heart disease (RHD) and congenital heart disease (CHD) using clinical and echocardiographic criteria in rural and urban school children of Andhra Pradesh, South India.
Materials & Methods: A total of 4213 school children between 5 and 16 years of age were screened. 1177 were from rural schools and 3036 from urban schools. Prevalence of RHD and CHD was estimated.
Results: Clinically, RHD was present in 3 (prevalence 0.7/1000). Using echocardiography RHD was detected in 32 (7.6/1000), 11 (7.3/1000) from rural and 21 (7/1000) from urban schools. (P=0.000, OR=0.093 and CI=0.023-0.317). Total prevalence of RHD is 8.3/1000. Clinically CHD was present in 39 (9.2/1000) children, rural 9 (7.6/1000) and urban 30 (9.9/1000). Using echocardiogram CHD was detected in 44 (10.4/1000) children, rural 11 (9.3/1000) and urban 33 (10.8/1000).
Conclusion: RHD was detected several fold using echocardiographic screening than by clinical examination alone. Longitudinal follow-up of children with echocardiographically diagnosed subclinical RHD is needed.