Day 3 :
- Diagnosis of Cardiac Problem
New Research in Cardiology and Cardiac Surgery
Florida Atlantic University, USA
Mayo Clinic Rochester, USA
Rainbow Babies and Children’s Hospital, USA
Time : 09:30-09:55
Christopher Snyder is the Director of Pediatric Cardiology at Rainbow Babies and Children’s Hospital, Case Western Reserve University School of Medicine. His interests include general pediatric cardiology and Adult with Congenital Heart disease as well as a sub-specialty in pediatric and adult congenital electrophysiology on an inpatient and outpatient basis.
Background and introduction: Anesthesia has become an important part of pediatric electrophysiology studies (PEP). The purpose was to determine, (1) the prevalence of supraventricular tachycardia (SVT) and sinus tachycardia (Stach) during anesthesia induction, and (2) lack of inducibility of SVT during PEP under anesthesia. Methods IRB approved, retrospective review of PEP (1/99-1/14). Inclusion criteria: ≤ 21 years, documented SVT prior to PEP, anesthesia.
Data review: demographics, EP and anesthesia records. Two groups identified, Intravenous (IV) and inhalational anesthesia (I). Induction of SVT and Stach prior to initiating EP study was recorded as was failure to induce SVT during PEP.
Results: Inclusion criteria was met by 378 patients, 57% males, median age 14 years. IV anesthesia in 72% . During induction, only 1 patient from IV group developed SVT, (WPW patient), 10% of patients developed Stach and patients with WPW are twice at risk of developing Stach (16.19% vs. 8.06%; p = 0.02). Stach was seen more commonly with I induction (59% Vs 41%; p < 0.0001). The most common drug for I was sevoflurane ( 89%); and no differences were identified between drugs. Failure to induce SVT during PEP was 13 % and no differences seen between groups.
Conclusion: Route of anesthesia induction, inhaled or intravenous do not increase the risk of developing SVT. Sinus tachycardia is a common occurrence, and failure to induce SVT was not affected route of anesthesia.
Ivan Wilmot received his medical degree from Emory University in 2002. He continued at Emory for his pediatric residency, and chief residency. He completed his pediatric cardiology fellowship at Texas Children’s Hospital, Baylor College of Medicine. He continued there to complete an advanced fellowship in heart failure and transplantation, and was actively involved in the Mechanical Circulatory Support (MCS) program. He has served as the co-director of Pediatric Heart Failure and Transplant at All Children’s Hospital in St. Petersburg, FL, and currently serve as an Assistant Professor at Cincinnati Children’s Hospital Medical Center in the Heart Institute. He is an active member of the Heart Failure, Transplant, and MCS team at CCHMC where he pursue research in pediatric heart failure, transplant, and MCS. He has published on the effectiveness of MCS in children with acute fulminant and persistent myocarditis, and the evolving field of pediatric MCS.
Mechanical circulatory support (MCS) in the pediatric heart failure population has a limited history especially for infants, and neonates. It has been increasingly recognized that there is a rapidly expanding population of children diagnosed and living with heart failure. This expanding population has resulted in increasing numbers of children with medically resistant end-stage heart failure. The traditional therapy for these children has been heart transplantation. However, children with heart failure unlike adults do not have symptoms until they present with end-stage heart failure and therefore, cannot safely wait for transplantation.
Many of these children were bridged to heart transplantation utilizing extracorporeal membranous oxygenation as a bridge to transplant which has yielded poor results. We discuss MCS options for short and long-term support that are currently available for infants and children with end-stage heart failure. Additionally, we discuss MCS as a bridge to transplantation and as chronic therapy in the pediatric population. Pediatric MCS options provide a life-saving option for the increasing population of children with refractory heart failure.
Cairo University, Egypt
Time : 10:20-10:45
Soha Emam is a Professor of Pediatrics & Pediatric Cardiology at Kasr-Alaini School of Medicine, Cairo University, Egypt. She has completed her MD at Cairo University School of Medicine and has been specialized in Pediatric Cardiology. She completed her Post-doctoral training in Pediatric Cardiology at Italy. She is the Medical Coordinator of the Pediatric Cardiology Department, Cairo University and is the Head of Scientific & Conferences activity committee and a Coordinator of Research Activities of the Department. She has many publications in pediatric cardiology field and is an editor in reputed journals and serving as reviewer for many others. Her field of interest is fetal echocardiography and new echo modalities.
Over the past three decades, fetal echocardiography has proven not only to be a valuable tool for prenatal diagnosis of CHD, but also to have a prognostic value for such diseases. However, the application is not easily feasible in developing countries, being a highly specialized technique that requires proper high training & sophisticated technology in addition to other socio-economic factors which act as obstacles for its proper application in these countries. This article reviews experience in two of the developing countries illustrating through numbers obstacles to its proper application and ways to overcome it.
Mayo Clinic, Rochester USA
Time : 10:45-11:10
Bryan Cannon is a pediatric cardiologist in Rochester, Minnesota and is affiliated with multiple hospitals in the area, including Mayo Clinic and Mayo Clinic - Saint Marys Hospital. He received his medical degree from University of Texas Southwestern Medical School and has been in practice for 19 years. He is one of 13 doctors at Mayo Clinic and one of 8 at Mayo Clinic - Saint Marys Hospital who specialize in Pediatric Cardiology.
Wolff-Parkinson-White (WPW) is a relatively common problem in the pediatric population occurring in 1 in 500-1000 children. WPW can present with supraventricular tachycardia, ventricular dysfunction due to pre-excitation or sudden death due to rapid conduction of atrial fibrillation through the accessory pathway.
As patients may present with sudden death as their first symptom, evaluation of patients with WPW is indicated, even if they are asymptomatic. In 2012, Pediatric and Congenital electrophysiology Society (PACES) and the Heart Rhythm Society (HRS) in conjunction with the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), the American Academy of Pediatrics (AAP), and the Canadian Heart Rhythm Society (CHRS) created a consensus statement on the management of asymptomatic young patient with WPW which serves as a guideline for evaluation and management of these patients.
Florida Atlantic University, USA
Time : 11:30-11:55
Xupei Huang has completed his medical training from Nanjing Medical University and his PhD in Biochemistry from University of Paris XII and Post-doctoral studies in Molecular Cardiology from University of Wisconsin School of Medicine. He is currently Professor in Biomedical Science, Charles E. Schmidt College of Medicine at Florida Atlantic University in Florida, USA and a Fellow of American Heart Association (FAHA). He has published more than 85 papers in reputed journals and has been serving as an Associate Editor for Cardiology and an Editorial Board Member of repute.
In the past, we have focused on heart failure with a reduced ejection fraction (HFrEF). Recently, we have begun to focus on heart failure with a preserved ejection fraction (HFpEF), in which patients suffer from a diastolic dysfunction with a normal or near normal cardiac contraction. Patients with HFrEF typically have hypertension, diabetes, and various cardiomyopathies. They have a stiff ventricle that is non-compliant compared with patients with HFrEF. Diastolic dysfunction or diastolic heart failure is commonly observed in pediatric patients with hypertrophic or restrictive cardiomyopathy, primary hypertension and diabetes. We have generated a transgenic mouse line modeling human restrictive cardiomyopathy (RCM). Using this animal model, we have demonstrated that myofibril hypersensitivity to calcium is a key that causes impaired relaxation, i.e. diastolic dysfunction in mice with RCM. Using a genetic way or desensitizing chemical molecules to reduce the myofibril hypersensitivity can correct the diastolic dysfunction and rescue the RCM mice. Calcium desensitization provides us with a promising option in the treatment of diastolic dysfunction and diastolic heart failure.
Brojendra Agarwala has completed his MBBS at the age of 23 years from University of Kolkata, India and completed Pediatric cardiology fellowship from New York university medical center New York, NY, USA. He is a pediatric cardiologist and professor of Pediatrics at the University of Chicago. He has received best teacher award be the pediatric residents and the medical students. He has published 68 papers in reputed journals. He is named as one of the Top Doctors and Best pediatricians in Chicago magazine for many years.
Competitive athletes are those who participates in an organized team or individual sports that requires regular competition against others. Athletic activities substantially increase the sympathetic drive resulting in surge in catecholamine level that increases blood pressure, heart rate, myocardial contractility and oxygen demand. This can cause myocardial ischemia and arrhythmia that may lead to sudden death in athletes with Known and unrecognized heart conditions during athletic activities.
There are many structural and acquired heart conditions that are not clinically manifested. Many physicians are involved in medical clearance of children for participations in school sports activities. Physicians have to recognize them to protect athletes from catastrophic events. In order to prevent sudden cardiac death physicians should be aware of cardiac conditions that may cause problem. Also physicians should be familiar with general guidelines for evaluation of an athlete and clearance for participation in athletic activities.
Guidelines vary in different parts of the world. In this presentation I will discuss guidelines for European, Italian and in USA outlined by American heart Association. In this presentation the causes of congenital and acquired heart conditions and arrhythmias that can cause sudden cardiac death will be discussed with authors experience and literature review.
Hospital Italiano de Buenos Aires, Argentina
Time : 12:20-12:45
Dr. Sofía Grinenco, Medicine Doctor (M.D.), is a Pediatric Cardiologist member of the Fetal Medicine Unit at Hospital Italiano Buenos Aires, professor of fetal cardiology at Fundación Hospitalaria, Council Member of the Cardiology Committee of the Argentine Society of Pediatrics (SAP), member of the Argentinian Society of Prenatal Diagnosis and Therapy (SADIPT), member of the Association for European Pediatric and Congenital Cardiology (AEPC), with several postgrade courses on Epidemiology and Statistics and on Clinical Bioethics.
The prenatal diagnosis of congenital heart defects has contributed to an increase in survival of patients and the decrease of costs for the healthcare system. In the past few years’ advances in technique and technology have allowed a better visualization of the fetal heart, as well as further understanding and interpretation of pathological findings, increasing accuracy of prenatal diagnosis of congenital heart defects and improving therapeutic strategies and patient’s outcome.
The experience in prenatal diagnosis in a specialized tertiary healthcare Centre is presented. In a 5-year period 230 patients with prenatal diagnosis of congenital heart defects were born in our Centre. In 90% of these cases prenatal and postnatal diagnosis were the same. In 7/230 (3 %) postnatal echocardiograms were normal, being Coarctation of the aorta the most frequent diagnosis in this group. In the period studied 3 patients with normal fetal echocardiogram performed in the second trimester developed aortic coarctation after birth requiring surgery. Identifying congenital heart defects with lower detection rates and/or higher false-positive rates helped to focus on those areas that required further attention and research.
Among these prenatal detection of Coarctation of the aorta represented the greatest diagnostic challenge. Prenatal diagnosis of most types of severe congenital heart defects is feasible and it contributes to the improvement of the patient’s outcome in many aspects. Continuous research in fetal cardiology has allowed better understanding of antenatal natural history of these diseases, more precise diagnosis and in some cases timely intervention and reduced morbidity and mortality.
Texas Children’s Hospital, USA
Time : 12:45-13:10
Jorge A Coss-Bu completed Pediatric residency and fellowship in Pediatric Critical Care Medicine at Baylor College of Medicine and Texas Children’s Hospital, Houston TX, USA and was appointed Associate Professor at the same institutions. He is board certified in Pediatrics and Pediatric Critical Care Medicine by the American Board of Pediatrics. He has over 100 scientific publications including manuscripts, abstracts and book chapters in the area of nutrition and metabolism of the critically ill child and his research work has been presented in 75 scientific events and invited to speak in more than 140 lectures in the US and worldwide.
Congenital heart disease (CHD) has a prevalence of 4 to 10 per 1000 live births. Neonates and young children with CHD have long been recognized to be at risk for poor growth and failure to thrive. Previous studies have found that young children with CHD often present with impaired growth parameters. Several studies have demonstrated a high incidence of both acute and chronic malnutrition in infants and children with CHD admitted to the hospital. The poor preoperative nutritional state of these patients is often exacerbated postoperatively as the metabolic response is characterized by altered energy demands, a complex inflammatory state, and protein catabolism. The malnourished patient is at greater risk for developing infection and experiencing poor wound healing given the decreased number of nutritional substrates available to respond to the increased catabolic effects of injury from surgery. Achieving adequate nutritional intake postoperatively is often difficult and may be affected by a combination of genetic factors, increased metabolic demands, inefficient nutrient absorption, postsurgical fluid restriction, oropharyngeal dysfunction, and frequent interruptions of enteral feeding for procedures. Malnutrition has been shown to impact the physiologic stability of critically ill children, which is of importance in the neonate or child who is often hemodynamically unstable following cardiopulmonary bypass and cardiac surgery. Although advancements in surgical technique and postoperative management have dramatically improved mortality rates and hospital outcomes in patients with CHD, appropriate nutritional intake to cover metabolic demand in infants and young children postoperatively remains a frequent obstacle.
University of Medicine and Pharmacy"Gr.T.Popa", Romania
Title: Could be the severity of temporo-mandibular disorder a significant prognosis marker for cardiac involvement in MASS phenotype children ?
Time : 14:00-14:25
Paloma Manea MD, Ph D, FACCP is a Specialist in Cardiology and Internal Medicine, competence in echocardiography, Lecturer at ’’Grigore T.Popa’’ University of Medicine and Pharmacy, Iasi, Romania. She was admited to ‘’Emil Racovita” high school in 1980, at first position, with 10 mark (written test at Mathematics and Roumanian Language). She was admitted to “Grigore T. Popa” University of Medicine and Pharmacy, Faculty of Medicine , in 1984, at first position( from 4,500 candidates), with 9.96 mark (written tests at Biology, Chemistry and Physics).
MASS phenotype associates skeletal features, one of them being temporo-mandibular disorder (TDM). Apparently an innocent condition, TDM affects life quality, provoking symptoms like headache, neck and shoulder pain, dizzeness, tinitus and even deafness. Connective tissue in fibrilinopathies has the same abnormalities in the mitral valve, as well as in temporo-mandibular joint and this affirmation has been proved by multiple studies during last decade.
We’ve selected 46 children, diagnosed with MASS phenotype, aged between 5-17 years, with a predominance of females (70%). They were monithorized for 24 months, quarterly, using cardio logical and dental examination; Ghent revised criteria, electrocardiogram, echocardiogram and magnetic resonance imaging (MRI) for temporo-mandibular joint. 40% of the patients (18 of 46) associated TMD, proved by dental examination and MRI. 6 of these 18 patients with TMD revealed a severe dysfunction of this joint and all of them increased their dyspnea (as symptom) and their mitral regurgitation, pulmonary pressure values ,during 24 months observation.
As an invasive investigation of mitral degeneration(biopsy) isn’t the best option for deciding the surgical moment , we consider that non-invasive assessment of temporo-mandibular joint, in this fibrillinopathy, could be a useful prognosis marker for mitral deterioration(if abnormalities of connective tissue are similar). We’ ve made an adequate and in time selection of those 6 patients with cardiac surgical indication, so we reffered them to the cardiac surgeon and we’ve made this decision accounting the following: worsening dyspneea, supported by augmented mitral regurgitation, pulmonary pressure values and a non-conventional, but very precise marker of connective tissue deterioration: MRI of temporo-mandibular joint affected by dysfunction.
Children’s Hospital of Chongqing Medical University, China
Title: Measurements in pediatric patients with cardiomyopathies: comparison of cardiac magnetic resonance imaging and echocardiography
Time : 14:25-14:50
He is the Professor of Pediatrics, Doctoral supervisor as well as Vice-president of Children’s Hospital of Chongqing Medical University. He is also Vice-Chairman of China Pediatric Cardiology Society and Deputy Director of Chongqing Cardiology Committee.
Aims: Cardiomyopathies are common cardiovascular diseases in children. Cardiac magnetic resonance imaging (cMRI) and echocardiography (Echo) are routinely used in the detection and diagnosis of pediatric cardiomyopathies. In this study, we compared and explored the correlation between these two measurements in pediatric patients with various cardiomyopathies.
Methods and Results: A total of 53 pediatric patients with cardiomyopathy hospitalized in recent three years in our hospital were collected and analyzed. All of them and 22 normal controls were measured with both cMRI and Echo. The cardiac functional score of the patients was graded according to the criteria set by New York Heart Association. The cardiac function indexes measured with both cMRI and echo included left ventricular end diastolic volume (EDV), end systolic volume (ESV), ejection fraction (EF), fractional shortening (FS). These parameters were somehow lower in cMRI measurements compared to that in echo measurements. Index of the diastolic function such as peak filling rate (PFR) measured with cMRI had a good correlation with clinical cardiac functional score, while the index of the diastolic function (E/A、IVRT) measured with Echo was not well correlated with the clinical cardiac functional score. Significant systolic dysfunction was detected by cMRI in 34 patients with dilated cardiomyopathy, left ventricular no compaction, or endocardia fibroelastosis. Significant diastolic dysfunction was detected by cMRI in 19 patients with hypertrophic cardiomyopathy or restrictive cardiomyopathy showing an alteration in PFR and EDV.
Conclusion: Both cMRI and Echo are of great value in the diagnosis and the assessment of cardiac function in pediatric patients with cardiomyopathy. CMRI could accurately display the characteristic morphological changes in the hearts with cardiomyopathies, and late gadolinium enhancement on cMRI may reveal myocardial fibrosis, which has obvious advantages over Echo measurements in the diagnosis. Furthermore, cMRI can measure quantitatively the ventricular function because it does not make invalid geometrical assumptions.
Najlaa AL Rajaa is working as Former Program director for Saudi board training program at MCH AL HASAA and Consultant pediatric and fetal cardiologist aslo at MOH. clinical research fellow in fetal and neonatal cardiology at University of Alberta. Educated from University of Ottawa.
Fetal echocardiography is the ultrasonic evaluation of the fetal CVS. It is the 1ry modality for defining & evaluating fetal cardiac status, it requires detailed analysis of the anatomy from numerous views. Fetal echocardiography aims for prenatal diagnosis of critical and simple CHD, it allows for improved clinical status after birth. Indications of Fetal echocardiography:
Fetal, maternal and Familial. Antenatal diagnosis of CHD May lead to better surgical outcomes, prepares The Medical Team to deal with critically sick. Good intra-natal & postnatal care can be offered to the NN. Finally, Family will prepared emotionally & financially to accept such a baby.
Antenatal diagnosis of CHD. Demands a systematic approach to the investigation of the fetal heart, this approach is called Sequential segmental analysis of the fetal CVS: depends on the recognition of the morphology & connections of the 3 segments of the fetal heart. Steps for sequential segmental analysis of fetal CVS (Showing Normal Video Images).Assessment of fetal cardiac function will be discussed as part of hemodynamic assessment of the feral cardiovascular system.
La Salle University, Mexico
Title: Echocardiographic screening vs. symptomatic diagnosis for patent ductus arteriosus in preterms
Time : 15:35-16:00
Gabriela Juarez is graduated from the Medicine School at La Salle University, and is Postgraduate in pediatrics at Children's Hospital of Mexico "Federico Gómez" and Neonatology in the Spanish Hospital of Mexico. Currently she is attending neonatologist in N.I.C.U. in the American British Cowdray Medical Center in Mexico City.
Background: The persistence of Ductus arteriosus, the aim of this study is to evaluate the possible benefit in the treatment for ductus closure when a early (less than 72 hours of life) echocardiographic screening is done versus when the echocardiographic diagnosis is realized only in present of associated symptoms. Methods: Preterm without malformation followed by two strategies: patent ductus arteriosus (PDA) screening or echocardiographic study on suspected PDA for symptoms (control group). We analyzed the ductus characteristics, the presence of pulmonary hypertension and the treatments for their closure. We analyze the result in relation of the premature age as: late preterm (34 to 36 gestational age weeks), moderate (30 to 33) and extreme (< 30). Results: There was no difference in the proportion of new borns diagnosed with PDA among the strategies (screening 18.6 % [101/543] vs 18.1 % [55/304], p = 0.92). In the control group, 53 % were diagnosed after 72 hours of life. There were no differences in realtion of the ductus characteristic among the groups. The closure treatment were similar in the two strategies among the moderate and late preterm, but was more aggressive in the control group in the extreme preterms.
Conclusion: The echocardiographic screening for PDA in extreme preterm new borns reduces the time to detect it, and allow to give less aggressive treatment. We do not recommend their use in moderate o late preterm new born.
Medanta- The Medicity, India
Title: Unconventional use of Amplatzer devices: Percutaneous closure of non-septal cardiac defects/malformations
Time : 16:00-16:25
Munesh Tomar is a well-known pediatrician in the country with about 10 to 15 years of work experience in the field of pediatric cardiology. Presently she is working as a Senior Consultant in the Department of Pediatric Cardiology and Congenital Heart Disease in Medanta, Gurgaon since March 2011. The major areas in which she is an expert includes- Echocardiography, transthoracic including 3D, transesophageal Ech., fetal echocardiography, evaluation and management of arrhythmias, diagnostic cardiac catheterization etc.
Introduction: Device closure for septal defects as fossa ovalis ASD, VSD and PDA is now a well-accepted indication. The Amplatzer devices are the most commonly used throughout the world. In this study, we are reporting the efficiency of closure of non septal defects with the Amplatzer group of devices although they have not been prototyped for use in such conditions.
Study design: Retrospective study, tertiary referral center.
Aim: To study the use of Amplatzer group of devices in non-septal defects/malformation.
Material & Methods: 29 patients in the age group 4 months-67 years, were treated percutaneously with Amplatzer devices for the following conditions: coronary arteriovenous (AV) fistula (Amplatzer duct occluder, n=6), pulmonary AV fistula (Amplatzer duct occluder, n=2), closure of ascending aorta perforation (Amplatzer septal occluder, n=2), ruptured sinus of Valsalva (Amplatzer duct occluder n=9), Fontan fenestration closure (Amplatzer PFO occluder and Amplatzer septal occluder one patient each), closure of large decompressing venous channel from Glenn (Amplatzer vascular plug, n=5) and closure of mitral paravalvular leak (Amplatzer septal occluder, n=1) and aortic paravalvular leak (Amplatzer duct occluder, n=2).
Results: Successful closure was achieved in all coronary AV fistula (immediately n=4, at 3 months in all), ruptured sinus of Valsalva (immediate in all), fenestrated Fontan (immediately in all), decompressing vein post Glenn (immediate) and ascending aorta perforation (immediate). The aortic paravalvular leak closed at 3 months follow-up. Continued residual flow persisted in mitral paravalvular leak at 6 months follow up.
Complication: Intravascular hemolysis and residual mitral regurgitation persisted in the patient with mitral paravalvular leak requiring surgical explanation and closure. On follow up ranging from 2 months-6 years, complete closure of the defects persisted with no adverse effect.
We conclude that, although devices have not been recommended for closure of non septal defects, it is possible in selected cases to treat these conditions non surgically with the use of non-prototype Amplatzer device without significant complications. Though strict long term follow up will be necessary before concluding that it can be safe alternative to surgery.
Hadassah University Hospital, Israel
Time : 16:25-16:50
David Gozal is Director of the Sedation Service, Dept of Anesthesiology and Critical Care Medicine, Hadassah University Hospital, Jerusalem, Israel The Hebrew University of Jerusalem, Israel
In the last decade, procedures in the Cardiac Catheterization lab become more complex, take longer time, and involve higher sick patients. That led to many changes in strategy, and move from the Operating Room to the Cathlab. This originated new challenges to attending physicians and Anesthesiologists particularly. More and more they are managing a large range of children of different ages, different cardiac anomalies (some very complex), requiring an intervention in the cathlab instead or as a supplement to the surgery. No need to say that the Cathlab is a remote location, creating a hostile and unfamiliar environment, that makes the management of these patients more challenging.
Therefore, many of these procedures require General Anesthesia instead of Sedation. The Anesthesiology Department must be active in developing protocols and management guidelines.
The aims of this lecture will be to:
1- Describe the different indications for cardiac interventional procedures
2- Discuss the choice of the anesthesia technique (General Anesthesia versus Sedation)
3- Explain the notion of sedation and its complications
4- Decide the level of expertise of the physicians in charge of these cases
5- Consider safety as an important concern in this special setup
Time : 16:50-17:15
Amir A Sepehri has received his PhD from ‘faculté polytechnique de mons’ (Mons University, Belgium), in Digital Audio Signal Processing. He has worked on a special research program on ‘Computerized Screening of Congenital Heart Disease’. The program was aimed toward obtaining a special diploma known as ‘l’Agrégation de l'Enseignement Supérieur’ in the same university. The result of his research work is formulated as Arash-Band and it is internationally patented. He has several publications on the CHD screening and detection. He is currently Director of CAPIS Biomedical R&D department.
Statistical analysis shows that around 1% of children are born with congenital heart diseases that count for about 10% of all congenital anomalies. While as many as 70% have asymptomatic extra sounds which are sometimes confused with pathological heart sounds during auscultation. It is sometimes vital that the conditions of these children be screened as early as possible and before 12 years of age. Studies show that the screening errors (positive or negative), are still substantial in primary health care centers, a large number of pediatric referrals for cardiac evaluation have normal hearts. Based on our unique and internationally patented processing method on murmur characterization, the Arash-Band method and its derivatives, an original digital phonocardiograph is developed. The new digital phonocardiograph has been tested on more than 1000 cases. The device has proven to have a >90% sensitivity, specificity and efficiency with correct diagnosis in children with heart diseases and 100% diagnostic accuracy with normal hearts with or without innocent murmurs The development of the new digital cardiograph also required automated end-pointing and segmentation of children´s heart sounds. For that purpose, we developed a novel method by paying special attention to physiological effects of respiration on pediatric heart sounds and using neural network classifiers. The new digital cardiograph exhibits superior performance than a pediatric cardiologist who relies on conventional or computer-assisted auscultation and drastically reduces unnecessary use of echocardiography. The new digital cardiograph is a children lives saver in developing countries and also it opens a new era for children heart states verification through telemedicine.