Comparison of chloral hydrate and pentobarbital sedation for pediatric echocardiography.

BACKGROUND: In 2013, outpatient use of chloral hydrate (CH) was limited and other alternatives such as oral pentobarbital (PB) were explored to achieve conscious sedation in young children for transthoracic echocardiography (TTE). We aimed to assess efficacy and safety of the two medications. METHODS: Clinical information, from a computerized database, about children who received sedation with either CH or PB for TTE at our center (2008-2015) was reviewed, and the two groups were compared for sedation effectiveness and complications. RESULTS: Three thousand eight hundred fifty one pediatric patients (median age 8 months) underwent conscious sedation during TTE (mean doses CH 50 mg/kg, PB 4 mg/kg). Demographic characteristics of the two groups were similar. Sedation failure rate (CH 2.4%, PB 2.9%, P = NS), need for supplemental doses (CH 17.9%, PB 16.2%, P = NS), and overall adverse event rate (PB 1.4%, CH 1.9%; P = NS) were similar in the two groups. There were fewer episodes of respiratory depression with PB (0.3% vs 1.6%, P < 0.05). The rate of paradoxical reactions was higher with PB (1% vs 0.03%, P < 0.05). Increasing age predicted the need for supplemental doses and for sedation failure in both groups. Neonates (7.5% vs 0%) and infants (2% vs 0.6%) given CH were more likely to develop adverse reactions. CONCLUSION: Chloral hydrate and PB are equally effective. However, CH is associated with an increased incidence of transient desaturation, while PB is associated with an increased incidence of a paradoxical reaction. Increasing age is predictive of the need for supplemental doses and for failure of sedation in both groups.

Validation of Right Atrial Area as a Measure of Right Atrial Size and Normal Values of in Healthy Pediatric Population by Two-Dimensional Echocardiography.

Right atrial (RA) size is a prognostic indicator for heart failure and cardiovascular death in adults. Data regarding use of RA area (RAA) by two-dimensional echocardiography as a surrogate for RA size and allometric modeling to define appropriate indexing of the RAA are lacking. Our objective was to validate RAA as a reliable measure of RA size and to define normal reference values by transthoracic echocardiography (TTE) in a large population of healthy children and develop Z-scores using a validated allometric model for indexing RAA independent of age, sex, and body size. Agreement between RAA and volume by 2D, 3D TTE, and MRI was assessed. RAA not volume by 2D TTE is an excellent surrogate for RA size. RAA/BSA1 has an inverse correlation with BSA with a residual relationship to BSA (r = - 0.54, p < 0.0001). The allometric exponent (AE) derived for the entire cohort (0.85) also fails to eliminate the residual relationship. The entire cohort divided into two groups with a BSA cut-off of 1 m2 to provide the best-fit allometric model (r = 0). The AE by least square regression analysis for each group is 0.95 and 0.88 for BSA < 1 m2 and > 1 m2, respectively, and was validated against an independent sample. The mean indexed RAA ± SD for BSA ≤ 1 m2 and > 1 m2 is 9.7 ± 1.3 cm2 and 8.7 ± 1.3 cm2, respectively, and was used to derive Z-scores. RAA by 2D TTE is superior to 2D or 3D echocardiography-derived RA volume as a measure of RA size using CMR as the reference standard. RAA when indexed to BSA1, decreases as body size increases. The best-fit allometric modeling is used to create Z scores. RAA/BSA0.95 for BSA < 1 m2 and RAA/BSA0.88 for those with BSA > 1 m2 can be used to derive Z scores.

Impact of changing indications and increased utilization of fetal echocardiography on prenatal detection of congenital heart disease.

BACKGROUND: Antenatal diagnosis of congenital heart defects (CHD) can impact outcomes in neonates with severe CHD. Obstetric screening guidelines and the indications for fetal echocardiography (FE) have evolved in an attempt to improve the early prenatal detection of CHD. Analyzing yield for specific indications will help clinicians better stratify at-risk pregnancies. METHODS: Retrospective cohort study of all FE performed between 2000 and 2010 at a single tertiary care academic medical center in New York City. A total of 9878 FE met inclusion criteria for our study. In cases of multiple gestations (MG), each fetus was counted as a separate study. RESULTS: The number of new diagnosis of fetal CHD by FEs increased 200%. There was a statistically significant increase in those referred for suspected CHD, increased nuchal translucency (NT), MG, and suboptimal imaging (P < .001). The indication of "suboptimal imaging" (SO) not only accounted for 5.23% of all referrals from 2000 to 2002, compared to 22.26% of all referrals from 2008 to 2010 (P < .0001), but also had the lowest yield for diagnoses of CHD (P < .02). CONCLUSIONS: Over the past decade, there has been an increase in utilization of FE with a proportional increase in prenatally diagnosed CHD. For indications such as suspected CHD, NT and MG increases in referrals have led to a proportionate increase in fetal diagnosis of CHD. SO as an indication has the lowest yield of fetal diagnosis of CHD. Antenatal detection of CHD may be improved by a change in obstetric imaging protocols to ensure appropriate referrals.

Three-dimensional echocardiography in congenital heart disease: an expert consensus document from the European Association of Cardiovascular Imaging and the American Society of Echocardiography.

Three-dimensional echocardiography (3DE) has become important in the management of patients with congenital heart disease (CHD), particularly with pre-surgical planning, guidance of catheter intervention, and functional assessment of the heart. 3DE is increasingly used in children because of good acoustic windows and the non-invasive nature of the technique. The aim of this paper is to provide a review of the optimal application of 3DE in CHD including technical considerations, image orientation, application to different lesions, procedural guidance, and functional assessment.

Normal values of left atrial volume in pediatric age group using a validated allometric model.

BACKGROUND: Left atrial volume (LAV) increase is an indicator of diastolic dysfunction and a surrogate marker of significant left to right shunts. Normalization of LAV is currently performed by indexing to body surface area(1) (BSA(1)). The indexed LAV thus derived does not account for the nonlinear relationship of physiologic variables to BSA and has not been tested for independence to body size. Our objective was to identify a valid allometric model for indexing LAV and use it to develop Z-scores in children. METHODS AND RESULTS: LAV was measured in 300 normal subjects by echocardiography using the biplane area length method. LAV/BSA(1) had a residual relationship to BSA (r=0.52, P<0.0001). The allometric exponent (AE) derived for the entire cohort (1.27) using the least squares regression analysis also failed to eliminate the residual relationship to BSA (r=-0.15, P=0.01). Dividing the cohort in two groups with a BSA cut-off of 1 m(2) provided the best-fit allometric model. The AE for each group was 1.48 and 1.08 for BSA≤1 m(2) and >1 m(2), respectively, and was validated against an independent sample. The mean indexed LAV±SD for BSA≤1 m(2) and >1 m(2) is 31.5±5.5 mL and 26.0±4.2 mL, respectively, and was used to derive Z-scores. CONCLUSIONS: This study demonstrates the fallacy of using "per-BSA(1) standards" for normalization of LAV in pediatrics. LAV/BSA(1.48) for children with BSA≤1 m(2) and LAV/BSA(1.08) for those with BSA>1 m(2) is accurate and can be used to derive Z-scores.

Midaortic syndrome in the fetus and premature newborn: a new etiology of nonimmune hydrops fetalis and reversible fetal cardiomyopathy.

Nonimmune hydrops fetalis is the final common pathway of many conditions that ultimately result in fetal anasarca. Even after extensive evaluation, the etiology of a small percentage of cases of hydrops remains unknown. We present a case of midaortic syndrome, also known as abdominal coarctation syndrome, in a fetus with hydrops and a severe cardiomyopathy. The clinical manifestations of midaortic syndrome in this fetus and premature newborn, including malignant hypertension and reversible cardiomyopathy, are detailed. The fetal pathophysiology of midaortic syndrome remains speculative, but likely includes fetal hypertension as the cause of cardiac dysfunction. To our knowledge, this is the first report of midaortic syndrome as an etiology for nonimmune hydrops fetalis.

Screening fetal echocardiography by telemedicine: efficacy and community acceptance.

OBJECTIVE: Our aim was to assess whether tertiary level screening fetal echocardiography can be extended to primary care facilities with telemedicine assistance. METHODS: Assessment of image quality and the adequacy of fetal echocardiograms recorded after random transmission at 128, 384, or 768 kbits/s was performed. Live fetal echocardiograms were transmitted at 384 kbits/s (3 integrated services digital network lines) from the remote primary care center. Patient satisfaction was assessed by surveys obtained after office-based and telemedicine consultations. RESULTS: A total of 58 recorded normal studies had similar image quality and adequacy on transmission at 384 and 768 kbits/s (P =.08 and.49, respectively) and were significantly better than 128 kbits/s (P <.01). During live screening transmitted at 384 kbits/s from the primary care center, 3 of 34 fetuses were diagnosed with heart disease. Surveys from patients with direct physician contact and by telemedicine showed a high satisfaction with telemedicine-assisted screening and counseling. CONCLUSION: Adequate screening for fetal heart disease is technically feasible at or above data transmission rates of 384 kbits/s. Community acceptance for telemedicine-assisted screening and counseling is not adversely affected by a lack of direct personal contact with the specialist.