Development of quality metrics for ambulatory pediatric cardiology: Transposition of the great arteries after arterial switch operation.

OBJECTIVE: To develop quality metrics (QMs) for the ambulatory care of patients with transposition of the great arteries following arterial switch operation (TGA/ASO). DESIGN: Under the auspices of the American College of Cardiology Adult Congenital and Pediatric Cardiology (ACPC) Steering committee, the TGA/ASO team generated candidate QMs related to TGA/ASO ambulatory care. Candidate QMs were submitted to the ACPC Steering Committee and were reviewed for validity and feasibility using individual expert panel member scoring according to the RAND-UCLA methodology. QMs were then made available for review by the entire ACC ACPC during an "open comment period." Final approval of each QM was provided by a vote of the ACC ACPC Council. PATIENTS: Patients with TGA who had undergone an ASO were included. Patients with complex transposition were excluded. RESULTS: Twelve candidate QMs were generated. Seven metrics passed the RAND-UCLA process. Four passed the "open comment period" and were ultimately approved by the Council. These included: (1) at least 1 echocardiogram performed during the first year of life reporting on the function, aortic dimension, degree of neoaortic valve insufficiency, the patency of the systemic and pulmonary outflows, the patency of the branch pulmonary arteries and coronary arteries, (2) neurodevelopmental (ND) assessment after ASO; (3) lipid profile by age 11 years; and (4) documentation of a transition of care plan to an adult congenital heart disease (CHD) provider by 18 years of age. CONCLUSIONS: Application of the RAND-UCLA methodology and linkage of this methodology to the ACPC approval process led to successful generation of 4 QMs relevant to the care of TGA/ASO pediatric patients in the ambulatory setting. These metrics have now been incorporated into the ACPC Quality Network providing guidance for the care of TGA/ASO patients across 30 CHD centers.

Signal-averaged electrocardiogram in Ebstein's anomaly.

We sought to establish pathogenetic links between electrophysiology, histopathology, and ventricular tachyarrhythmias in patients with Ebstein's anomaly. The atrialized right ventricle (ARV) is the site of mechanically inducible ventricular tachyarrhythmias, but relations between the arrhythmogenic substrate, the type of tachyarrhythmias, and the trigger(s) have not been established. This study comprised 23 patients (10 men and 13 women; aged 18 to 58 years; mean 32 +/- 3) who did not undergo surgery and 6 pre- and postoperative patients with Ebstein's anomaly, diagnosed by transthoracic and transesophageal echocardiography. Twenty-one patients had classic Ebstein's anomaly and 2 had mild forms. Signal-averaged electrocardiograms (SAECGs) identified slow conduction by using 3 time-domain variables calculated by an automated algorithm and inspected visually. Two variables were required to establish the presence of late potentials. SAECGs were repeated in 6 patients after surgical exclusion of the ARV. Five surgical specimens of the ARV and the true right atrium were examined histologically. Mathematic simulations were used to illustrate anchored and unanchored spiral/scroll waves. SAECGs were positive in 21 patients with classic Ebstein's anomaly and were negative postoperatively in the 6 so studied. The ARV was characterized histologically by clusters of cardiomyocytes isolated within a fibrous matrix. We hypothesize that SAECGs identify slow conduction residing in the ARV, and that excitation of this arrhythmogenic substrate provokes spiral/scroll waves that cannot anchor because clusters of cardiomyocytes are isolated within a fibrous matrix. The waves meander erratically as polymorphic ventricular tachycardia or break up into ventricular fibrillation.

Performance of the neonatal pig heart subjected to oxygen insufficiency.

Isolated, paced, isovolumically beating, neonatal pig (n = 32) hearts underwent retrograde aortic perfusion with a solution containing insulin (100 microU/ml), glucose (5.5 mM), and palmitate (0.55 mM). Glycolysis, lactate release, glucose oxidation, palmitate oxidation, and oxygen consumption were assessed. The hearts were perfused during three periods: (1) baseline, pO(2) approximately 500 mm Hg, heart rate 150 bpm; (2) hypoxia, pO(2) approximately 60-80 mm Hg, heart rate 150 bpm, or tachycardia, pO(2) approximately 500 mm Hg, heart rate 300 bpm, and (3) recovery, return to baseline conditions. For hypoxia and tachycardia, the oxygen supply-demand ratio was comparable ( approximately 1 nmol O(2)/mm Hg/g(dry)). During baseline, the left ventricular peak systolic pressure (PSP) averaged 126 +/- 6 mm Hg, the end-diastolic pressure (EDP) 5 mm Hg, and the relaxation time constant (Tau) 34 +/- 2 ms; the coronary flow was 36 +/- 2 ml/min/g(dry). During hypoxia, the PSP decreased to 70 +/- 2 mm Hg, while EDP, Tau, and coronary flow increased to 26 +/- 2 mm Hg, 104 +/- 14 ms, and 70 +/- 2 ml/min/g(dry), respectively; palmitate oxidation and oxygen consumption decreased well below baseline. During tachycardia, the PSP decreased to 88 +/- 1 mm Hg, and the EDP increased to 11 +/- 1 mm Hg, while Tau and coronary flow did not change significantly; palmitate oxidation and oxygen consumption increased above baseline. For both stressors, the predicted lactate release underestimated the measured values by a factor of approximately 2, but were comparable during baseline and recovery. Upon recovery, PSP returned to approximately 80% of baseline, while EDP remained elevated, for both stressors. Glucose oxidation returned to baseline, but palmitate oxidation became accelerated. We conclude for neonatal pig hearts subjected to oxygen insufficiency: (1) that PSP decreases and (2) that EDP and Tau increase with hypoxia, whereas EDP increases, while Tau remains unchanged with tachycardia. Following both stressors, palmitate oxidation becomes enhanced and dissociated from mechanical activity.