The relationship between microRNAs and COVID-19 complications.

Over the past three years, since the onset of COVID-19, several scientific studies have concentrated on understanding susceptibility to the virus, the progression of the illness, and possible long-term complexity. COVID-19 is broadly recognized with effects on multiple systems in the body, and various factors related to society, medicine, and genetics/epigenetics may contribute to the intensity and results of the disease. Additionally, a SARS-CoV-2 infection can activate pathological activities and expedite the emergence of existing health issues into clinical problems. Forming easily accessible, distinctive, and permeable biomarkers is essential for categorizing patients, preventing the disease, predicting its course, and tailoring treatments for COVID-19 individually. One promising candidate for such biomarkers is microRNAs, which could serve various purposes in understanding diverse forms of COVID-19, including susceptibility, intensity, disease progression, outcomes, and potential therapeutic options. This review provides an overview of the most significant findings related to the involvement of microRNAs in COVID-19 pathogenesis. Furthermore, it explores the function of microRNAs in a broad span of effects that may arise from accompanying or underlying health status. It underscores the value of comprehending how diverse conditions, such as neurological disorders, diabetes, cardiovascular diseases, and obesity, interact with COVID-19.

Fatores intervenientes na gerência do cuidado de enfermagem à criança hospitalizada com cardiopatia reumática / Intervening factors in the management of nursing care for children hospitalized with rheumatic heart disease / Factores que intervienen en la gestión del cuidado de enfermería al niño hospitalizado con cardiopatía reumática

Objetivo: analisar os fatores intervenientes na gerência do cuidado de enfermagem à criança hospitalizada com cardiopatia reumática. Método: estudo descritivo-exploratório com abordagem qualitativa, que utilizou a Teoria Fundamentada em Dados e o Interacionismo Simbólico, respectivamente, como referencial metodológico e teórico. A coleta de dados foi realizada em uma instituição especializada em atendimento cardiológico, no munícipio do Rio de Janeiro. Foram entrevistados 19 profissionais de enfermagem através de um roteiro semiestruturado. Resultado: emergiram os seguintes fatores intervenientes na prática da gerência do cuidado: condição socioeconômica da família, comportamento da criança, condições de trabalho, comunicação ineficaz, educação permanente, trabalho em equipe e experiência profissional. Conclusão: os resultados apontam para a necessidade de proposição de estratégias de ação e interação que facilitem a prática gerencial de cuidado à criança com cardiopatia reumática e sua família face aos fatores intervenientes identificados.

Objective: to analyze the factors involved in the management of nursing care for children hospitalized with rheumatic heart disease. Method: this is a descriptive-exploratory study with a qualitative approach, which used Data-Based Theory and Symbolic Interactionism, respectively, as methodological, and theoretical references. Data was collected in an institution specializing in cardiac care in the city of Rio de Janeiro. Nineteen nursing professionals were interviewed using a semi-structured script. Result: the following intervening factors in the practice of care management emerged: the family's socioeconomic status, the child's behavior, working conditions, ineffective communication, continuing education, teamwork, and professional experience. Conclusion: the results point to the need to propose strategies for action and interaction that facilitate management practice in caring for children with rheumatic heart disease and their families, given the intervening factors identified.

Objetivo: analizar los factores que intervienen en la gestión del cuidado de enfermería al niño hospitalizado con cardiopatía reumática. Método: estudio descriptivo-exploratorio con enfoque cualitativo, cuyos marcos metodológico y teórico fueron la Teoría Fundamentada y el Interaccionismo Simbólico, respectivamente. La recolección de datos se realizó en una institución especializada en atención cardiológica, en la ciudad de Río de Janeiro. Fueron entrevistados 19 profesionales de enfermería mediante un cuestionario semiestructurado. Resultado: surgieron los siguientes factores intervinientes en la práctica de la gestión del cuidado: condición socioeconómica de la familia, comportamiento del niño, condiciones de trabajo, comunicación ineficaz, educación continua, trabajo en equipo y experiencia profesional. Conclusión: los resultados indican que es necesario proponer estrategias de acción e interacción que faciliten la práctica de la gestión del cuidado al niño con cardiopatía reumática y a sus familiares, con respecto a los factores intervinientes identificados.

A machine learning algorithm for the identification elevated Lp(a) in patients with, or high-risk of having, coronary heart disease.

BACKGROUND: Decision tree algorithms, obtained by machine learning, provide clusters of patients with similar clinical patterns by the identification of variables that best merge with a given dependent variable. METHODS: We performed a multicenter registry, with 7 hospitals form Spain, of patients with, or high-risk of having, coronary heart disease (CHD). Elevated Lp(a) was defined as >50 mg/dl. Machine learning based decision trees were obtained by Chi-square automatic interaction detection. RESULTS: We analyzed 2301 patients. Median Lp(a) was 26.7 (9.3-79.9) mg/dl and 887 (38.6 %) patients had Lp(a) >50 mg/dl. The machine learning algorithm identified 6 clusters based on LDLc, CHD, FH of premature CHD and age (Fig. 1). Clusters 1 (LDLc <100 mg/dl, no CHD and, no FH of CHD) and 3 (LDLc <100 mg/dl, CHD and, no FH and, age < 50 yo) had the lowest Lp(a) values (Fig. 2); patients classified in cluster 5 (LDLc >100 mg/dl, CHD and, FH of CHD) and 6 (LDLc >100 mg/dl) had the highest values. We collapsed clusters in 3 groups: group 1 with clusters 1 and 3; group 2 with clusters 2 and 4; group 3 with clusters 5 and 6. The 3 groups have significantly different (p < 0.001) and progressively higher Lp(a) values. The prevalence of Lp(a) >50 mg/dl was 15.4 % in group 1, 29.2 % in group 2 and 91.1 % in group 3; similarly, the prevalence of Lp(a) >180 mg/dl was 1.0 %, 3.0 % and 7.6 % respectively. CONCLUSIONS: A decision tree algorithm, performed by machine learning, identified patients with, or at high risk of having, CHD have higher probabilities of having elevated Lp(a).

Tetralogy of Fallot With Absent Pulmonary Valve Syndrome: The Experience of a Tertiary Care Center in a Developing Country.

BACKGROUND: Tetralogy of Fallot with an absent pulmonary valve is a very rare variant of tetralogy. It is characterized by absent valve tissue, severe pulmonary regurgitation, and secondary aneurysmal dilatation of the pulmonary arteries. AIM: In this study, we aim to investigate the clinical presentations, management strategies, and outcomes of patients with tetralogy of Fallot and absent pulmonary valve. METHODOLOGY: We retrospectively reviewed the charts of all patients who presented to the American University of Beirut Medical Center between January 2010 and December 2020 and who were diagnosed with this anomaly. RESULTS: A total of 300 cases of tetralogy of Fallot were identified, of which 18 patients had absent pulmonary valves. They were followed up for an average of 8.2 years. Prenatal diagnoses were made in four patients, while 13 patients were identified in the neonatal period, with an average age of 4.5 days. Genetic testing confirmed DiGeorge syndrome in one patient. Five patients underwent surgical intervention in the neonatal period, while the remaining patients were operated on during their early childhood. While overall there were no surgical mortalities nor any need for reinterventions, a variety of morbidities were encountered. CONCLUSION: This study provides an overview of this rare anomaly and its management in a developing country.

Long term follow-up of bilateral internal thoracic artery use in young coronary artery bypass grafting patients: 29 year single surgeon experience.

BACKGROUND: Improved long term survival has demonstrated by grafting left internal thoracic artery (LITA) to the left anterior descending artery (LAD). This study investigated the prognostic benefits of BITA versus single LITA with common anastomotic configurations of BITA. METHODS: Elective patients age below 60 years, undertaken by a single surgeon, between 1992 and 2014 were explored. Cox regression models were fitted to investigate prognostic benefits of BITA. Specific comparisons were made with BITA subgroups who received LITA to LAD or RITA to LAD to establish long-term prognostic difference with the use of the RITA to LAD as compared to the LITA to LAD anastomosis. Comparisons were made with other BITA configurations to establish long-term difference in survival as a result of the actual targets bypassed with BITA grafts. RESULTS: Both groups had similar baseline patient characteristics. Following risk adjustment, the use of a second ITA conferred a significant 48% reduction in long-term mortality to BITA group [HR 0.52 (95%CI: 0.36-0.74) p < .001]. The use of the RITA to LAD, instead of LITA, resulted in no difference in the long-term prognostic benefit. The targets grafted with second ITA conferred a significant prognostic benefit for common configurations it was used in for bypass surgery. CONCLUSIONS: The use of BITA confers long term prognostic benefit to patients. Grafting RITA to LAD instead of more common LITA to LAD made no difference in long term prognosis when compared to CABG patients with single ITA. The use of a second ITA conduit in common configurations for CABG confers prognostic benefits irrespective of distal target grafted.

Evaluating artificial intelligence-driven stress echocardiography analysis system (EASE study): A mixed method study.

INTRODUCTION: The use and value of artificial intelligence (AI)-driven tools and techniques are under investigation in detecting coronary artery disease (CAD). EchoGo Pro is a patented AI-driven stress echocardiography analysis system produced by Ultromics Ltd. (henceforth Ultromics) to support clinicians in detecting cardiac ischaemia and potential CAD. This manuscript presents the research protocol for a field study to independently evaluate the accuracy, acceptability, implementation barriers, users' experience and willingness to pay, cost-effectiveness and value of EchoGo Pro. METHODS AND ANALYSIS: The 'Evaluating AI-driven stress echocardiography analysis system' (EASE) study is a mixed-method evaluation, which will be conducted in five work packages (WPs). In WP1, we will examine the diagnostic accuracy by comparing test reports generated by EchoGo Pro and three manual raters. In WP2, we will focus on interviewing clinicians, innovation/transformation staff, and patients within the National Health Service (NHS), and staff within Ultromics, to assess the acceptability of this technology. In this WP, we will determine convergence and divergence between EchoGo Pro recommendations and cardiologists' interpretations and will assess what profile of cases is linked with convergence and divergence between EchoGo Pro recommendations and cardiologists' interpretations and how these link to outcomes. In WP4, we will conduct a quantitative cross-sectional survey of trust in AI tools applied to cardiac care settings among clinicians, healthcare commissioners and the general public. Lastly, in WP5, we will estimate the cost of deploying the EchoGo Pro technology, cost-effectiveness and willingness to pay cardiologists, healthcare commissioners and the general public. The results of this evaluation will support evidence-informed decision-making around the widespread adoption of EchoGo Pro and similar technologies in the NHS and other health systems. ETHICS APPROVAL AND DISSEMINATION: This research has been approved by the NHS Health Research Authority (IRAS No: 315284) and the London South Bank University Ethics Panel (ETH2223-0164). Alongside journal publications, we will disseminate study methods and findings in conferences, seminars and social media. We will produce additional outputs in appropriate forms, for example, research summaries and policy briefs, for diverse audiences in NHS.

Surgical repair of "Swiss Cheese" ventricular septal defects with two-patch and right ventricular apex-exclusion technique: mid-term follow-up results.

BACKGROUND: "Swiss Cheese" ventricular septal defects represent a serious congenital heart disease with suboptimal clinical outcomes and a lack of consensus regarding its management. This study presents mid-term follow-up results of surgical repairs for "Swiss Cheese" ventricular septal defects, utilizing the two-patch and right ventricle apex-exclusion technique. METHODS: A retrospective review was conducted on 13 patients who underwent surgical repair utilizing the two-patch and right ventricle apex-exclusion technique at our institution between May 2014 and October 2021. The procedure involved the closure of defects in the outflow tract ventricular septal and the apex trabecular ventricular septal regions using two patches, with concurrent exclusion of the right ventricular apex from the right ventricular inflow tract. RESULTS: Median follow-up was 4.9 ± 2.1 years (range: 2-9 years). All cases were successful without mortality or major complications. Two years post-surgery, cardiac magnetic resonance revealed median values for left ventricular ejection fraction, right ventricular ejection fraction, left ventricular end-diastolic volume and right ventricular end-diastolic volume of 63.9% ± 1.8% (range: 61-67%), 49.2% ± 2.6% (range: 46-55%), 39.15 ± 2.11 ml (range: 36.2-42.7 ml), 44.55 ± 3.33 ml (range: 38.7-48.6 ml), respectively. No thrombosis occurred. The latest echocardiography results confirmed normal cardiac function in all cases. CONCLUSIONS: The surgical repair of "Swiss Cheese" ventricular septal defects utilizing the two-patch and right ventricle apex-exclusion technique is a viable approach with favorable mid-term outcomes. More cases and long-term follow-up results are needed to validate the feasibility and safety of this technique.

Considering User Experience and Behavioral Approaches in the Design of mHealth Interventions for Atrial Fibrillation: Systematic Review.

BACKGROUND: Atrial fibrillation (AF) is a leading chronic cardiac disease associated with an increased risk of stroke, cardiac complications, and general mortality. Mobile health (mHealth) interventions, including wearable devices and apps, can aid in the detection, screening, and management of AF to improve patient outcomes. The inclusion of approaches that consider user experiences and behavior in the design of health care interventions can increase the usability of mHealth interventions, and hence, hopefully, yield an increase in positive outcomes in the lives of users. OBJECTIVE: This study aims to show how research has considered user experiences and behavioral approaches in designing mHealth interventions for AF detection, screening, and management; the phases of designing complex interventions from the UK Medical Research Council (MRC) were referenced: namely, identification, development, feasibility, evaluation, and implementation. METHODS: Studies published until September 7, 2022, that examined user experiences and behavioral approaches associated with mHealth interventions in the context of AF were extracted from multiple databases. The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines were used. RESULTS: A total of 2219 records were extracted, with only 55 records reporting on usability, user experiences, or behavioral approaches more widely for designing mHealth interventions in the context of AF. When mapping the studies onto the phases of the UK MRC's guidance for developing and evaluating complex interventions, the following was found: in the identification phase, there were significant differences between the needs of patients and health care workers. In the development phase, user perspectives guided the iterative development of apps, interfaces, and intervention protocols in 4 studies. Most studies (43/55, 78%) assessed the usability of interventions in the feasibility phase as an outcome, although the data collection tools were not designed together with users and stakeholders. Studies that examined the evaluation and implementation phase entailed reporting on challenges in user participation, acceptance, and workflows that could not be captured by studies in the previous phases. To realize the envisaged human behavior intended through treatment, review results highlight the scant inclusion of behavior change approaches for mHealth interventions across multiple levels of sociotechnical health care systems. While interventions at the level of the individual (micro) and the level of communities (meso) were found in the studies reviewed, no studies were found intervening at societal levels (macro). Studies also failed to consider the temporal variation of user goals and feedback in the design of long-term behavioral interventions. CONCLUSIONS: In this systematic review, we proposed 2 contributions: first, mapping studies to different phases of the MRC framework for developing and evaluating complex interventions, and second, mapping behavioral approaches to different levels of health care systems. Finally, we discuss the wider implications of our results in guiding future mHealth research.

Comprehensive Review of the Psychosocial Impact on Parents of Newborns With Congenital Heart Disease: A Significant Problem in Low- and Middle-Income Countries.

Congenital heart disease (CHD) is a common and significant congenital disorder. Despite advancements in neonatal care, Congenital heart disease remains a leading cause of death among infants with congenital malformations. Congenital heart disease is responsible for a significant portion of stillbirths and includes several forms with various anatomical variations. A CHD diagnosis leads to significant emotional distress for parents, affecting family dynamics and quality of life. Parents often experience psychological impacts, such as anxiety, depression, and guilt, particularly when diagnoses occur after birth. This literature review explores the psychosocial impact of CHD on families and examines how the timing of diagnosis influences outcomes. Parents face numerous challenges, including managing complex medical care and addressing financial and emotional burdens. Effective communication between healthcare providers and families is crucial, as is providing continuous emotional support and counseling. Early psychological interventions can alleviate depression and anxiety, and pediatric psychologists play a significant role in reducing the negative long-term effects on neurodevelopment. Further research is needed to develop strategies to improve mental health services and enhance the quality of life for families affected by CHD.

Stepped-Care Web-Based Parent Support Following Congenital Heart Disease: Protocol for a Randomized Controlled Trial.

BACKGROUND: Early neurodevelopmental risks, compounded with traumatic medical experiences, contribute to emotional and behavioral challenges in as many as 1 in 2 children with congenital heart disease (CHD). Parents report a strong need for supports; yet, there remains a lack of accessible, evidence-based behavioral interventions available for children with CHD and their families. I-InTERACT-North is a web-based stepped-care mental health program designed to support family well-being and reduce behavioral concerns through positive parenting for children with early medical complexity. In previous pilot studies, the program was effective in increasing positive parenting skills and decreasing child behavior problems, with high parent-reported acceptability. This paper presents the protocol for the first randomized study of stepped-care parent support for families of children with CHD. OBJECTIVE: This study will involve a single-site, 2-arm, single-blind randomized controlled trial to evaluate (1) the feasibility and acceptability of a web-based stepped-care parent support program (I-InTERACT-North) and (2) the effectiveness of the program in enhancing positive parenting skills and reducing behavioral concerns among families of children with CHD. METHODS: Families will be randomized (1:1) to either receive treatment or continue with care as usual for 12 months. Randomization will be stratified by child's sex assigned at birth and baseline parent-reported child behavior intensity. Primary outcomes include positive parenting skills and child behavior at baseline, 3 months, 6 months, and 12 months. Secondary outcomes include parental mental health, quality of life, service usage, and feasibility including program reach and adherence. A sample size of 244 families will provide >95% power to detect an effect size of d=0.64. Based on attrition data from pilot studies, a target of 382 families will be enrolled. Parent reports of acceptability, adoption, and suggested adaptability of the program will be examined using cross-case thematic analyses. Primary efficacy analysis will be conducted using an intent-to-treat approach. Generalized estimating equations will be used to examine changes in positive parenting. Child behavior, quality of life, and parent mental health will be tested with repeated-measures analyses. Additional sensitivity and replication analyses will also be carried out. RESULTS: Recruitment began in February 2024, and recruitment and follow-up will continue until January 2029. We anticipate results in late 2029. CONCLUSIONS: This study aims to test the effectiveness of I-InTERACT-North web-based stepped-care parent support in improving positive parenting skills and reducing child behavior problems in families of children with CHD compared with a care as usual control group. Results will inform future clinical implementation and expansion of this program among families of children with early medical conditions. TRIAL REGISTRATION: ClinicalTrials.gov NCT06075251; https://clinicaltrials.gov/study/NCT06075251. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/64216.

Identifying Frailty and Its Risk Factors in Pediatric Patients with Fontan Physiology.

Frailty is a clinical syndrome common in adults with chronic disease with resultant vulnerability to adverse health outcomes. Little is known about frailty in pediatric patients, including those with single-ventricle heart disease. This study aimed to examine the prevalence of frailty and its associated risk factors in patients with Fontan circulation. A single-center, prospective cohort study assessed frailty in patients (10-21 years old) after Fontan palliation. Slowness, weakness, exhaustion, shrinkage, and diminished physical activity were evaluated and scored using a modified Fried frailty assessment comprised of validated pediatric tests. Providers estimated subjects' degree of frailty. Patient-reported quality of life (QOL) was assessed. Of 54 participants (median age 15.3 years, 61% male), 18 (33%) were identified as frail, while 26 (48%) were pre-frail. Patients frequently exhibited frailty in the domains of slowness (93%), weakness (41%), and diminished physical activity (39%). There was poor correlation between frailty scores and provider estimates of frailty (Kappa = 0.11). Frail subjects had lower PedsQL physical functioning scores (mean 62.8 ± SD 18.5 in Frail vs. 75.7 ± 16.0 in No/pre-Frail; p = 0.01). Factors associated with frailty included protein-losing enteropathy (p = 0.03) and at least one hospitalization in the last year (p = 0.047). One-third of pediatric patients after Fontan palliation were frail which was associated with lower physical functioning and higher healthcare utilization. Providers poorly recognized frailty. These findings highlight the need for improved screening and support for an at-risk population where frailty is not easily identified.

Hemodynamic Assessment of Infants With Congenital Heart Disease Using Ferumoxytol-Enhanced 4D Flow Cardiac Magnetic Resonance.

In complex congenital heart disease, characterization of the circulation is necessary to anticipate the clinical course. Four-dimensional cardiac magnetic resonance imaging enhanced by superparamagnetic iron oxide contrast agents (ferumoxytol) enables detailed and efficient assessment of both anatomy and physiology in neonates. We demonstrate this impact in 3 cases of neonates with congenital heart disease.

The Effect of Stenting on Post-Stenotic Dilatation in Coarctation of The Aorta.

The effect of stenting of native aortic coarctation (CoA) on post-stenotic dilatation (PSD) has not been previously described. We hypothesized that CoA stenting may lead to positive remodeling of PSD. Retrospective analysis of patients who underwent stent implantation for native CoA from 1999 to 2021 was performed. Primary outcome was incremental change PSD diameter and the PSD/DescAo (Descending Aorta) following stent implantation and comparison between covered and bare-metal stents. 90 consecutive patients, (26 female, average age at first intervention 12.0 years) were included. 35 patients (38.9%) underwent dilatation with bare-metal stents and 55 patients (61.1%) with covered stents. The covered stent subgroup was older (14.0 vs. 9.2 years old, p < 0.001) and PSD was larger (17.0 vs 14.0 mm, p < 0.001). Over a mean of 3.2 years, mean inter-catheterization growth of the PSD was blunted [- 0.05 mm, 95% CI (- 1.5 to 1.4)]. The covered stent subgroup demonstrated a negative inter-catheterization growth compared to the bare-metal stent subgroup (- 0.7 vs 1.6 mm, p < 0.001). When controlled for somatic growth, the PDS/DescAo decreased more significantly among those with covered stent vs bare metal (- 0.12 vs - 0.058, p = 0.004). Stenting of native CoA blunts the growth of PSD; covered stents were significantly associated with regression of the diameter of the PSD over time compared to bare-metal stents.

Team dynamics after implementation of guidelines for anaesthesia for children with CHD.

Guidelines were created at our single centrer institution for which anesthesiology team should care for pediatric cardiac patients for noncardiac surgery. The goal of the survey was to assess inter-team dynamics after the implementation of guidelines and revealed that practice behaviour can quickly change but a sustained change in team dynamics and workplace culture takes time.

Hospital variation in post-operative cardiac extracorporeal membrane oxygenation use and relationship to post-operative mortality.

OBJECTIVE: It is unclear how extracorporeal membrane oxygenation use varies across paediatric cardiac surgical programmes and how it relates to post-operative mortality. We aimed to determine hospital-level variation in post-operative extracorporeal membrane oxygenation use and its association with case-mix adjusted mortality. METHODS: Retrospective analysis of 37 hospitals contributing to the Pediatric Cardiac Critical Care Consortium clinical registry from 1 August 2014 to 31 December 2019. Hospitalisations including cardiothoracic surgery and post-operative admission to paediatric cardiac ICUs were included. Two-level multivariable logistic regression with hospital random effect was used to determine case-mix adjusted post-operative extracorporeal membrane oxygenation use rates and in-hospital mortality. Hospitals were grouped into extracorporeal membrane oxygenation use tertiles, and mortality was compared across tertiles. RESULTS: There were 43,640 eligible surgical hospitalisations; 1397 (3.2%) included at least one post-operative extracorporeal membrane oxygenation run. Case-mix adjusted extracorporeal membrane oxygenation rates varied more than sevenfold (0.9-6.9%) across hospitals, and adjusted mortality varied 10-fold (0-5.5%). Extracorporeal membrane oxygenation rates were 2.0%, 3.5%, and 5.2%, respectively, for low, middle, and high extracorporeal membrane oxygenation use tertiles (P < 0.0001), and mortality rates were 1.9%, 3.0%, and 3.1% (p < 0.0001), respectively. High extracorporeal membrane oxygenation use hospitals were more likely to initiate extracorporeal membrane oxygenation support intraoperatively (1.6% vs. 0.6% low and 1.1% middle, p < 0.0001). Extracorporeal membrane oxygenation indications were similar across hospital tertiles. When extracorporeal cardiopulmonary resuscitation was excluded, variation in extracorporeal membrane oxygenation use rates persisted (1.5%, 2.6%, 3.8%, p < 0.001). CONCLUSIONS: There is hospital variation in adjusted post-operative extracorporeal membrane oxygenation use after paediatric cardiac surgery and a significant association with adjusted post-operative mortality. These findings suggest that post-operative extracorporeal membrane oxygenation use could be a complementary quality metric to mortality to assess performance of cardiac surgical programmes.

Direct Oral Anticoagulants for Rheumatic Heart Disease-Associated Atrial Fibrillation Post-Bioprosthetic Mitral Valve Replacement.

BACKGROUND: The efficacy of direct oral anticoagulants (DOACs) in preventing ischemic and thromboembolic events may be suboptimal in atrial fibrillation (AF) patients with rheumatic mitral stenosis. However, their safety and effectiveness after mitral valve replacement (MVR) using bioprosthetic valves is unclear. OBJECTIVES: This study sought to evaluate the safety and effectiveness of DOACs vs warfarin among patients with rheumatic heart disease (RHD)-associated AF after bioprosthetic MVR. METHODS: We performed an observational analysis identifying patients with RHD and AF who underwent bioprosthetic MVR. Primary effectiveness and safety outcomes were ischemic events and major bleeding, respectively. Secondary outcomes included all-cause mortality, cardiac thrombosis, myocardial infarction, and all-cause hospitalization. Propensity score matching was performed to account for the differences in baseline characteristics and comorbidities. RESULTS: A total of 3,950 patients were identified; 76% were on warfarin and 24% on DOAC post-MVR. The DOAC group had a higher burden of baseline comorbidities and prior cardiovascular procedures compared with the warfarin group. The propensity score matching balanced baseline characteristics in 1,832 patients (916 in each group), with a mean age of 69 years. At the 5-year follow-up, DOACs were associated with a lower incidence of major bleeding compared with warfarin (HR: 0.76; 95% CI: 0.62-0.94), with no significant difference in ischemic events, mortality, cardiac thrombosis, myocardial infarction, or hospitalization. CONCLUSIONS: Among patients with RHD-associated AF patients post-bioprosthetic MVR, DOACs are associated with lower major bleeding and comparable effectiveness, indicating a potential alternative to warfarin. Further randomized controlled trials are warranted to validate these findings in this population.

Assessment of accuracy of two pulse oximeters in infants with cyanotic and acyanotic congenital heart diseases.

BACKGROUND: Peripherally measured oxygen saturation (SpO2) may often differ from arterial oxygen saturation (SaO2), measured by co-oximetry, especially within the lower range of oxygen saturations. This can potentially impact clinical decisions and therapy in children with congenital heart disease, as critical hypoxemia might remain unnoticed. AIMS: Our aim was to investigate the accuracy of two different pulse oximeters compared to SaO2 in infants with congenital heart diseases. METHODS: Simultaneous recordings of SpO2, measured by two different pulse oximeters (Philips IntelliVue X3 Monitor and Nellcor™ OxiMax™), were compared to SaO2 obtained by arterial blood gas analysis. RESULTS: A total of 153 measurements were performed in 44 infants with arterial oxygen saturation between 70 and 100%. We divided the measurements into 3 subgroups: group 1-SaO2 70.0%-85.0%, group 2-SaO2 85.1%-94.0%, group 3-SaO2 >94.1%. For Philipps, the median bias was 5.3 (IQR: 2.6-8.7) %, 2.3 (IQR: 0.9-6.0) % and 1.1 (IQR: -0.8-2.4) % in group 1, 2 and 3, respectively. For OxiMax™, the median bias was 2.7 (IQR: 0.5-5.1) %, 0.2 (IQR: -0.9-2.6) % and -0.5 (IQR: -1.3-0.6) % in group 1, 2 and 3, respectively. Regarding the accuracy of these oximeters, as evaluated with the Accuracy root mean squared index (Arms), it was 9.8 versus 4.5% in group 1, 4.5 versus 2.9% in group 2 and 2.4 versus 1.9% in group 3 for Philipps and OxiMax™, respectively. CONCLUSIONS: In lower range saturations between 70% and 85% the accuracy of both pulse oximeters exceeded the threshold of ≤3% recommended by the Food and Drug Administration (FDA). Therefore, peripheral pulse oximetry within the lower range of oxygen saturations should be interpreted with caution in infants with congenital heart diseases, taking into consideration its limitations. Direct co-oximetry should be the preferred method to support clinical decisions in children with cyanotic congenital heart diseases.

Congenital Heart Disease among Children Undergoing Echocardiography in the Department of Paediatrics of Tertiary Care Centre: A Descriptive Cross-sectional Study.

INTRODUCTION: Congenital heart disease in children are a major cause of infant mortality and morbidity. It is important to detect and manage these disorders timely as they are preventable. The objective of this study was to find out proportion of congenital heart disease in children in paediatric department in a tertiary hospital. METHODS: This is a descriptive cross-sectional study carried out in the Department of Paediatric at Nepal Medical College and Teaching Hospital where all children (0-18 years) suspected to have congenital heart disease who underwent echocardiography were studied over a period of 1 year (2020-2021). The presence or absence of congenital heart disease were confirmed by echocardiography performed by paediatric cardiologist. The socioeconomic variables,clinical features and echocardiography findings were noted. RESULTS: Out of total 249 patients,the proportion of patients diagnosed to have cardiac disorders was 73 with male predominance of 165 (66.26%). The most common age group was found to be neonates 111 (44%).The notable clinical features were murmur 47 (18.87%), tachypnoea 27 (10.84%) ,tachycardia 27 (10.84%) and cyanosis 9 (3.61%), clubbing 2 (0.80%), oedema 1 (0.40%), hypertension 9 (3.65%), murmur 47 (18.87%).Out of the total, there were 49 (19.67%) cases of acyanotic congenital heart disease, and 27 (10.84%) cases of cyanotic congenital heart disease. CONCLUSIONS: Our study focuses on early recognition of cardiac diseases which is crucial for preventing morbidity and mortality.

Stakeholder perceptions of factors contributing to effective implementation of exercise cardiac telerehabilitation in clinical practice.

AIMS: Cardiac exercise telerehabilitation is effective and can be cost-effective for managing ischaemic heart disease, but implementation of evidence-based interventions in clinical practice remains a challenge. We aimed to identify factors that cardiac rehabilitation stakeholders perceived could influence the effectiveness of implementing an evidence-based, real-time remotely monitored cardiac exercise telerehabilitation intervention (REMOTE-CR). METHODS AND RESULTS: Online interviews and focus groups were conducted with cardiac rehabilitation consumers (n = 16, 5 female, 61.1 ± 10.0 years), practitioners (n = 20, 14 female; 36.6 ± 11.8 years), and health service managers (n = 11, 7 female; 46.2 ± 9.2 years) recruited from one metropolitan and three inner-regional healthcare services in Western Victoria, Australia. Discussions were guided by two theoretical frameworks (Non-adoption, Abandonment, Scale-up, Spread, and Sustainability; Consolidated Framework for Implementation Research), and analysed thematically. Factors perceived to influence effective implementation of REMOTE-CR spanned all domains of the theoretical frameworks, related to six major themes (resources, change management, stakeholder targeting, knowledge, intervention design, security) and were largely consistent across study sites; however, the relative importance of each factor may vary between sites. CONCLUSION: Effective implementation of exercise telerehabilitation interventions like REMOTE-CR will require a coordinated context-specific approach that considers factors across all levels of the healthcare system and implementation science frameworks. Key requirements include prioritizing resources, managing change, selecting target stakeholders, developing digital health capabilities, and selecting fit-for-purpose technologies that enable programme delivery objectives.