Impact of Appropriate Use Criteria for Cross-Sectional Imaging on Medical Decision-Making in Patients with Conotruncal Defects.

Associations between Appropriate Use Criteria (AUC) ratings and medical decision-making in congenital heart disease are not well-established. We applied the 2020 AUC for multimodality imaging in follow-up care of pediatric and young adult patients with conotruncal defects to evaluate appropriateness of cardiac magnetic resonance (CMR) and computed tomography (CCT) use in this population and impact on clinical decision-making. Records were reviewed and assigned AUC indications and corresponding ratings for CMR and CCT. We examined the relationship between AUC indications, their ratings, and change in management. Of the 200 studies (133 CMR, 67 CCT) performed on 187 patients, no studies were rated Rarely Appropriate (R), and most studies were obtained for routine follow-up (151/200 [75.5%]) and were not prompted by clinical concerns. There were 70/200 (35.0%) studies which led to management changes; these included transcatheter intervention (29/70 [41.4%]), surgical intervention (25/70 [35.7%]), other interventions (10/70 [14.3%]), and medical intervention (6/70 [8.6%]). Among all studies, studies prompted by clinical concerns and studies rated M more frequently resulted in change in management (46.9 vs 31.1%, p = 0.04 and 54.1 vs 30.7%, p = 0.003, respectively). In conclusion, we found that all studies were ordered for indications rated Appropriate (A) or May be Appropriate (M), indicating compliance in ordering practices as outlined by published AUC. Studies ordered for clinical change or rated M more frequently led to management change in patient care. Findings may help inform provider expectations of testing yield in this population and serve as a platform for development of future iterations of AUC.

Pigmented Villonodular Synovitis Mimicking an Acute Septic Hip in an Eight-Year-Old Male.

Pigmented villonodular synovitis (PVNS) is a less common but known cause of joint pain in the adult population. PVNS in pediatric patients is even more rare, with only case reports of occurrence in persons under the age of 18 years. Presentation is typically that of more insidious pain and limited range of motion, and is primarily seen in the knee joint. Diagnosis can be suspected with imaging, but ultimately surgical intervention is needed for tissue confirmation. We present a case of PVNS in a pediatric patient with acute symptoms concerning for a septic joint. The patient's workup revealed a large effusion on hip ultrasound, with operative intervention pursued and further imaging deferred given the patient's symptom burden. A 4 × 1 × 1.5 cm intra-articular pigmented mass excised from the synovium in the operating room. The patient's symptoms improved after the procedure, with pathology showing sheets of plump mononuclear cells in a collagenized stroma with hemosiderin deposits, confirming the diagnosis. This case highlights the importance of keeping non-infectious etiologies in the differential diagnosis of acute onset joint pain.

Cardiac Function and Sudden Cardiac Death in Heart Failure With Preserved Ejection Fraction (from the TOPCAT Trial).

Patients with heart failure with preserved ejection fraction (HFpEF) have a significantly elevated risk of sudden cardiac death (SCD). However, few imaging data have been correlated to this risk. We evaluated the value of multiple echocardiographic markers of left ventricular (LV) function to predict SCD in HFpEF patients. The Treatment of Heart Failure with Preserved Ejection Fraction with Aldosterone Trial (TOPCAT)-Americas cohort was used to evaluate the echocardiographic predictors of SCD and/or aborted cardiac arrest (SCD/ACA). A retrospective cohort design was used. Cox proportional hazards and Poisson regression models were used to determine the associations between the risk of SCD/ACA and echocardiographic parameters: diastolic dysfunction grade, left ventricle ejection fraction, and LV global longitudinal strain (GLS) during follow-up. Impaired left ventricle ejection fraction and GLS were associated with SCD/ACA in univariate models (p = 0.007 and 0.002, respectively), but not diastolic function grade. After multivariate adjustment, only GLS remained a significant predictor of the incidence rate of SCD/ACA (p = 0.006). There was a 58% increase in the hazard of incident SCD/ACA for every 1 unit increase in GLS (1.58, 95%CI: 1.12 to 2.22, p = 0.009). These findings remained robust in the competing risk analyses. In conclusion, amongst the multiple echocardiographic parameters of LV function, GLS may help prognosticate the risk of SCD/ACA in HFpEF patients.