ICU Admission Tool for Congenital Heart Catheterization (iCATCH): A Predictive Model for High Level Post-Catheterization Care and Patient Management.

OBJECTIVES: Currently, there are no prediction tools available to identify patients at risk of needing high-complexity care following cardiac catheterization for congenital heart disease. We sought to develop a method to predict the likelihood a patient will require intensive care level resources following elective cardiac catheterization. DESIGN: Prospective single-center study capturing important patient and procedural characteristics for predicting discharge to the ICU. Characteristics significant at the 0.10 level in the derivation dataset (July 1, 2017 to December 31, 2019) were considered for inclusion in the final multivariable logistic regression model. The model was validated in the testing dataset (January 1, 2020 to December 31, 2020). The novel pre-procedure cardiac status (PCS) feature, collection started in January 2019, was assessed separately in the final model using the 2019 through 2020 dataset. SETTING: Tertiary pediatric heart center. PATIENTS: All elective cases coming from home or non-ICU who underwent a cardiac catheterization from July 2017 to December 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 2,192 cases were recorded in the derivation dataset, of which 11% of patients ( n = 245) were admitted to the ICU, while 64% ( n = 1,413) were admitted to a medical unit and 24% ( n = 534) were discharged home. In multivariable analysis, the following predictors were identified: 1) weight less than 5 kg and 5-9.9 kg, 2) presence of systemic illness, 3) recent cardiac intervention less than 90 days, and 4) ICU Admission Tool for Congenital Heart Catheterization case type risk categories (1-5), with C -statistics of 0.79 and 0.76 in the derivation and testing cohorts, respectively. The addition of the PCS feature fit into the final model resulted in a C -statistic of 0.79. CONCLUSIONS: The creation of a validated pre-procedural risk prediction model for ICU admission following congenital cardiac catheterization using a large volume, single-center, academic institution will improve resource allocation and prediction of capacity needs for this complex patient population.

Interpreting Quality Improvement When Introducing New Technology: A Collaborative Experience in ASD Device Closures.

The objective of this study was to evaluate the impact of the regular introduction of new technologies into interventional cardiac catheterization procedures, in this case new atrial septal defect (ASD) closure devices, while conducting a multi-center collaborative initiative to reduce radiation usage during all procedures. Data were collected prospectively by 8 C3PO institutions between January 1, 2014 and December 31, 2017 for ASD device closure procedures in the cardiac catheterization lab during a quality improvement (QI) initiative aimed at reducing patient radiation exposure. Radiation exposure was measured in dose area product per body weight (µGy*m2/kg). Use of proposed practice change strategies at the beginning and end of the QI intervention period was assessed. Radiation exposure was summarized by institution and by initial type of device used for closure. This study included 602 ASD device closures. Without changes in patient characteristics, total fluoroscopy duration, or number of digital acquisitions, median radiation exposure decreased from 37 DAP/kg to 14 DAP/kg from 2014 to 2017. While all individual centers decreased overall median DAP/kg, the use of novel devices for ASD closure correlated with a temporary period of worsening institutional radiation exposure and increased fluoroscopy time. The introduction of new ASD closure devices resulted in increased radiation exposure during a QI project designed to reduce radiation exposure. Therefore, outcome assessment must be contextualized in QI projects, hospital evaluation, and public reporting, to acknowledge the expected variation during innovation and introduction of novel therapies.

Procedural Risk in Congenital Cardiac Catheterization (PREDIC3T).

Background Advancements in the field, including novel procedures and multiple interventions, require an updated approach to accurately assess patient risk. This study aims to modernize patient hemodynamic and procedural risk classification through the creation of risk assessment tools to be used in congenital cardiac catheterization. Methods and Results Data were collected for all cases performed at sites participating in the C3PO (Congenital Cardiac Catheterization Project on Outcomes) multicenter registry. Between January 2014 and December 2017, 23 119 cases were recorded in 13 participating institutions, of which 88% of patients were <18 years of age and 25% <1 year of age; a high-severity adverse event occurred in 1193 (5.2%). Case types were defined by procedure(s) performed and grouped on the basis of association with the outcome, high-severity adverse event. Thirty-four unique case types were determined and stratified into 6 risk categories. Six hemodynamic indicator variables were empirically assessed, and a novel hemodynamic vulnerability score was determined by the frequency of high-severity adverse events. In a multivariable model, case-type risk category (odds ratios for category: 0=0.46, 1=1.00, 2=1.40, 3=2.68, 4=3.64, and 5=5.25; all P≤0.005) and hemodynamic vulnerability score (odds ratio for score: 0=1.00, 1=1.27, 2=1.89, and ≥3=2.03; all P≤0.006) remained independent predictors of patient risk. Conclusions These case-type risk categories and the weighted hemodynamic vulnerability score both serve as independent predictors of patient risk for high-severity adverse events. This contemporary procedure-type risk metric and weighted hemodynamic vulnerability score will improve our understanding of patient and procedural outcomes.

The Burden of Radiation Exposure During Transcatheter Closure of Atrial Septal Defect.

Radiation reduction in the pediatric cardiac catheterization laboratory is well-suited for targeted quality improvement (QI) interventions. Transcatheter atrial septal defect (ASD) closure was chosen for this QI project based on a homogenous procedural population and inter-operator variability in radiation usage, with the aim to reduce radiation exposure during ASD device closure by 50% over 1 year. The aim for this project was defined and a Key Driver Diagram (KDD) was created with three domains for change: modification of procedural practice, reporting and monitoring/feedback, and team engagement. All patients undergoing attempted transcatheter ASD closure were considered for inclusion. The primary outcome, % reduction in median radiation dose (DAP/Kg), was determined through comparison with a historical cohort. Additional radiation metrics, procedural characteristics, and adverse events (AE) were compared to the historical cohort. Radiation exposure (DAP/kg) was reduced by 55% with a median dose reduction from 26 (15, 61) in a historical cohort to 12 (6, 22) in the intervention population (p <0.001). Fluoroscopy time and cine acquisition utilization significantly decreased. Procedure time, procedural success (defined as successful delivery of the device) and AE did not increase in the QI cohort. Successful practice changes included standardized procedural strategies to limit fluoroscopy and cine acquisition, improved fluoroscopic practice, engagement of the multidisciplinary team, and feedback with data reporting by electronic and in-person reminders. In conclusion, application of QI methodologies such as KDD with engagement of a multidisciplinary team can effectively reduce radiation in the pediatric catheterization laboratory.

Ankle syndesmosis: a qualitative and quantitative anatomic analysis.

BACKGROUND: Syndesmosis sprains can contribute to chronic pain and instability, which are often indications for surgical intervention. The literature lacks sufficient objective data detailing the complex anatomy and localized osseous landmarks essential for current surgical techniques. PURPOSE: To qualitatively and quantitatively analyze the anatomy of the 3 syndesmotic ligaments with respect to surgically identifiable bony landmarks. STUDY DESIGN: Descriptive laboratory study. METHODS: Sixteen ankle specimens were dissected to identify the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), interosseous tibiofibular ligament (ITFL), and bony anatomy. Ligament lengths, footprints, and orientations were measured in reference to bony landmarks by use of an anatomically based coordinate system and a 3-dimensional coordinate measuring device. RESULTS: The syndesmotic ligaments were identified in all specimens. The pyramidal-shaped ITFL was the broadest, originating from the distal interosseous membrane expansion, extending distally, and terminating 9.3 mm (95% CI, 8.3-10.2 mm) proximal to the central plafond. The tibial cartilage extended 3.6 mm (95% CI, 2.8-4.4 mm) above the plafond, a subset of which articulated directly with the fibular cartilage located 5.2 mm (95% CI, 4.6-5.8 mm) posterior to the anterolateral corner of the tibial plafond. The primary AITFL band(s) originated from the tibia 9.3 mm (95% CI, 8.6-10.0 mm) superior and medial to the anterolateral corner of the tibial plafond and inserted on the fibula 30.5 mm (95% CI, 28.5-32.4 mm) proximal and anterior to the inferior tip of the lateral malleolus. Superficial fibers of the PITFL originated along the distolateral border of the posterolateral tubercle of the tibia 8.0 mm (95% CI, 7.5-8.4 mm) proximal and medial to the posterolateral corner of the plafond and inserted along the medial border of the peroneal groove 26.3 mm (95% CI, 24.5-28.1 mm) superior and posterior to the inferior tip of the lateral malleolus. CONCLUSION: The qualitative and quantitative anatomy of the syndesmotic ligaments was reproducibly described and defined with respect to surgically identifiable bony prominences. CLINICAL RELEVANCE: Data regarding anatomic attachment sites and distances to bony prominences can optimize current surgical fixation techniques, improve anatomic restoration, and reduce the risk of iatrogenic injury from malreduction or misplaced implants. Quantitative data also provide the consistency required for the development of anatomic reconstructions.