Congenital Heart Interventions

The epidemiology and outcomes of pericardial effusion in hospitalized children: a national database analysis Sasaki J, Sendi P, Hey MT, Evans CJ, Sasaki N, Totapally BR. Journal of Pediatrics 2022;249:29-34. doi: 10.1016/j.jpeds.2022.07.005. Epub 2022 Jul 11. PMID: 35835227   Take home points: 1)  KIDS inpatient database, authors found a prevalence for pericardial effusion of 0.1% in inpatients; pericardial drainage occurred in 12.3% of these patients 2) Top diagnoses in hospitalized patients with pericardial effusion were structural heart disease (40%), post cardiac surgery (28%), rheumatological diagnosis (15%), hematologic malignancy (11%), solid organ tumor (9%) and organ transplant (2.6%). 3) Mortality among patients with pericardial effusion was 6.8%; mortality was higher in younger patients with solid organ tumors and lower in older patients with cardiac or rheumatologic diagnoses.   Commentary from Dr. Thomas Zellers (Dallas, USA), section editor of Congenital Heart Disease Interventions and ACHD Journal Watch: Summary:  The authors used the Healthcare Cost and Utilization Projects (HCUP) Kids inpatient database from the Agency for Healthcare Research and Quality (AHRQ). This is the largest and most comprehensive database for all payor pediatric inpatients. The authors performed a retrospective analysis of all hospital admissions for children with pericardial effusions using specific ICD-10  codes that would allow for diagnoses, pericardial drainage procedures and mortality. Clinical classification software (CCS) was also used to identify a broad range of etiological factors associated with pericardial effusion. They created 7 etiologic categories which included cardiac surgery, cardiac structural disease, organ transplant, hematologic malignancy, solid organ tumors, rheumatologic diagnoses and OTHER. Infectious etiologies could not be identified separately. The authors further separated the cohorts by age at the time of diagnosis: neonate (< 28 days), infant (> 28 days but < 1 year), preschool (1-5 years), child (6-12 years) and teen (13-20 years). There were 6.26 million patients evaluated and 6417 (0.1%) were diagnosed as having a pericardial effusion. The prevalence was highest in infants (0.28%) and lowest in neonates (0.04%). The prevalence was twice as high in black children (0.15%) compared to white children (0.08%). In children with pericardial effusion, the most common diagnoses were (in order) structural heart disease, post op cardiac surgery, rheumatologic diagnosis, hematologic malignancy, solid organ tumor and post organ transplant. Cardiac structural diagnoses were more prevalent in neonates and infants, whereas the other diagnoses were seen more frequently in older age groups. Pericardial drainage occurred in 12.3% of the patients. Drainage occurred most frequently in teenagers and occurred least frequently in the 6-12 year old age range. Pericardial effusion drainage was required most commonly in post op cardiac surgery patients and those with hematologic malignancy. It was least frequent in patients with rheumatologic diagnoses. Mortality occurred in 6.8% of children with pericardial effusion. Of those who required pericardial drainage, 10.8% died. Using an adjusted risk for mortality model, the adjusted risk for mortality was lowest in older age groups and highest in neonates. Cardiac structural disease and rheumatologic disease was associated with the lowest adjusted mortality risk; it was highest in patients with solid organ tumor. Other associated risks that increased risk adjusted mortality included acute respiratory failure, acute kidney injury, need for dialysis and need for pericardial drainage. This paper represents one of the largest studies- using a single database- offering current insights into the etiologies of pericardial effusion in hospitalized patients. It is a retrospective study, however, and the study was not geared to explore the reasons for drainage or the nuances surrounding mortality. The idiopathic etiologies (often viral illness) were not evaluated except as an OTHER category and little information is given about this group of patients. There is also no information as to why a patient had an echocardiogram or a point of care ultrasound to diagnose the pericardial effusion nor any information about the qualifications of the person doing the ultrasound or the severity of the effusion. So, it is possible that the denominator may be over or underestimated.

Short- and medium-term outcomes for patent ductus arteriosus stenting in neonates ≤2.5 kg with duct-dependent pulmonary circulation. Nasef MA, Shahbah DA, Batlivala SP, Darwich R, Qureshi AM, Breatnach CR, Linnane N, Walsh KP, Oslizlok P, McCrossan B, Momenah T, Alshahri A, Abdulhamed J, Arafat A, Tamimi OA, Diraneyya OM, Goldstein BH, Kenny D. Catheter Cardiovasc Interv. 2022 Oct;100(4):596-605. doi: 10.1002/ccd.30351. Epub 2022 Jul 29.PMID: 35904221   Take Home Points: 1) Stenting the patent ductus arteriosus in infants ≤ 2.5 kg with DDPBF is technically feasible and achieves short-term outcomes comparable to or better than surgical systemic-to-pulmonary shunting. 2) There is relatively high incidence of morbidity with this procedure, especially related to arterial access.       Commentary from Dr. Konstantin Averin (Cohen Children’s Heart Center), catheterization section editor of Pediatric Cardiology Journal Watch: Stenting of the patent ductus arteriosus (PDA) has become an accepted alternative to a surgical systemic-to-pulmonary shunting (SPS) in patients with ductal dependent pulmonary blood flow DDPBF).  Infants who are ≤ 2.5 kg are at highest risk for SPS, so PDA stenting is an attractive option in this patient population.  The authors sought to assess procedural and short-term outcomes in infants ≤ 2.5 kg undergoing PDA stenting for DDPBF using data from 4 large cardiac centers. From March 2007 to February 2020, 38 patients – median age at procedure 10 days (IQR 6-15), median procedural weight 2.2 kg (IQR 2-2.4 kg) (11 under 2.0kg) - underwent PDA stenting.  There were a variety of diagnoses, but a majority had pulmonary atresia or pulmonary stenosis (71%).  A majority (79%) of the PDA’s had complex anatomy with a tortuosity index of II or III.  In 47% of patients the procedure was performed via the femoral artery, while the carotid artery was used in 8 (21%), umbilical artery in 6, axillary artery in 4, and femoral vein in 2 (Figure 1). Patient outcomes are summarized in Figure 3.  Successful stent implant was achieved in 92% of initial procedures (35/38) with no procedural deaths.  There was a high incidence (18%, 7/38) of serious adverse events related to the primary procedure (Figure 2) – most commonly related to carotid and femoral artery access.  The thirty-day survival for the entire cohort was 97%.  Twenty patients required reintervention. The authors conclude that PDA stenting in infants ≤ 2.5 kg is feasible and effective.  The authors should be commended for providing important data on a challenging procedure in a very challenging patient population.  Despite the relatively high risk of access related complications, it is interesting that none of the patients who underwent axillary artery access had any complications related to this.  Recognizing that this was one of the access sites used least frequently further investigation as to whether the axillary artery may be a safer approach for this procedure is warranted.  This study highlights the need for additional data to inform decision making around PDA stenting.