Resynchronization Therapy in Pediatric and Congenital Heart Disease Patients: An International Multi-Center Study
Anne M. Dubin, Jan Janousek, Edward Rhee, Margaret J. Strieper, Frank Cecchin, Ian H. ...Law, Kevin M. Shannon, Joel Temple, Eric Rosenthal, Frank J. Zimmerman, Andrew Davis, Peter P. Karpawich, Amin Al Ahmad, Victoria L. Vetter, Naomi J. Kertesz, Maully Shah, Christopher Snyder, Elizabeth Stephenson, Mathias Emmel, Shubhayan Sanatani, Ronald Kanter, Anjan Batra, Kathryn K. Collins
This is a multi-center retrospective evaluation of cardiac resynchronization therapy in 103 pediatric patients and patients with congenital heart disease (CHD) from 22 institutions. Patient diagnoses included CHD in 71%, cardiomyopathy in 16%, and congenital complete atrioventricular block in 13%. Ejection fraction (EF) increased by 12.8 ± 12.7 EF units (p < 0.05). Cardiac resynchronization therapy appears to offer benefit in pediatric and CHD patients who differ from the adult populations in whom this therapy has been most thoroughly evaluated to date.
Our objective was to evaluate the short-term safety and efficacy of cardiac resynchronization therapy (CRT) in children.
Cardiac resynchronization therapy has been beneficial for adult patients with poor left ventricular function and intraventricular conduction delay. The efficacy of this therapy in the young and in those with congenital heart disease (CHD) has not yet been established.
This is a multi-center, retrospective evaluation of CRT in 103 patients from 22 institutions.
Median age at time of implantation was 12.8 years (3 months to 55.4 years). Median duration of follow-up was four months (22 days to 1 year). The diagnosis was CHD in 73 patients (71%), cardiomyopathy in 16 (16%), and congenital complete atrioventricular block in 14 (13%). The QRS duration before pacing was 166.1 ± 33.3 ms, which decreased after CRT by 37.7 ± 30.7 ms (p < 0.01). Pre-CRT systemic ventricular ejection fraction (EF) was 26.2 ± 11.6%. The EF increased by 12.8 ± 12.7 EF units with a mean EF after CRT of 39.9 ± 14.8% (p < 0.05). Of 18 patients who underwent CRT while listed for heart transplantation, 3 improved sufficiently to allow removal from the transplant waiting list, 5 underwent transplant, 2 died, and 8 others are currently awaiting transplant.
Cardiac resynchronization therapy appears to offer benefit in pediatric and CHD patients who differ substantially from the adult populations in whom this therapy has been most thoroughly evaluated to date. Further studies looking at the long-term benefit of this therapy in this population are needed.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
IntroductionUncertainty remains regarding the utility of isoproterenol (ISO) testing for risk stratification in children with Wolff-Parkinson-White syndrome (WPW).HypothesisISO use during invasive ...electrophysiology study (EPS) would increase sensitivity and decrease specificity of identifying children who had a life-threatening event (LTE) in a large cohort of children with WPW.MethodsPatients ≤ 21 years with WPW who underwent EPS with risk stratification using ISO were identified from 2 multicenter databases. EPS risk stratification data and occurrence of LTE were collected. AP effective refractory period (APERP), shortest preexcited RR interval (SPERRI) in atrial fibrillation at EPS (EPS-SPERRI), and shortest pre-excited paced cycle length (SPPCL) were compared at baseline and with ISO. A rapidly conducting AP (rapid-AP) was defined as APERP, SPERRI, or SPPCL ≤ 250ms. LTE was defined as aborted sudden death or clinical preexcited atrial fibrillation with SPERRI ≤ 250ms.ResultsThere were 442 patients included with mean age 13.4±3.9 years, 18 (4%) with a LTE. At baseline, rapid-APs were seen more frequently in patients with LTE (50 vs 12%, p<0.001). With ISO, mean APERP (327±64 vs 272±53ms, p<0.001), EPS-SPERRI (330±83 vs 277±62ms, p<0.001), and SPPCL (341±90 vs 270±66ms, p<0.001) shortened. There was no difference in the proportion of rapid-APs between patients with and without LTE on ISO (78 vs 57%, p=0.09). In non-LTE patients, 53% were reclassified as having a rapid-AP on ISO. Rapid-AP classification at baseline compared to ISO has a sensitivity of 50% (95% CI 27-73%) vs 78% (95% CI 52-93%) p=0.125 and specificity of 88% (95% CI 85-91%) vs 43% (95% CI 39-48%) p<0.01 for identifying patients with a history of LTE. General anesthesia was used in 93% of patients and was not associated with rapid-AP at baseline or with ISO (p>0.067).ConclusionsThe use of ISO at EPS increases the sensitivity but decreases the specificity of identifying patients with prior LTE, with more than half of non-LTE patients reclassified as rapid-AP.
IntroductionPrimary prevention (PP) ICD are increasingly placed in children with Hypertrophic Cardiomyopathy (HCM) to prevent SCD using adult criteria. The reliability of PPICD to prevent SCD is ...unclear.MethodsWe collected data on HCM children ≤20 years with PPICD. Risk factors (RF) for SCD were 1) family history (FH) of SCD 2) syncope; 3) maximal Left ventricular (LV) wall thickness (LVWT) Z value > 5; 4) non-sustained VT (NSVT) on ambulatory ECG; and 5) abnormal BP response to exercise (ABPR).ResultsOf 347 patients (age 14.61± 4.18), with PP-ICD, appropriate interventions (AI) occurred in 55 (16%). RF presence pre-ICD implant was FH-SCD in 114 (33%); LVWT in 230 (66%); NSVT in 25 (7%); ABPR in 105 (30%) and syncope in 84 (20%). Follow up after ICD implant was 0.07 to 32.95 (mean 8.82 ± 6.03) years and incidence of AI was 18.40 cases per 1000 person-years. AI incidence for each RF wasFH-SCD20/114 (17.5%); LVWT 36/230 (15.7%); NSVT 4/25 (16.0%); ABPR 18/105 (17.1%) and syncope 22/84( 26.2%). Risk of AI based on # of RF were5/31 (16%) for 0 RF; 16/126 (13%) for 1 RF; 20/146 (14%) for 2 RF; 12/36 (33%) for 3 RF and 2/8 (25%) for 4 RF.ConclusionsThe incidence of AI in HCM children with PP-ICD based on adult criteria was high. Syncope was the commonest RF associated with AI. All other RF’s had similar incidence in patients with AI. Presence of ≥ 3 RF was associated with AI.
IntroductionIntermittent pre-excitation (I-PX) in patients with Wolff Parkinson White syndrome (WPW) is thought to indicate low risk of a life-threatening event (LTE), which is reflected by recent ...guidelines. We sought to determine if I-PX is associated with a lower incidence of a high-risk accessory pathway (AP).MethodsUsing an international, multicenter database of young WPW subjects (<25yrs) with and without LTE (sudden death SD, aborted SD, or pre-excited atrial fibrillation PAF), we analyzed clinical and electrophysiology study (EPS) data. Subjects were classified as having I-PX or persistent pre-excitation (P-PX). I-PX was defined as loss of pre-excitation on ECG, Holter, or exercise stress testing. A high-risk AP was defined as having any one high-risk EPS characteristicAP effective refractory period (APERP), shortest pre-excited R-R interval (SPERRI), or shortest paced pre-excited cycle length (SPPCL) ≤ 250ms.ResultsOf the 776 WPW subjects evaluated, 151 had I-PX and 625 had P-PX. There were no differences in mean age at EPS (13.7 vs 13.4 yrs, p=0.399) or sex (57% vs 59% male, p=0.640). There was no difference in incidence of LTE in the I-PX and P-PX groups (8% vs 5%, p=0.242). LTE occurred in 12 subjects with I-PX1 with aborted SD, 5 with PAF and SPERRI <240ms, and 6 with PAF and SPERRI ≥240ms or unknown SPERRI. AP characteristics were assessed at EPS in 138 (91%) and 583 (93%) patients with I-PX and P-PX, respectively. Patients with I-PX had longer mean APERP (316±55 vs 305±53ms, p=0.034) and SPPCL (338±85 vs 308±72ms, p=0.001), with no difference in SPERRI (289±65 vs 314±77ms, p=0.138) compared to P-PX. The incidence of high-risk APs in I-PX and P-PX groups was similar (20% vs 27%, p=0.120) at baseline. AP characteristics were assessed on isoproterenol in 44/138 (32%) of I-PX and in 131/583 (22%) of P-PX patients and there were no differences in APERP (271±38 vs 263±45 ms, p=0.381), SPERRI (276±41 vs 294±47ms, p=0.382), or SPPCL (276±62 vs 256±51ms, p=0.082) between groups. On isoproterenol, there was a lower incidence of high-risk APs for patients with I-PX compared to P-PX (41 vs 64%, p=0.007).ConclusionsYoung patients with WPW and I-PX are at risk of LTE. I-PX does not indicate a lower frequency of high-risk APs as compared to P-PX.
This paper investigates automatic epileptic seizure detection from audio recordings using convolutional neural networks. The labeling and analysis of seizure events are necessary in the medical field ...for patient monitoring, but the manual annotation by expert annotators is time-consuming and extremely monotonous. The proposed method treats all seizure vocalizations as a single target event class, and models the seizure detection problem in terms of detecting the target vs non-target classes. For detection, the method employs a convolutional neural network trained to detect the seizure events in short time segments, based on mel-energies as feature representation. Experiments carried out with different seizure types on 900 hours of audio recordings from 40 patients show that the proposed approach can detect seizures with over 80% accuracy, with a 13% false positive rate and a 22.8% false negative rate.
Background: Chronic pain is a common, disabling, and costly comorbidity, particularly in people living with HIV (PLWH). This study developed and pilot tested a pain self-management intervention for ...chronic pain tailored to PLWH called Skills TO Manage Pain (STOMP).
Objectives: Given the additional resources needed to deliver STOMP in HIV clinical settings, an important objective of the pilot study was to assess not only STOMP's preliminary efficacy, but also its cost-effectiveness.
Research design and subjects: The present study draws from a 44-participant, 2-arm randomized pilot trial of the STOMP intervention vs usual care among PLWH and at least moderate chronic pain (Clinicaltrials.gov: NCT02824562). Cost-effectiveness is presented as the incremental cost-effectiveness ratio (ICER). Costs were considered from the clinic perspective over a 1-year time horizon using real costs from the pilot trial. It was conservatively assumed there would be no costs savings. The Standard Gamble (SG) method was used to directly measure utilities.
Results: Thirty-six participants met inclusion criteria for the present analyses. Mean age was 52 years; 61% were female and 86% were black. The total cost of STOMP was $483.83 per person. Using the SG method, the change in QALYs was 0.15, corresponding to an ICER of $3,225.
Conclusions: STOMP's cost/QALY is substantially lower than the $50,000 to $100,000/QALY benchmark often used to indicate cost-effectiveness. Although based on a pilot trial and, therefore, preliminary, these findings are promising, and suggest the importance of cost analyses in future STOMP trials.
PDF
