Risk Factors Associated With Bleeding in Children With Cardiac Disease Receiving Extracorporeal Membrane Oxygenation: A Multi-Center Data Linkage Analysis

Background: Bleeding is a common complication of extracorporeal membrane oxygenation (ECMO) for pediatric cardiac patients. We aimed to identify anticoagulation practices, cardiac diagnoses, and surgical variables associated with bleeding during pediatric cardiac ECMO by combining two established databases, the Collaborative Pediatric Critical Care Research Network (CPCCRN) Bleeding and Thrombosis in ECMO (BATE) and the Extracorporeal Life Support Organization (ELSO) Registry.Methods: All children (<19 years) with a primary cardiac diagnosis managed on ECMO included in BATE from six centers were analyzed. ELSO Registry criteria for bleeding events included pulmonary or intracranial bleeding, or red blood cell transfusion >80 ml/kg on any ECMO day. Bleeding odds were assessed on ECMO Day 1 and from ECMO Day 2 onwards with multivariable logistic regression.Results: There were 187 children with 114 (61%) bleeding events in the study cohort. Biventricular congenital heart disease (94/187, 50%) and cardiac medical diagnoses (75/187, 40%) were most common, and 48 (26%) patients were cannulated directly from cardiopulmonary bypass (CPB). Bleeding events were not associated with achieving pre-specified therapeutic ranges of activated clotting time (ACT) or platelet levels. In multivariable analysis, elevated INR and fibrinogen were associated with bleeding events (OR 1.1, CI 1.0–1.3, p = 0.02; OR 0.77, CI 0.6–0.9, p = 0.004). Bleeding events were also associated with clinical site (OR 4.8, CI 2.0–11.1, p < 0.001) and central cannulation (OR 1.75, CI 1.0–3.1, p = 0.05) but not with cardiac diagnosis, surgical complexity, or cannulation from CPB. Bleeding odds on ECMO day 1 were increased in patients with central cannulation (OR 2.82, 95% CI 1.15–7.08, p = 0.023) and those cannulated directly from CPB (OR 3.32, 95% CI 1.02–11.61, p = 0.047).Conclusions: Bleeding events in children with cardiac diagnoses supported on ECMO were associated with central cannulation strategy and coagulopathy, but were not modulated by achieving pre-specified therapeutic ranges of monitoring assays.

Sex Disparities in Sudden Cardiac Death

The overall incidence of sudden cardiac death is considerably lower among women than men, reflecting significant and often under-recognized sex differences. Women are older at time of sudden cardiac death, less likely to have a prior cardiac diagnosis, and less likely to have coronary artery disease identified on postmortem examination. They are more likely to experience their death at home, during sleep, and less likely witnessed. Women are also more likely to present in pulseless electrical activity or systole rather than ventricular fibrillation or ventricular tachycardia. Conversely, women are less likely to receive bystander cardiopulmonary resuscitation or receive cardiac intervention post-arrest. Underpinning sex disparities in sudden cardiac death is a paucity of women recruited to clinical trials, coupled with an overall lack of prespecified sex-disaggregated evidence. Thus, predominantly male-derived data form the basis of clinical guidelines. This review outlines the critical sex differences concerning epidemiology, cause, risk factors, prevention, and outcomes. We propose 4 broad areas of importance to consider: physiological, personal, community, and professional factors.

Cerebral and Somatic Oxygen Saturation in Neonates with Congenital Heart Disease before Surgery

BACKGROUND: We investigated preoperative cerebral (ScO2) and abdominal (StO2) regional oxygen saturations according to cardiac diagnosis in neonates with critical CHD, their time trends, and the clinical and biochemical parameters associated with them. METHODS: Thirty-seven neonates with a prenatal diagnosis of CHD were included. ScO2 and StO2 values were continuously evaluated using near-infrared spectroscopy. Measurements were obtained hourly before surgery. A linear mixed effects model was used to assess the effects of time and cardiac diagnosis on regional oxygenation and to explore the contributing factors. RESULTS: Regional oxygenation differed according to cardiac diagnosis (p < 0.001). ScO2 was lowest in the patients with severe atrioventricular valvar regurgitation (AVVR) (48.1 ± 8.0%). StO2 tended to be lower than ScO2, and both worsened gradually during the period between birth and surgery. There was also a significant interaction between cardiac diagnosis and time. The factors related to ScO2 were hemoglobin and arterial saturation, whereas no factor was associated with StO2. CONCLUSIONS: Preoperative ScO2 and StO2 in critical CHD differed according to cardiac diagnosis. ScO2 in the patients with severe AVVR was very low, which may imply cerebral hypoxia. ScO2 gradually decreased, suggesting that the longer the time to surgery, the higher the risk of hypoxic brain injury.

Use of a smartphone ECG to diagnose arrhythmias in athletes: a case series

Funding Acknowledgements Type of funding sources: None. Background While athletes are generally very fit, intense exercise can increase the risk of atrial fibrillation (AF), resulting in distressing symptoms during or after exercise. Moreover, other arrhythmias such as atrial flutter or supraventricular tachycardia (SVT) can also cause troublesome, exercise-related symptoms. Accurate diagnosis is essential to guide appropriate treatment. Given the symptoms are infrequent and/or occur in specific circumstances, traditional monitoring devices are often impractical to use during exercise or too invasive. Recently, smartphone ECGs such as the Alivecor KardiaMobile device (iECG) has been shown to be interpretable by a cardiologist in 95% of cases and may be the portable tool required to help identify arrhythmias in this challenging population. Purpose This case series was designed to highlight the use of iECG devices in aiding the diagnosis of arrhythmias in exercise-related symptoms. Methods Five cases are reported where the iECG was used to document at least one episode of exercise-related symptoms. Participants were eligible if they were over 18 years of age and had had an iECG trace taken during an episode of exercise-related symptoms (e.g. light-headedness, shortness of breath, palpitations). which could be associated with an arrhythmia All participants were identified by authors from previous clinical experiences (or from clinical colleagues) and provided written, informed consent. Results The cases included one amateur middle-distance runner in his 40s, two amateur ultra-endurance runners in their 30s and two young elite cricketers (Figure 1). In four of the cases, an accurate diagnosis of an arrhythmia (atrial flutter, AF and 2x SVT) was obtained using the iECG device, which helped to guide definitive treatment (e.g. medication or ablation). Two of these cases had been investigated using traditional methods such as stress ECG or Holter monitor over many months without achieving a diagnosis. The final case did not obtain a cardiac diagnosis using the iECG device despite using it on multiple occasions during symptomatic events. This reassured this athlete that the symptoms experienced were not cardiac related and she is now confident to exercise. Conclusion The iECG was able to accurately detect arrhythmias and provide a diagnosis in cases where traditional monitoring had not. The utility of detecting no arrhythmia during symptoms in one case was also highlighted, providing the athlete with the confidence to continue exercising. This reassurance and confidence across all cases is perhaps the most valuable aspect of this device, where clinicians and athletes can be more certain of reaching a diagnosis and undertaking appropriate management. Abstract Figure 1: iECG traces

Segmentation of Biventricle in Cardiac Cine MRI via Nested Capsule Dense Network

Cardiac magnetic resonance image (MRI) has been widely used in diagnosis of cardiovascular diseases because of its noninvasive nature and high image quality. The evaluation standard of physiological indexes in cardiac diagnosis is essentially the accuracy of segmentation of left ventricle (LV) and right ventricle (RV) in cardiac MRI. In this paper, we propose a novel Nested Capsule Dense Network (NCDN) structure based on the FC-DenseNet model and capsule convolution-capsule deconvolution. Different from the traditional symmetric single codec network structure such as U-net, NCDN uses multiple codecs instead of a single codec to achieve multi-resolution, which makes it possible to save more spatial information and improve the robustness of the model. The proposed model is tested on three datasets that includes York University Cardiac MRI dataset, Automated Cardiac Diagnosis Challenge (ACDC-2017), and local dataset. The results show that the proposed NCDN outperforms the state-of-the-art methods.

Edge-Sensitive Left Ventricle Segmentation Using Deep Reinforcement Learning

Deep reinforcement learning (DRL) has been utilized in numerous computer vision tasks, such as object detection, autonomous driving, etc. However, relatively few DRL methods have been proposed in the area of image segmentation, particularly in left ventricle segmentation. Reinforcement learning-based methods in earlier works often rely on learning proper thresholds to perform segmentation, and the segmentation results are inaccurate due to the sensitivity of the threshold. To tackle this problem, a novel DRL agent is designed to imitate the human process to perform LV segmentation. For this purpose, we formulate the segmentation problem as a Markov decision process and innovatively optimize it through DRL. The proposed DRL agent consists of two neural networks, i.e., First-P-Net and Next-P-Net. The First-P-Net locates the initial edge point, and the Next-P-Net locates the remaining edge points successively and ultimately obtains a closed segmentation result. The experimental results show that the proposed model has outperformed the previous reinforcement learning methods and achieved comparable performances compared with deep learning baselines on two widely used LV endocardium segmentation datasets, namely Automated Cardiac Diagnosis Challenge (ACDC) 2017 dataset, and Sunnybrook 2009 dataset. Moreover, the proposed model achieves higher F-measure accuracy compared with deep learning methods when training with a very limited number of samples.

Myocardial Dysfunction in Elderly Patients Admitted with Non-Cardiac Diagnosis in Intensive Care Unit

Background and Objectives: The diagnosis of acute coronary syndromes can be challenging inpatients admitted with the non-cardiac disease to the Intensive Care Unit (ICU). The study aimed todetermine the clinical profile of critically ill elderly patients developing myocardial injury who wereadmitted to ICU for non-cardiac diagnosis. Materials and Methods: The retrospective studysubjects are 130 patients admitted to the medical ICU. Within 24 hours of admission to ICU adetailed history, a 12 lead ECG, CK-MB, Cardiac troponin T was done and as required based on ECGfindings and development of clinical symptoms. Results: Our study showed that 35 out of 130patients developed acute myocardial injury. 13 out of 35 patients who had myocardial injury had afatal outcome. The prevalence of hypertension, diabetes mellitus, history of CVA, history of IHD andCOPD reached statistical significance (p<0.001) between the two groups of patients who developedmyocardial injury and who did not develop a myocardial injury. In patients with multiplecomorbidities, the presence of factors like hypoxia, hypotension and the use of vasopressorsincreases the risk of mortality. Conclusion: All elderly patients who are hospitalized with or withoutmultiple comorbidities with an acute form of stressors must be evaluated aggressively forprecipitants and adequately treated to prevent myocardial injury.

Outcomes in hospitalisations of women with Turner syndrome compared to women without Turner syndrome

Objective: To evaluate outcomes in patients with Turner Syndrome, especially those with cardiac conditions, compared to those without Turner syndrome. Design: Retrospective cohort study utilising hospitalisation data from 2006 to 2012. Conditional logistic regression models are used to analyse outcomes of interest: all-cause mortality, increased length of stay, and discharge to home. Participants: We identified 2978 women with Turner syndrome, matched to 11,912 controls by primary diagnosis. Results: Patients with Turner syndrome were more likely to experience inpatient mortality (odds ratio 1.44, 95% confidence interval 1.02–2.02, p = 0.04) and increased length of stay (OR 1.31, CI 1.18–1.46, p = 0.03) than primary diagnosis matched controls, after adjusting for age, race, insurance status, and Charlson comorbidity index. Patients with Turner syndrome were 32% less likely to be discharged to home (OR 0.68, CI 0.60–0.78, p < 0.001). When restricting the sample of patients to those admitted with a cardiac diagnosis, the likelihood of mortality (OR 3.10, CI 1.27–7.57, p = 0.01) and prolonged length of stay (OR 1.42, CI 1.03–1.95, p = 0.03) further increased, while the likelihood of discharge to home further decreased (OR 0.55, CI 0.38–0.80, p = 0.001) in Turner syndrome compared to primary diagnosis matched controls. Specifically, patients with congenital heart disease were more likely to have prolonged length of stay (OR: 1.53, CI 1.18–2.00, p = 0.002), but not increased mortality or decreased discharge to home. Conclusions: Hospitalised women with Turner syndrome carry a higher risk of adverse outcomes even when presenting otherwise similarly as controls, an important consideration for those treating them in these settings.

Atrial septal aneurysm in Sub-Saharan Africa: From an asymptomatic incidental echocardiographic finding to a potential cause of cardio embolic stroke

Atrial Septal Aneurysm (ASA) is an abnormality of the interatrial septum that has continued to generate interest because of its rarity, asymptomatic presentation and possibility to cause cardioembolic stroke. There are many published accounts of atrial septal aneurysm in USA, Europe and Asia but very few published reports from sub-Saharan Africa. Our first case is a 48 years old female patient with type 1 ASA presented as an incidental finding during echocardiographic investigative procedures for other cardiac diagnosis. The second case is a 58 years old female with type 2L ASA, who presented with transient loss of consciousness lasting for 5 minutes. Our third case is a 25 years old male with type 5 ASA with heart failure who presented with exertional dyspnoea for 3 years. In this presentation, we ask questions about the reason for rare presentations and or publications of atrial septal aneurysm from Africa. We also re-examined the different associations of ASA as well as clinical presentations. ASA is an often asymptomatic but treatable cause of cardiovascular disease that includes cardioembolic stroke. A high index of suspicion is required to make the diagnosis during routine trans thoracic echocardiography and the availability of transesophageal echocardiography will definitely improve diagnosis and management of cases in sub-Saharan Africa.