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Prakoso R, Simanjorang CNS, Kurniawati Y, Mendel B, Rahmat B, Zahara R, Rudiktyo E, Sakti DDA, Sukmawan R. Ductal stenting vs. surgical shunting in late presenting duct-dependent pulmonary circulation: a single-center experience. Front Cardiovasc Med 2024; 11:1382879. [PMID: 38707893 PMCID: PMC11066280 DOI: 10.3389/fcvm.2024.1382879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 04/09/2024] [Indexed: 05/07/2024] Open
Abstract
Introduction PDA stenting is an option to mBTT shunt for younger patients; nevertheless, few reports of this palliative approach have been made for the late presenter population, especially for patients who are older than 30 days but under 5 years. This study aimed to evaluate the clinical result and intra-hospital costs of ductal stenting in late-presenting patients in comparison to surgical shunting. Methods A single-center, retrospective cohort study was conducted from August 2016 to August 2022. This study included patients with pulmonary duct dependent CHD who were hospitalized for palliative therapy. The extracted data were baseline characteristics, clinical findings, supportive examination findings, complications, outcomes, and length of stay of the patients. Monitoring was carried out during treatment up to 30 days after the procedure. Results A total of 143 patients were included in the analysis; 43 patients underwent PDA stent and 100 patients underwent mBTT shunt with median age of PDA stent group 110 (31-1,498) days and mBTT shunt group 174.5 (30-1,651) days. Primary outcome composite was not significant in both groups including 30 days mortality [6 (14%) vs. 14 (14%), p = 1.000], reintervention [1 (2.3%) vs. 7 (7%), p = 0.436], and 30 days rehospitalization [0 (0%) vs. 2 (2%), p = 0.319]. Secondary outcome analysis showed shorter ICU length of stay in the PDA stent group [2 (0-16) days vs. 4 (1-63) days, p = 0.002]. Conclusions PDA stent has an outcome that is non inferior from the mBTT shunt procedure in the composite outcome including 30 days mortality, reintervention, and 30 days rehospitalization but significantly lower in ICU length of stay.
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Affiliation(s)
- Radityo Prakoso
- Division of Pediatric Cardiology and Congenital Heart Disease, Department of Cardiology and Vascular Medicine, National Cardiovascular Centre Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
| | | | - Yovi Kurniawati
- Division of Pediatric Cardiology and Congenital Heart Disease, Department of Cardiology and Vascular Medicine, National Cardiovascular Centre Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
| | - Brian Mendel
- Division of Pediatric Cardiology and Congenital Heart Disease, Department of Cardiology and Vascular Medicine, National Cardiovascular Centre Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
- Department of Cardiology and Vascular Medicine, Sultan Sulaiman Government Hospital, Serdang Bedagai, Indonesia
| | - Budi Rahmat
- Division of Pediatric and Congenital Heart Surgery, Department of Surgery, National Cardiovascular Centre of Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
| | - Rita Zahara
- Division of Intensive and Cardiovascular Care, Department of Cardiology and Vascular Medicine, National Cardiovascular Centre Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
| | - Estu Rudiktyo
- Division of Non-Invasive Diagnostic and Cardiovacular Imaging, Department of Cardiology and Vascular Medicine, National Cardiovascular Centre Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
| | - Damba Dwisepto Aulia Sakti
- Division of Pediatric Cardiology and Congenital Heart Disease, Department of Cardiology and Vascular Medicine, National Cardiovascular Centre Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
| | - Renan Sukmawan
- Division of Non-Invasive Diagnostic and Cardiovacular Imaging, Department of Cardiology and Vascular Medicine, National Cardiovascular Centre Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
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Hoagland A, Kipping S. Challenges in Promoting Health Equity and Reducing Disparities in Access Across New and Established Technologies. Can J Cardiol 2024:S0828-282X(24)00178-8. [PMID: 38417572 DOI: 10.1016/j.cjca.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 03/01/2024] Open
Abstract
Medical innovations and novel technologies stand to improve the return on high levels of health spending in developed countries, particularly in cardiovascular care. However, cardiac innovations also disrupt the landscape of accessing care, potentially creating disparities in who has access to novel and extant technologies. These disparities might disproportionately harm vulnerable groups, including those whose nonmedical conditions-including social determinants of health-inhibit timely access to diagnoses, referrals, and interventions. We first document the barriers to access novel and existing technologies in isolation, then proceed to document their interaction. Novel cardiac technologies might affect existing available services, and change the landscape of care for vulnerable patient groups who seek access to cardiology services. There is a clear need to identify and heed lessons learned from the dissemination of past innovations in the development, funding, and dissemination of future medical technologies to promote equitable access to cardiovascular care. We conclude by highlighting and synthesizing several policy implications from recent literature.
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Affiliation(s)
- Alex Hoagland
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Ontario Shores Centre for Mental Health Sciences, Toronto, Ontario, Canada.
| | - Sarah Kipping
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Ontario Shores Centre for Mental Health Sciences, Toronto, Ontario, Canada
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Han PL, Jiang L, Cheng JL, Shi K, Huang S, Jiang Y, Jiang L, Xia Q, Li YY, Zhu M, Li K, Yang ZG. Artificial intelligence-assisted diagnosis of congenital heart disease and associated pulmonary arterial hypertension from chest radiographs: A multi-reader multi-case study. Eur J Radiol 2024; 171:111277. [PMID: 38160541 DOI: 10.1016/j.ejrad.2023.111277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 12/10/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES To explore the possibility of automatic diagnosis of congenital heart disease (CHD) and pulmonary arterial hypertension associated with CHD (PAH-CHD) from chest radiographs using artificial intelligence (AI) technology and to evaluate whether AI assistance could improve clinical diagnostic accuracy. MATERIALS AND METHODS A total of 3255 frontal preoperative chest radiographs (1174 CHD of any type and 2081 non-CHD) were retrospectively obtained. In this study, we adopted ResNet18 pretrained with the ImageNet database to establish diagnostic models. Radiologists diagnosed CHD/PAH-CHD from 330/165 chest radiographs twice: the first time, 50% of the images were accompanied by AI-based classification; after a month, the remaining 50% were accompanied by AI-based classification. Diagnostic results were compared between the radiologists and AI models, and between radiologists with and without AI assistance. RESULTS The AI model achieved an average area under the receiver operating characteristic curve (AUC) of 0.948 (sensitivity: 0.970, specificity: 0.982) for CHD diagnoses and an AUC of 0.778 (sensitivity: 0.632, specificity: 0.925) for identifying PAH-CHD. In the 330 balanced (165 CHD and 165 non-CHD) testing set, AI achieved higher AUCs than all 5 radiologists in the identification of CHD (0.670-0.858) and PAH-CHD (0.610-0.688). With AI assistance, the mean ± standard error AUC of radiologists was significantly improved for CHD (ΔAUC + 0.096, 95 % CI: 0.001-0.190; P = 0.048) and PAH-CHD (ΔAUC + 0.066, 95 % CI: 0.010-0.122; P = 0.031) diagnosis. CONCLUSION Chest radiograph-based AI models can detect CHD and PAH-CHD automatically. AI assistance improved radiologists' diagnostic accuracy, which may facilitate a timely initial diagnosis of CHD and PAH-CHD.
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Affiliation(s)
- Pei-Lun Han
- Department of Radiology and West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China
| | - Lei Jiang
- College of Computer Science, Sichuan University, Chengdu, China
| | - Jun-Long Cheng
- College of Computer Science, Sichuan University, Chengdu, China
| | - Ke Shi
- Department of Radiology and West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China
| | - Shan Huang
- Department of Radiology and West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yu Jiang
- Department of Radiology and West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China
| | - Li Jiang
- Department of Radiology and West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China
| | - Qing Xia
- SenseTime Research, Beijing, China
| | - Yi-Yue Li
- Department of Radiology and West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China
| | - Min Zhu
- College of Computer Science, Sichuan University, Chengdu, China
| | - Kang Li
- Department of Radiology and West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China; Med-X Center for Informatics, Sichuan University, Chengdu, China; Shanghai Artificial Intelligence Laboratory, Shanghai, China
| | - Zhi-Gang Yang
- Department of Radiology and West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China.
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Chen J, Huang S, Zhang Y, Chang Q, Zhang Y, Li D, Qiu J, Hu L, Peng X, Du Y, Gao Y, Chen DZ, Bellou A, Wu J, Liang H. Congenital heart disease detection by pediatric electrocardiogram based deep learning integrated with human concepts. Nat Commun 2024; 15:976. [PMID: 38302502 PMCID: PMC10834950 DOI: 10.1038/s41467-024-44930-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/10/2024] [Indexed: 02/03/2024] Open
Abstract
Early detection is critical to achieving improved treatment outcomes for child patients with congenital heart diseases (CHDs). Therefore, developing effective CHD detection techniques using low-cost and non-invasive pediatric electrocardiogram are highly desirable. We propose a deep learning approach for CHD detection, CHDdECG, which automatically extracts features from pediatric electrocardiogram and wavelet transformation characteristics, and integrates them with key human-concept features. Developed on 65,869 cases, CHDdECG achieved ROC-AUC of 0.915 and specificity of 0.881 on a real-world test set covering 12,000 cases. Additionally, on two external test sets with 7137 and 8121 cases, the overall ROC-AUC were 0.917 and 0.907 while specificities were 0.937 and 0.907. Notably, CHDdECG surpassed cardiologists in CHD detection performance comparison, and feature importance scores suggested greater influence of automatically extracted electrocardiogram features on CHD detection compared with human-concept features, implying that CHDdECG may grasp some knowledge beyond human cognition. Our study directly impacts CHD detection with pediatric electrocardiogram and demonstrates the potential of pediatric electrocardiogram for broader benefits.
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Affiliation(s)
- Jintai Chen
- State Key Laboratory of Transvascular Implantation Devices of the Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, 310009, Hangzhou, China
| | - Shuai Huang
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 510080, Guangzhou, Guangdong Province, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080, Guangzhou, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), 510080, Guangzhou, Guangdong Province, China
| | - Ying Zhang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080, Guangzhou, Guangdong Province, China
- Department of Cardiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 510080, Guangzhou, Guangdong Province, China
| | - Qing Chang
- Liaoning Engineering Research Center of Intelligent Diagnosis and Treatment Ecosystem, 110004, Shenyang, Liaoning Province, China
- Clinical Research Center of Shengjing Hospital of China Medical University, 110004, Shenyang, Liaoning Province, China
| | - Yixiao Zhang
- Liaoning Engineering Research Center of Intelligent Diagnosis and Treatment Ecosystem, 110004, Shenyang, Liaoning Province, China
- Department of Urology Surgery, Shengjing Hospital of China Medical University, 110004, Shenyang, Liaoning Province, China
| | - Dantong Li
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 510080, Guangzhou, Guangdong Province, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080, Guangzhou, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), 510080, Guangzhou, Guangdong Province, China
| | - Jia Qiu
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080, Guangzhou, Guangdong Province, China
- Department of Cardiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 510080, Guangzhou, Guangdong Province, China
| | - Lianting Hu
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 510080, Guangzhou, Guangdong Province, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080, Guangzhou, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), 510080, Guangzhou, Guangdong Province, China
| | - Xiaoting Peng
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 510080, Guangzhou, Guangdong Province, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080, Guangzhou, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), 510080, Guangzhou, Guangdong Province, China
| | - Yunmei Du
- College of Information Technology and Engineering, Guangzhou College of Commerce, 510363, Guangzhou, Guangdong Province, China
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 510623, Guangzhou, Guangdong Province, China
| | - Yunfei Gao
- Zhuhai Precision Medical Center, Zhuhai People's Hospital/ Zhuhai Hospital Affiliated with Jinan University, Jinan University, 519000, Zhuhai, Guangdong Province, China
- The Biomedical Translational Research Institute, Jinan University Faculty of Medical Science, Jinan University, 510632, Guangzhou, Guangdong Province, China
| | - Danny Z Chen
- Department of Computer Science and Engineering, University of Notre Dame, Notre Dame, IN, 46556, USA
| | - Abdelouahab Bellou
- Institute of Sciences in Emergency Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080, Guangzhou, China.
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI, 48201, USA.
| | - Jian Wu
- State Key Laboratory of Transvascular Implantation Devices of the Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, 310009, Hangzhou, China.
- School of Public Health, Zhejiang University, 310058, Hangzhou, China.
| | - Huiying Liang
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 510080, Guangzhou, Guangdong Province, China.
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080, Guangzhou, Guangdong Province, China.
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), 510080, Guangzhou, Guangdong Province, China.
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5
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Prakoso R, Kurniawati Y, Siagian SN, Sembiring AA, Sakti DDA, Mendel B, Pratiwi I, Lelya O, Lilyasari O. Right ventricular outflow tract stenting for late presenter unrepaired Fallot physiology: a single-center experience. Front Cardiovasc Med 2024; 11:1340570. [PMID: 38361582 PMCID: PMC10867157 DOI: 10.3389/fcvm.2024.1340570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 01/19/2024] [Indexed: 02/17/2024] Open
Abstract
Objectives The purpose of this study was to assess the clinical outcome after right ventricular outflow tract (RVOT) stenting in late presenter patient with unrepaired Fallot physiology. Background In younger patients, RVOT stenting is an alternative to mBTT shunt; however, there have been few reports of this palliative technique in late presenter population, including adults. Methods This was a single-center, retrospective study of nonrandomized, palliated Fallot patients. Clinical outcomes such as left ventricular ejection fraction and saturation were measured in 32 individuals following RVOT stenting in adults (n = 10) and children (n = 22). The Statistical Package for Social Science (SPSS) 26.0 software was used to analyze the statistical data. Results During the procedure, the average stent diameter and length were 8.84 ± 1.64 mm and 35.46 ± 11.23 mm, respectively. Adult patients received slightly longer stents than pediatric patients (43.60 ± 11.64 mm vs. 31.77 ± 9.07 mm). Overall, patients' saturation increased from 58.56 ± 19.03% to 91.03 ± 8.98% (p < 0.001), as did their left ventricular ejection fraction (LVEF) from 64.00 ± 18.21% to 75.09 ± 12.98% (p = 0.001). Three patients improved their LVEF from 31 to 55%, 31 to 67%, and 26 to 50%. The median length of stay was 8 (2-35) days, with an ICU stay of 2 (0-30) days. The median time from RVOT stent palliation to total repair was 3 months (range: 1 month-12 months). Conclusions RVOT stenting is a safe and effective method for increasing saturation and ejection fraction not only in newborn infants but also in late presenters, including adults with unrepaired Fallot physiology.
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Affiliation(s)
- Radityo Prakoso
- Division of Pediatric Cardiology and Congenital Heart Disease, Department of Cardiology and Vascular Medicine, National Cardiovascular Center of Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
| | - Yovi Kurniawati
- Division of Pediatric Cardiology and Congenital Heart Disease, Department of Cardiology and Vascular Medicine, National Cardiovascular Center of Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
| | - Sisca Natalia Siagian
- Division of Pediatric Cardiology and Congenital Heart Disease, Department of Cardiology and Vascular Medicine, National Cardiovascular Center of Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
| | - Aditya Agita Sembiring
- Division of Pediatric Cardiology and Congenital Heart Disease, Department of Cardiology and Vascular Medicine, National Cardiovascular Center of Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
| | - Damba Dwisepto Aulia Sakti
- Division of Pediatric Cardiology and Congenital Heart Disease, Department of Cardiology and Vascular Medicine, National Cardiovascular Center of Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
| | - Brian Mendel
- Division of Pediatric Cardiology and Congenital Heart Disease, Department of Cardiology and Vascular Medicine, National Cardiovascular Center of Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
- Department of Cardiology and Vascular Medicine, Sultan Sulaiman Government Hospital, Serdang Bedagai, Indonesia
| | - Indah Pratiwi
- Department of Cardiology and Vascular Medicine, National Cardiovascular Center of Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
| | - Olfi Lelya
- Division of Pediatric Cardiology and Congenital Heart Disease, Department of Cardiology and Vascular Medicine, National Cardiovascular Center of Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
| | - Oktavia Lilyasari
- Division of Pediatric Cardiology and Congenital Heart Disease, Department of Cardiology and Vascular Medicine, National Cardiovascular Center of Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
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Dilli D, Akduman H, Zenciroğlu A, Çetinkaya M, Okur N, Turan Ö, Özlü F, Çalkavur Ş, Demirel G, Koksal N, Çolak R, Örün UA, Öztürk E, Gül Ö, Tokel NK, Erdem S, Meşe T, Erdem A, Bostan ÖM, Polat TB, Taşar M, Hatemi AC, Doyurgan O, Özkan M, Avşar MK, Sarıosmanoğlu ON, Uğurlucan M, Sığnak IŞ, Başaran M. Neonatal Outcomes of Critical Congenital Heart Defects: A Multicenter Epidemiological Study of Turkish Neonatal Society : Neonatal Outcomes of CCHD. Pediatr Cardiol 2024; 45:257-271. [PMID: 38153547 DOI: 10.1007/s00246-023-03362-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 11/20/2023] [Indexed: 12/29/2023]
Abstract
Critical congenital heart disease (CCHD) is one of the leading causes of neonatal and infant mortality. We aimed to elucidate the epidemiology, spectrum, and outcome of neonatal CCHD in Türkiye. This was a multicenter epidemiological study of neonates with CCHD conducted from October 2021 to November 2022 at national tertiary health centers. Data from 488 neonatal CCHD patients from nine centers were entered into the Trials-Network online registry system during the study period. Transposition of great arteria was the most common neonatal CHD, accounting for 19.5% of all cases. Sixty-three (12.9%) patients had extra-cardiac congenital anomalies. A total of 325 patients underwent cardiac surgery. Aortic arch repair (29.5%), arterial switch (25.5%), and modified Blalock-Taussig shunt (13.2%). Overall, in-hospital mortality was 20.1% with postoperative mortality of 19.6%. Multivariate analysis showed that the need of prostaglandin E1 before intervention, higher VIS (> 17.5), the presence of major postoperative complications, and the need for early postoperative extracorporeal membrane oxygenation were the main risk factors for mortality. The mortality rate of CCHD in our country remains high, although it varies by health center. Further research needs to be conducted to determine long-term outcomes for this vulnerable population.
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Affiliation(s)
- Dilek Dilli
- Department of Neonatology, Dr. Sami Ulus Research and Application Center, Health Science University of Turkey, Ankara, Turkey.
| | - Hasan Akduman
- Department of Neonatology, Dr. Sami Ulus Research and Application Center, Health Science University of Turkey, Ankara, Turkey
| | - Ayşegül Zenciroğlu
- Department of Neonatology, Dr. Sami Ulus Research and Application Center, Health Science University of Turkey, Ankara, Turkey
| | - Merih Çetinkaya
- Department of Neonatology, Başakşehir Çam Sakura City Hospital, Health Science University of Turkey, İstanbul, Turkey
| | - Nilüfer Okur
- Department of Neonatology, Gazi Yaşargil Research and Application Center, Health Science University of Turkey, Diyarbakır, Turkey
| | - Özden Turan
- Department of Neonatology, Başkent University, Medical Faculty, Ankara, Turkey
| | - Ferda Özlü
- Department of Neonatology, Çukurova University, Medical Faculty, Adana, Turkey
| | - Şebnem Çalkavur
- Department of Neonatology, Dr. Behçet Uz Pediatric Diseases and Surgery Training and Research Hospital, Health Science University of Turkey, İzmir, Turkey
| | - Gamze Demirel
- Department of Neonatology, İstanbul Medipol University, International Faculty of Medicine, Istanbul, Turkey
| | - Nilgün Koksal
- Department of Neonatology, Uludağ University, Medical Faculty, Bursa, Turkey
| | - Rüya Çolak
- Department of Neonatology, Beykent University Medical Faculty, Istanbul, Turkey
| | - Utku Arman Örün
- Department of Pediatric Cardiology, Dr. Sami Ulus Research and Application Center, Health Science University of Turkey, Ankara, Turkey
| | - Erkut Öztürk
- Department of Pediatric Cardiology, Başakşehir Çam Sakura City Hospital, Health Science University of Turkey, Istanbul, Turkey
| | - Özlem Gül
- Department of Pediatric Cardiology, Gazi Yaşargil Research and Application Center, Health Science University of Turkey, Diyarbakır, Turkey
| | - Niyazi Kürşad Tokel
- Department of Pediatric Cardiology, Başkent University, Medical Faculty, Ankara, Turkey
| | - Sevcan Erdem
- Department of Pediatric Cardiology, Çukurova University, Medical Faculty, Adana, Turkey
| | - Timur Meşe
- Department of Pediatric Cardiology, Dr. Behçet Uz Pediatric Diseases and Surgery Training and Research Hospital, Health Science University of Turkey, İzmir, Turkey
| | - Abdullah Erdem
- Department of Pediatric Cardiology, İstanbul Medipol University, International Faculty of Medicine, İstanbul, Turkey
| | - Özlem Mehtap Bostan
- Department of Pediatric Cardiology, Uludağ University, Medical Faculty, Bursa, Turkey
| | - Tuğçin Bora Polat
- Department of Pediatric Cardiology, Beykent University, Medical Faculty, İstanbul, Turkey
| | - Mehmet Taşar
- Department of Pediatric Cardiovascular Surgery, Dr. Sami Ulus Research and Application Center, Health Science University of Turkey, Ankara, Turkey
| | - Ali Can Hatemi
- Department of Pediatric Cardiovascular Surgery, Başakşehir Çam Sakura City Hospital, Health Science University of Turkey, İstanbul, Turkey
| | - Onur Doyurgan
- Department of Pediatric Cardiovascular Surgery, Gazi Yaşargil Research and Application Center, Health Science University of Turkey, Diyarbakır, Turkey
| | - Murat Özkan
- Department of Pediatric Cardiovascular Surgery, Başkent University, Medical Faculty, Ankara, Turkey
| | - Mustafa Kemal Avşar
- Department of Pediatric Cardiovascular Surgery, Çukurova University, Medical Faculty, Adana, Turkey
| | - Osman Nejat Sarıosmanoğlu
- Department of Pediatric Cardiovascular Surgery, Dr. Behçet Uz Pediatric Diseases and Surgery Training and Research Hospital, Health Science University of Turkey, İzmir, Turkey
| | - Murat Uğurlucan
- Department of Pediatric Cardiovascular Surgery, İstanbul Medipol University, International Faculty of Medicine, İstanbul, Turkey
| | - Işık Şenkaya Sığnak
- Department of Pediatric Cardiovascular Surgery, Uludağ University, Medical Faculty, Bursa, Turkey
| | - Murat Başaran
- Department of Pediatric Cardiovascular Surgery, Beykent University, Medical Faculty, Istanbul, Turkey
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Cheng SPS, Heo K, Joos E, Vervoort D, Joharifard S. Barriers to Accessing Congenital Heart Surgery in Low- and Middle-Income Countries: A Systematic Review. World J Pediatr Congenit Heart Surg 2024; 15:94-103. [PMID: 37915213 DOI: 10.1177/21501351231204328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
BACKGROUND Congenital heart disease (CHD) is the most common major congenital anomaly. Ninety percent of children with CHD are born in low- and middle-income countries (LMICs), where over 90% of patients lack access to necessary treatments. Reports on barriers to accessing CHD care are limited. Accordingly, it is difficult to design evidence-based interventions to increase access to congenital cardiac surgical care in LMICs. OBJECTIVE We performed a qualitative systematic review to understand barriers to accessing congenital cardiac surgical care in LMICs. METHODS We conducted a search of Ovid MEDLINE and CINAHL databases to identify relevant articles from January 2000 to May 2021. We then used a thematic analysis to summarize qualitative data into a framework of preoperative, perioperative, and postoperative barriers. RESULTS Our search yielded 1,585 articles, of which 67 satisfied the inclusion criteria. Notable preoperative barriers included delayed diagnosis, insufficient caregiver education, financial constraints, difficulty reaching treatment centers, sociocultural stigma of CHD, sex-based discrimination of patients with CHD, and Indigeneity. Perioperative barriers included lack of hospital resources and workforce, need for prolonged hospitalization, and strained physician-patient relationships. Many patients faced barriers postoperatively and into adulthood due to a shortage of critical care resources, inadequate caregiver counseling and patient education, lack of follow-up, and debt from hospital bills and missed work. CONCLUSION Reducing neonatal and childhood mortality begins with recognizing barriers to accessing health care. Our systematic review identifies and classifies challenges in accessing CHD in LMICs and suggests solutions to major barriers.
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Affiliation(s)
- Samuel P S Cheng
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kayoung Heo
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Emilie Joos
- Division of General Surgery, Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dominique Vervoort
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Shahrzad Joharifard
- Division of Pediatric Surgery, Department of Surgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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Vervoort D, Jin H, Edwin F, Kumar RK, Malik M, Tapaua N, Verstappen A, Hasan BS. Global Access to Comprehensive Care for Paediatric and Congenital Heart Disease. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:453-463. [PMID: 38205434 PMCID: PMC10777200 DOI: 10.1016/j.cjcpc.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/05/2023] [Indexed: 01/12/2024]
Abstract
Paediatric and congenital heart disease (PCHD) is common but remains forgotten on the global health agenda. Congenital heart disease is the most frequent major congenital anomaly, affecting approximately 1 in every 100 live births. In high-income countries, most children now live into adulthood, whereas in low- and middle-income countries, over 90% of patients do not get the care they need. Rheumatic heart disease is the most common acquired cardiovascular disease in children and adolescents. While almost completely eradicated in high-income countries, over 30-40 million people live with rheumatic heart disease in low- and middle-income countries. Challenges exist in the care for PCHD and, increasingly, adult congenital heart disease (ACHD) worldwide. In this review, we summarize the current status of PCHD and ACHD care through the health systems lens of workforce, infrastructure, financing, service delivery, information management and technology, and governance. We further highlight gaps in knowledge and opportunities moving forward to improve access to care for all those living with PCHD or ACHD worldwide.
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Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Hyerang Jin
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Frank Edwin
- School of Medicine, University of Health and Allied Sciences, Ho, Ghana
- National Cardiothoracic Center, Accra, Ghana
| | - Raman Krishna Kumar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Mahim Malik
- Department of Cardiac Surgery, Rawalpindi Institute of Cardiology, Rawalpindi, Punjab, Pakistan
| | - Noah Tapaua
- Department of Surgery, University of Papua New Guinea, Port Moresby, Papua New Guinea
| | - Amy Verstappen
- Global Alliance for Rheumatic and Congenital Hearts, Philadelphia, Pennsylvania, USA
| | - Babar S. Hasan
- Division of Cardiothoracic Sciences, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
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9
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Ng'eno M, Quadros DRS, Gachara N, Kihurani I, Yonga G. Late diagnosis of CHD and its associated factors in Kenya: an analytic cross-sectional study. Cardiol Young 2023; 33:1902-1908. [PMID: 36330814 DOI: 10.1017/s1047951122003353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Burden of CHD in Africa is generally underestimated mainly due to significant under-reporting and early-related fetal and neonatal mortality. OBJECTIVES Determine the prevalence and factors associated with late diagnosis of CHD seen at three tertiary care hospitals in Kenya. DESIGN A cross-sectional study on paediatric patients with CHDs, aged 0-18 years, seen over a 5-year period, between January, 2011 and December, 2016. SETTING Aga Khan University Hospital Nairobi, Mater Hospital, and Kenyatta National Hospital. METHODS Patients were stratified into those diagnosed late (>1 year of age) and those diagnosed early (<1 year of age). Multiple logistic regression analysis was done to determine factors associated with late diagnosis. RESULTS The study enrolled 411 patients, with equal gender distribution. Prevalence of late diagnosis (>1 year of age) of CHD was 60.6% (95% CI 55.7-65.3). Median age at diagnosis was 15 (IQR 5-48) months. Presence of a cardiac murmur (OR = 0.87; 95% CI 0.72-0.92, p-value = 0.016) and level of parental education (OR = 4.99; 95% CI 2.25-11.40, p-value <0001) were associated with a decreased odds of late diagnosis. Other factors like cyanosis, an increase in the number of healthcare workers and healthcare facilities per 10,000 population showed some association with decreased odds of late diagnosis of CHD, but these were not statistically significant. CONCLUSION Late diagnosis of CHD remains alarmingly high in our setting. Initiatives to enhance early detection and screening of CHD should be adopted to reduce related mortality and morbidity.
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Affiliation(s)
- Mercy Ng'eno
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Nairobi, Kenya
| | - Del-Rossi S Quadros
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Nairobi, Kenya
| | - Naomi Gachara
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Nairobi, Kenya
| | - Isaac Kihurani
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Nairobi, Kenya
| | - Gerald Yonga
- Non-Communicable Disease Research to Policy unit, Aga Khan University, Nairobi, Kenya
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Ashiq S, Sabar MF, Hyder SN. Genetic Risk Score Constructed from Polymorphisms in the VEGFA, TBX5, and SMAD7 Genes Provides Novel Insights into the Molecular Mechanisms of the Tetralogy of Fallot and Ventricular Septal Defect (Case-Control Study from the Pakistani Population). Am J Cardiol 2023; 203:368-375. [PMID: 37523935 DOI: 10.1016/j.amjcard.2023.06.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/25/2023] [Accepted: 06/18/2023] [Indexed: 08/02/2023]
Abstract
Congenital heart defects are common and complex birth-defect malformations in developed and developing countries. It is a multifactorial disease that involves the interaction of either gene-gene or gene-environment. This comparative study was the first report on the genotypic-phenotypic correlation in the Pakistani population. The single nucleotide polymorphisms (SNPs) were further tested for association with maternal diabetes mellitus or hypertension. In addition, the cumulative genetic risk score (GRS) for low to moderately-associated SNPs was calculated for each study subject, which can ultimately guide us for better therapeutic options and prevention strategies. According to the predefined selection criteria, 376 subjects were recruited. The multiplex mini-sequencing genotyping technique opted for the cost-effective genotyping of selected loci. The association of variants with the disease was examined using logistic regression analysis. The statistical and graphical analysis was conducted using SPSS, Haploview, SNPStats, and GraphPad Prism. The results for all SNPs analysis suggested a nonsignificant association with overall congenital heart defect risk except rs3809923. However, interestingly on stratified analysis variants, rs3809923 and rs3809922 showed an association only with tetralogy of Fallot. The remaining risk factor analysis for maternal hypertension and diabetes mellitus association with SNPs were nonsignificant. The GRS was the first time constructed for this low to moderately-associated variants. Interestingly, the cumulative GRS was significantly different from the control group revealing the cumulative effect of these polymorphisms panel in patients. In conclusion, the use of GRS in the clinical setting can predict better risk association and patient outcomes.
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Affiliation(s)
- Sana Ashiq
- Centre for Applied Molecular Biology, University of the Punjab, Lahore, Pakistan
| | | | - Syed Najam Hyder
- Department of Pediatric Cardiology, University of Child Health Sciences, The Children's Hospital, Lahore, Pakistan
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11
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Schmidt J, Chiu A, Okiror W, Kolkowitz I, Svenson JE, Olupot-Olupot P. Training for Pediatric Cardiac and Pulmonary Point of Care Ultrasound in Eastern Uganda. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:2461-2467. [PMID: 36137847 DOI: 10.1016/j.ultrasmedbio.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/17/2022] [Accepted: 07/19/2022] [Indexed: 06/16/2023]
Abstract
Caring for children with acute illness is a challenge in limited-resource settings, especially when diagnostic imaging is limited or unavailable. We developed a training program in cardiac and lung point-of-care ultrasound (POCUS) for pediatric patients in eastern Uganda. Fourteen trainees including physicians, resident physicians and midlevels received training in cardiac and lung POCUS. Training included formal lectures, hands-on skills practice and individualized teaching sessions. Assessment included written knowledge assessment, direct observation and longitudinal image review. Blinded review of 237 consecutive ultrasound studies revealed satisfactory image quality (94.2% for lung and 93% for cardiac) and accurate image interpretation. Sensitivity and specificity of image interpretation were 0.93 (0.75-0.99) and 0.94 (0.78-0.99) for lung and 0.86 (0.71-0.95) and 0.94 (0.84-0.99) for cardiac compared with expert review. All trainees passed written knowledge assessments. After training, 100% of trainees reported that they would use POCUS in clinical activity and thought it would improve patient outcomes. Our training program indicated that trainees were able to perform high-quality cardiac and lung POCUS for pediatric patients with accurate interpretation. This builds a foundation for future studies addressing how POCUS can change outcomes for children in limited-resource settings.
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Affiliation(s)
- Jessica Schmidt
- Department of Emergency Medicine, University of Wisconsin, Madison, Wisconsin, USA.
| | - Arthur Chiu
- Department of Emergency Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - William Okiror
- Department of Pediatrics, Busitema University, Mbale, Uganda
| | - Ilan Kolkowitz
- Emergency Medicine, Adventist Health Hospital, Ukiah, California, USA
| | - James E Svenson
- Department of Emergency Medicine, University of Wisconsin, Madison, Wisconsin, USA
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Kumar S, Memon D, Raj M, Sen AC, Jayasankar JP, Leeladharan SP, Sudhakar A, Kumar RK. Comparison of intravenous sildenafil with inhaled nitric oxide for acute vasodilator testing in pulmonary arterial hypertension. Pulm Circ 2022; 12:e12180. [PMID: 36583117 PMCID: PMC9791914 DOI: 10.1002/pul2.12180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 11/17/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Acute vasodilator testing (AVT) identifies acute responders for initiation of calcium channel blockers in pulmonary arterial hypertension (PAH) and operability in congenital heart disease (CHD). We sought to determine the feasibility of intravenous sildenafil (ivS) as an alternative to inhaled nitric oxide (iNO) in AVT. All patients with PAH undergoing cardiac catheterization for AVT (November 2015 to December 2020) were prospectively enrolled. Hemodynamic data were obtained at baseline, with iNO 20 ppm and ivS (0.25 mg/kg for children and 10 mg for adults). We studied 44 patients with a mean age of 20.5 ± 14.4 years (27 [61%] females and 20 [45%] children). There were 17 (38.6%) patients in the CHD group for operability assessment and 27 patients in non-CHD group (idiopathic pulmonary arterial hypertension-16 [36.3%], residual PAH after shunt closure-7 [15.9%], and 2 cases [4.5%] each of familial PAH and portopulmonary hypertension). There was an excellent intraclass correlation for mean pulmonary artery pressures (0.903, 95% confidence interval, CI: 0.809-0.949, p < 0.001), mean aortic pressures (0.745, 95% CI: 0.552-0.858, p < 0.001), pulmonary vascular resistance index (0.920, 95% CI: 0.858-0.956, p < 0.001), systemic vascular resistance (SVR) index (0.828, 95% CI: 0.706-0.902, p < 0.001), and the ratio of pulmonary and SVR indices (0.857, 95% CI: 0.752-0.919, p < 0.001) between the two agents. There were two responders, both in non-CHD group, and were identified by iNO and ivS. The hemodynamic effects of ivS show excellent correlation with iNO and could be a potential alternative agent for identifying acute responders during AVT.
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Affiliation(s)
- Shine Kumar
- Department of Pediatric Cardiology, Pulmonary Hypertension Clinic, Amrita Institute of Medical SciencesAmrita Vishwa Vidyapeetham UniversityKochiKeralaIndia
| | - Danish Memon
- Department of Pediatric Cardiology, Pulmonary Hypertension Clinic, Amrita Institute of Medical SciencesAmrita Vishwa Vidyapeetham UniversityKochiKeralaIndia
| | - Manu Raj
- Department of Pediatrics and Health Sciences Research, Amrita Institute of Medical SciencesAmrita Vishwa Vidyapeetham UniversityKochiKeralaIndia
| | - Amitabh C. Sen
- Department of Cardiac AnesthesiologySultan Qaboos University HospitalMuscatOman
| | - Jessin P. Jayasankar
- Department of Cardiac Anesthesiology, Amrita Institute of Medical SciencesAmrita Vishwa Vidyapeetham UniversityKochiKeralaIndia
| | - Sreelakshmi P. Leeladharan
- Department of Cardiac Anesthesiology, Amrita Institute of Medical SciencesAmrita Vishwa Vidyapeetham UniversityKochiKeralaIndia
| | - Abish Sudhakar
- Department of Pediatric Cardiology, Pulmonary Hypertension Clinic, Amrita Institute of Medical SciencesAmrita Vishwa Vidyapeetham UniversityKochiKeralaIndia
| | - Raman K. Kumar
- Department of Pediatric Cardiology, Pulmonary Hypertension Clinic, Amrita Institute of Medical SciencesAmrita Vishwa Vidyapeetham UniversityKochiKeralaIndia
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Gupta SK. Cyanotic congenital heart disease - Not always blue to provide a clue: Time to replace cyanosis with arterial desaturation! Ann Pediatr Cardiol 2022; 15:511-514. [PMID: 37152515 PMCID: PMC10158465 DOI: 10.4103/apc.apc_226_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 02/11/2022] [Accepted: 04/07/2022] [Indexed: 03/03/2023] Open
Abstract
Despite right-to-left shunt, not all patients with so-called cyanotic congenital heart disease (CHD) are cyanosed at all times. Moreover, despite undisputed clinical utility, cyanosis is unreliable for the detection of arterial desaturation. Pulse oximetry, on the other hand, provides a much easier, reliable, and accurate method for detecting arterial desaturation. For optimal detection, therefore, it is perhaps sensible to replace cyanosis with pulse oximetry-based detection of arterial desaturation in all cases with suspected CHD.
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Affiliation(s)
- Saurabh Kumar Gupta
- Department of Cardiology, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
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14
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Predictors of short versus prolonged PCICU stay after primary repair of tetralogy of Fallot at a tertiary care unit, Karachi: A single-center study. PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2022.101541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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15
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Abbas Q, Hussain MZH, Shahbaz FF, Siddiqui NUR, Hasan BS. Performance of a Risk Analytic Tool (Index of Tissue Oxygen Delivery "IDO2") in Pediatric Cardiac Intensive Care Unit of a Developing Country. Front Pediatr 2022; 10:846074. [PMID: 35722489 PMCID: PMC9203960 DOI: 10.3389/fped.2022.846074] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 05/16/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To determine the performance of a commercially available risk analytic tool (IDO2) to estimate the risk for SVO2 < 40% in patients admitted in cardiac intensive care unit (CICU). METHODS Medical and T3 records of all patients (aged 1 day to 12 years, weight >2 kg) who received care in the CICU between October 1st, 2019 and October 1st, 2020, had SvO2 lab(s) drawn during CICU course and whose data was transmitted to T3, were included. The average IDO2 Index was computed in the 30-min period immediately prior to each SvO2 measurement and used as a predictor score for SvO2 < 40%. RESULTS A total of 69 CICU admissions from 65 patients, median age 9.3 months (interquartile range 20.8) were identified. Surgical and medical patients were 61 (88%) and 8 (12%) respectively; 4 (5.7%) patients had single ventricle physiology. Tetralogy of Fallot n = 23 (33.3%) and ventricular septal defects 17 (24.6%) were major cardiac diagnosis. Sixty-one (89.9%) of the admissions were successfully discharged from the hospital. Of the 187-total included SvO2 labs, 17 (9%) were <40%. The AUC of estimating SvO2 < 40% IDO2 was 0.87 [confidence interval (CI): 0.79-0.94]. Average IDO2 above 75 had the highest absolute risk (42.11, CI: 20.25-66.50) and highest RR (4.63, CI: 2.31-9.28, p-value < 0.0001) of SvO2 < 40%. CONCLUSION IDO2 performed well in estimating low SvO2 (<40%) in pediatric patients presenting to a CICU in a low resource setting. Future work is needed to determine the effect of this risk analytic tool on clinical outcomes in such a setting.
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Affiliation(s)
- Qalab Abbas
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | | | | | | | - Babar S Hasan
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
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16
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Arvind B, Saxena A, Ramakrishnan S. Utility of pulse-oximetry screening in newborns with nonductus-dependent cyanotic congenital heart defects: A reason to alarm? Ann Pediatr Cardiol 2022; 15:41-43. [PMID: 35847403 PMCID: PMC9280103 DOI: 10.4103/apc.apc_9_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/10/2022] [Accepted: 04/01/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES We aimed to compare the performance of pulse-oximetry screening in detecting nonductus-dependent cyanotic congenital heart defects (CCHDs). METHODS In a prospective cross-sectional study, we recorded post ductal saturation of neonates (<48 h old) born at a community hospital in northern India. Subsequently, all underwent clinical examination and echocardiogram by a trained cardiologist. A saturation <95% was considered a "failed" screen. RESULTS Ten neonates were identified to have nonductus-dependent CCHD on echocardiogram, five of whom had passed pulse-oximetry screen. This translated to a sensitivity of 50% (95% confidence interval [CI] 23.7%-76.3%) and a positive predictive value of 0.08 (95% CI 0.03-0.2), both of which were significantly less compared to that in ductus-dependent congenital heart defect. CONCLUSIONS Up to half of the nonductus-dependent CCHD may be missed if screened only using pulse oximetry. Parents should not be reassured regarding the absence of CCHD only based on a "pass" in pulse-oximetry screening.
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Affiliation(s)
- Balaji Arvind
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Anita Saxena
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India,Pt BD Sharma University of Health Sciences, Rohtak, Haryana, India,Address for correspondence: Dr. Anita Saxena, Vice Chancellor, Pt. BD Sharma University of Health Sciences, Rohtak, Haryana - 124 001, India. E-mail:
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Sivakumar K, Sagar P, Qureshi S, Promphan W, Sasidharan B, Awasthy N, Kappanayil M, Suresh PV, Koneti NR. Outcomes of Venus P-valve for dysfunctional right ventricular outflow tracts from Indian Venus P-valve database. Ann Pediatr Cardiol 2021; 14:281-292. [PMID: 34667398 PMCID: PMC8457277 DOI: 10.4103/apc.apc_175_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 05/17/2021] [Accepted: 05/27/2021] [Indexed: 12/05/2022] Open
Abstract
Background : Balloon-expandable pulmonary valves are usually not suitable for dilated native outflow tracts. Methods : Indian Venus P-valve registry was retrospectively analyzed for efficacy, complications, and midterm outcomes. Straight valve was used in prestented conduits in patients with right ventricular pressure above two-thirds systemic pressure and/or right ventricular dysfunction. Flared valve 1–4 mm larger than balloon waist was used in native outflow in symptomatic patients, large ventricular volumes, and ventricular dysfunction. Objectives : A self-expanding porcine pericardial Venus P-valve is available in straight and flared designs.. Results : Twenty-nine patients were included. Straight valve was successful in all seven conduits, reducing gradients significantly, including one patient with left pulmonary artery (LPA) stent. Flared valve was successfully implanted in 20 out of 22 native outflow tracts. Sharp edges of the older design contributed to two failures. Complications included two migrations with one needing surgery, endocarditis in one, insignificant wire-frame fractures in three, and groin vascular complication in one patient. There were no deaths or valve-related reinterventions at a mean follow-up of 47.8 ± 24.5 months (1–85 months). Modifications of technique succeeded in three patients with narrow LPA. There was significant improvement in symptoms, right ventricular volume, and pulmonary regurgitant fraction. Conclusion : Straight and flared Venus P-valves are safe and effective in appropriate outflow tracts. Straight valve is an alternative to balloon-expandable valves in stenosed conduits. Flared valve is suitable for large outflows up to 34 mm, including patients with LPA stenosis. Recent design modifications may correct previous technical failures. Studies should focus on durability and late complications.
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Affiliation(s)
- Kothandam Sivakumar
- Department of Pediatric Cardiology, Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai, Tamil Nadu, India
| | - Pramod Sagar
- Department of Pediatric Cardiology, Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai, Tamil Nadu, India
| | - Shakeel Qureshi
- Department of Pediatric Cardiology, Evelina London Children's Hospital, Guy's and St. Thomas' NHS, London, UK
| | - Worakan Promphan
- Department of Pediatric Cardiology, Queen Sirikit National Institute of Child Health, Bangkok, Thailand
| | - Bijulal Sasidharan
- Department of Pediatric Cardiology, Sree Chitra Tirunal Institute, Thiruvananthapuram, Kerala, India
| | - Neeraj Awasthy
- Department of Pediatric Cardiology, Max Super Specialty Hospital, Delhi, India
| | - Mahesh Kappanayil
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
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Keepanasseril A, Pfaller B, Metcalfe A, Siu SC, Davis MB, Silversides CK. Cardiovascular Deaths in Pregnancy: Growing Concerns and Preventive Strategies. Can J Cardiol 2021; 37:1969-1978. [PMID: 34600086 DOI: 10.1016/j.cjca.2021.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 12/16/2022] Open
Abstract
There has been an increase in maternal deaths from cardiovascular disease in many countries. In high-income countries, cardiovascular deaths secondary to cardiomyopathies, ischemic heart disease, sudden arrhythmic deaths, aortic dissection, and valve disease are responsible for up to one-third of all pregnancy-related maternal deaths. In low- and middle-income countries, rheumatic heart disease is a much more common cause of cardiac death during pregnancy. Although deaths occur in women with known heart conditions or cardiovascular risk factors such as hypertension, many women present for the first time in pregnancy with unrecognised heart disease or with de novo cardiovascular conditions such as preeclampsia, peripartum cardiomyopathy, spontaneous coronary artery dissection. Not only has maternal cardiovascular mortality increased, but serious cardiac morbidity, or "near misses," during pregnancy also have increased in frequency. Although maternal morbidity and mortality are often preventable, many health professionals remain unaware of the impact of cardiovascular disease in this population, and the lack of awareness contributes to inappropriate care and preventable deaths. In this review, we discuss the maternal mortality from cardiovascular causes in both high- and low- and middle-income countries and strategies to improve outcomes.
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Affiliation(s)
- Anish Keepanasseril
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Post-graduate Medical Education and Research, Puducherry, India
| | - Birgit Pfaller
- Department of Internal Medicine 1, University Hospital of St Pölten, Karl Landsteiner University of Health Sciences, Karl Landsteiner Institute for Nephrology, St Pölten, Austria
| | - Amy Metcalfe
- Department of Obstetrics and Gynecology, Department of Community Health Sciences and Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Samuel C Siu
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, University of Toronto, Toronto, Ontario, Canada; Division of Cardiology, University of Western Ontario, London, Ontario, Canada
| | - Melinda B Davis
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Candice K Silversides
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, University of Toronto, Toronto, Ontario, Canada.
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Saquib N, Al Sarraj AN, Oubaied BTZ, Rajab AM, Agha BN, Hossain J, Almazrou A, Saquib J. Gain in growth after surgical repair of congenital heart disease among children with Down syndrome. Am J Med Genet A 2021; 188:24-30. [PMID: 34496118 DOI: 10.1002/ajmg.a.62483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/29/2021] [Accepted: 08/16/2021] [Indexed: 11/12/2022]
Abstract
Down syndrome (DS) is a common genetic disorder among Saudi children, for which limited data is available on growth for those who undergo surgery for congenital heart disease (CHD). We assessed the magnitude of growth over time following surgery and the factors associated with growth change. Eighty-eight children with DS and CHD who underwent surgery between 2009 and 2017 at the tertiary children's hospital in Al-Qassim, Saudi Arabia, were eligible. Information on gender, height, and weight (at surgery, 6 and 12 months), age at surgery, and type of CHD were abstracted from the medical records. Repeated measure analysis of variance (ANOVA) was used for data analysis. The sample's mean age (SD) was 16.2 months (20.1); 47% were male. Height, weight, and body mass index (BMI) increased significantly at both follow-up points. There was a significant interaction between age at surgery, type of heart disease, and time for all three physical indices (p-values <0.001). The increase in height, weight, and BMI was significantly greater for children ≤8 months old with acyanotic CHD compared to children >8 months with cyanotic CHD. Overall, the gain in growth was greater for the children with DS who had had surgery at a younger age.
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Affiliation(s)
- Nazmus Saquib
- College of Medicine, Sulaiman Al Rajhi University, Al Bukairyah, Saudi Arabia
| | | | | | - Ahmad Mamoun Rajab
- Calderdale and Huddersfield NHS Foundation Trust, Calderdale Royal Hospital, Halifax, UK
| | - Bana Nasser Agha
- Prince Sultan Cardiac Center at the Maternity and Children's Hospital, Buraydah, Saudi Arabia
| | - Jesmin Hossain
- Department of Paediatric Cardiology, National Heart Foundation, Dhaka, Bangladesh
| | | | - Juliann Saquib
- College of Medicine, Sulaiman Al Rajhi University, Al Bukairyah, Saudi Arabia
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Is Doppler Echocardiography Adequate for Surgical Planning of Single Ventricle Patients? Cardiovasc Eng Technol 2021; 12:606-617. [PMID: 33931807 DOI: 10.1007/s13239-021-00533-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 03/12/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Surgical planning has shown great potential for optimizing outcomes for patients affected by single ventricle (SV) malformations. Phase-contrast magnetic resonance imaging (PC-MRI) is the routine technique used for flow acquisition in the surgical planning paradigm. However, PC-MRI may suffer from possible artifacts in certain cases; furthermore, this technology may not be readily available for patients in low and lower-middle-income countries. Therefore, this study aims to investigate the effectiveness of using Doppler echocardiography (echo-Doppler) for flow acquisitions of SV surgical planning. METHODS This study included eight patients whose blood flow data was acquired by both PC-MRI and echo-Doppler. A virtual surgery platform was used to generate two surgical options for each patient: (1) a traditional Fontan conduit and (2) a Y-graft. Computational fluid dynamics (CFD) simulations were conducted using the two flow acquisitions to assess clinically relevant hemodynamic metrics: indexed power loss (iPL) and hepatic flow distribution (HFD). RESULTS Differences exist in flow data acquired by PC-MRI and echo-Doppler, but no statistical significance was obtained. Flow fields, therefore, exhibit discrepancies between simulations using flow acquisitions by PC-MRI and echo-Doppler. In virtual surgery, the two surgical options were ranked based on these metrics. No difference was observed in the ranking of surgical options between using different flow acquisitions. CONCLUSION Doppler echocardiography is an adequate alternative approach to acquire flow data for SV surgical planning. This finding encourages broader usage of SV surgical planning with echo-Doppler when MRI may present artifacts or is not available, especially in low and lower-middle-income countries.
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21
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Murni IK, Wirawan MT, Patmasari L, Sativa ER, Arafuri N, Nugroho S, Noormanto. Delayed diagnosis in children with congenital heart disease: a mixed-method study. BMC Pediatr 2021; 21:191. [PMID: 33882901 PMCID: PMC8059230 DOI: 10.1186/s12887-021-02667-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 04/13/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Delayed diagnosis of congenital heart disease (CHD) causes significant morbidity and mortality. We aimed to determine the proportion of delayed diagnosis of CHD and factors related to the delayed diagnosis. METHODS A prospective cohort study with mixed-methods was conducted in Dr. Sardjito Hospital, Yogyakarta, Indonesia. Patients aged < 18 years with newly diagnosed CHD and echocardiography confirmed CHD were included. Data were recorded from medical records and interviews from direct caregivers. Logistic regression was used to identify independent factors associated with the delay. RESULTS A total of 838 patients were included with median age of 2.9 years (0-17.7 years), with female predominance (54.2%, n = 454). The proportions of delayed diagnosis were 60.8% (510), 54.9% (373) and 86.2% (137) in all children with CHD, acyanotic and cyanotic CHD, respectively. Delayed diagnosis by doctor was the most common cause, followed by delayed diagnosis related to midwifery care, financial, referral/follow-up, and social factors. In multivariate analysis, cyanotic CHD, residence outside the city, non-syndromic, low family income, normal labour and at term gestation at birth were independently associated with the delay. At diagnosis, heart failure and pulmonary hypertension occurred in 414 (49.4%) and 132 (15.8%) children with CHD, respectively. CONCLUSIONS Six in ten children with CHD were diagnosed with significant delay. Delayed diagnosis by doctor was the most common cause. Children with cyanotic CHD, residence outside the city, non-syndromic, low family income, normal labour and at term gestation at birth were independently associated with the delay. Comorbid complications in delayed diagnosis of CHD were prevalent.
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Affiliation(s)
- Indah K Murni
- Department of Child Health, Dr. Sardjito Hospital / Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jalan Kesehatan No 1, Sekip, Yogyakarta, 55281, Indonesia.
| | - Muhammad Taufik Wirawan
- Department of Child Health, Dr. Sardjito Hospital / Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jalan Kesehatan No 1, Sekip, Yogyakarta, 55281, Indonesia
| | - Linda Patmasari
- Department of Child Health, Dr. Sardjito Hospital / Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jalan Kesehatan No 1, Sekip, Yogyakarta, 55281, Indonesia
| | - Esta R Sativa
- Department of Child Health, Dr. Sardjito Hospital / Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jalan Kesehatan No 1, Sekip, Yogyakarta, 55281, Indonesia
| | - Nadya Arafuri
- Department of Child Health, Dr. Sardjito Hospital / Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jalan Kesehatan No 1, Sekip, Yogyakarta, 55281, Indonesia
| | - Sasmito Nugroho
- Department of Child Health, Dr. Sardjito Hospital / Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jalan Kesehatan No 1, Sekip, Yogyakarta, 55281, Indonesia
| | - Noormanto
- Department of Child Health, Dr. Sardjito Hospital / Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jalan Kesehatan No 1, Sekip, Yogyakarta, 55281, Indonesia
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22
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Hummel K, Whittaker S, Sillett N, Basken A, Berghammer M, Chalela T, Chauhan J, Garcia LA, Hasan B, Jenkins K, Ladak LA, Madsen N, March A, Pearson D, Schwartz SM, St Louis JD, van Beynum I, Verstappen A, Williams R, Zheleva B, Hom L, Martin GR. Development of an international standard set of clinical and patient-reported outcomes for children and adults with congenital heart disease: a report from the International Consortium for Health Outcomes Measurement Congenital Heart Disease Working Group. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 7:354-365. [PMID: 33576374 DOI: 10.1093/ehjqcco/qcab009] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/17/2021] [Accepted: 02/03/2021] [Indexed: 12/30/2022]
Abstract
AIMS Congenital heart disease (CHD) is the most common congenital malformation. Despite the worldwide burden to patient wellbeing and health system resource utilization, tracking of long-term outcomes is lacking, limiting the delivery and measurement of high-value care. To begin transitioning to value-based healthcare in CHD, the International Consortium for Health Outcomes Measurement aligned an international collaborative of CHD experts, patient representatives, and other stakeholders to construct a standard set of outcomes and risk-adjustment variables that are meaningful to patients. METHODS AND RESULTS The primary aim was to identify a minimum standard set of outcomes to be used by health systems worldwide. The methodological process included four key steps: (i) develop a working group representative of all CHD stakeholders; (ii) conduct extensive literature reviews to identify scope, outcomes of interest, tools used to measure outcomes, and case-mix adjustment variables; (iii) create the outcome set using a series of multi-round Delphi processes; and (iv) disseminate set worldwide. The Working Group established a 15-item outcome set, incorporating physical, mental, social, and overall health outcomes accompanied by tools for measurement and case-mix adjustment variables. Patients with any CHD diagnoses of all ages are included. Following an open review process, over 80% of patients and providers surveyed agreed with the set in its final form. CONCLUSION This is the first international development of a stakeholder-informed standard set of outcomes for CHD. It can serve as a first step for a lifespan outcomes measurement approach to guide benchmarking and improvement among health systems.
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Affiliation(s)
- Kevin Hummel
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA.,Department of Pediatric Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, USA
| | - Sarah Whittaker
- International Consortium for Health Outcomes Measurement, Cambridge, MA, USA
| | - Nick Sillett
- International Consortium for Health Outcomes Measurement, Cambridge, MA, USA
| | - Amy Basken
- Pediatric Congenital Heart Association, Madison, WI, USA.,Conquering CHD, Madison, WI, USA
| | - Malin Berghammer
- Queen Silvia Children Hospital/Sahlgrenska University Hospital, Gothenburg, Sweden.,University West, Trollhättan, Sweden
| | | | - Julie Chauhan
- All India Institute of Medical Sciences, New Delhi, India
| | | | - Babar Hasan
- Department of Pediatrics, Aga Khan University, Karachi City, Pakistan
| | - Kathy Jenkins
- Department of Pediatric Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, USA
| | - Laila Akbar Ladak
- Department of Pediatrics, Aga Khan University, Karachi City, Pakistan.,Susan Wakil School of Nursing, The University of Sydney, Sydney, Australia
| | - Nicolas Madsen
- Department of Cardiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | | | - Disty Pearson
- Department of Pediatric Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, USA
| | - Steven M Schwartz
- Department of Cardiology, The Hospital for Sick Children, Toronto, ON, Canada
| | - James D St Louis
- Department of Surgery, Medical College of Georgia, Augusta, GA, USA
| | - Ingrid van Beynum
- Department of Pediatric Cardiology, Erasmus Medical Centre, Rotterdam, Netherlands.,Sophia Children's Hospital, Rotterdam, Netherlands
| | - Amy Verstappen
- Global Alliance for Rheumatic and Congenital Hearts, Philadelphia PA, USA
| | - Roberta Williams
- Department of Cardiology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | | | - Lisa Hom
- Department of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Gerard R Martin
- Department of Cardiology, Children's National Hospital, Washington, DC, USA
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23
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Choi S, Shin H, Heo J, Gedlu E, Nega B, Moges T, Bezabih A, Park J, Kim WH. How do caregivers of children with congenital heart diseases access and navigate the healthcare system in Ethiopia? BMC Health Serv Res 2021; 21:110. [PMID: 33526022 PMCID: PMC7852139 DOI: 10.1186/s12913-021-06083-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 01/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surgery can correct congenital heart defects, but disease management in low- and middle-income countries can be challenging and complex due to a lack of referral system, financial resources, human resources, and infrastructure for surgical and post-operative care. This study investigates the experiences of caregivers of children with CHD accessing the health care system and pediatric cardiac surgery. METHODS A qualitative study was conducted at a teaching hospital in Ethiopia. We conducted semi-structured interviews with 13 caregivers of 10 patients with CHD who underwent cardiac surgery. We additionally conducted chart reviews for triangulation and verification. Interviews were conducted in Amharic and then translated into English. Data were analyzed according to the principles of interpretive thematic analysis, informed by the candidacy framework. RESULTS The following four observations emerged from the interviews: (a) most patients were diagnosed with CHD at birth if they were born at a health care facility, but for those born at home, CHD was discovered much later (b) many patients experienced misdiagnoses before seeking care at a large hospital, (c) after diagnosis, patients were waiting for the surgery for more than a year, (d) caregivers felt anxious and optimistic once they were able to schedule the surgical date. During the care-seeking journey, caregivers encountered financial constraints, struggled in a fragmented delivery system, and experienced poor service quality. CONCLUSIONS Delayed access to care was largely due to the lack of early CHD recognition and financial hardships, related to the inefficient and disorganized health care system. Fee waivers were available to assist low-income children in gaining access to health services or medications, but application information was not readily available. Indirect costs like long-distance travel contributed to this challenge. Overall, improvements must be made for district-level screening and the health care workforce.
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Affiliation(s)
- Sugy Choi
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA
- Program in Global Surgery and Implementation Science, JW LEE Center for Global Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Heesu Shin
- Program in Global Surgery and Implementation Science, JW LEE Center for Global Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Seoul National University College of Nursing, Seoul, Republic of Korea
| | - Jongho Heo
- Program in Global Surgery and Implementation Science, JW LEE Center for Global Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
- National Assembly Futures Institute, Seoul, Republic of Korea.
| | - Etsegenet Gedlu
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Berhanu Nega
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tamirat Moges
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abebe Bezabih
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Jayoung Park
- Program in Global Surgery and Implementation Science, JW LEE Center for Global Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Woong-Han Kim
- Program in Global Surgery and Implementation Science, JW LEE Center for Global Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea.
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24
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Khoshhal SQ, Albasri AM, Morsy MMF, Alnajjar AA. The trends and patterns of congenital heart diseases at Madinah Cardiac Center, Madinah, Saudi Arabia. Saudi Med J 2021; 41:977-983. [PMID: 32893280 PMCID: PMC7557563 DOI: 10.15537/smj.2020.9.25275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objectives: To characterize the pattern of congenital heart diseases (CHDs) in Madinah, Saudi Arabia. Methods: We retrospectively collected and analyzed the demographic and diagnostic details of all patients with CHDs referred at Madinah Cardiac Center (MCC) over a period of 3 years from January 2017 to December 2019. Results: During the study period, 1,127 patients with CHDs were identified. The male to female ratio was 1.1:1, with a mean age of 8.4±2.4 years. The acyanotic CHDs were the predominant lesions, accounting for 84.8% of all cases, while the cyanotic types accounted for 13%. Patent ductus arteriosus (PDA), ventricular septal defects (VSD), atrial septal defects (ASD), coarctation of the aorta (CoA), and atrioventricular septal defect (AVSD) were the most common acyanotic CHDs and represented 27.9%, 24.8%, 18.9%, 6.4%, and 4.4% of the total cases, respectively. Tetralogy of Fallot (ToF) (8.7%), followed by transposition of the great arteries (TGA) (1.7%) and truncus arteriosus (1.1%), were the most common cyanotic CHDs. There was a male predominance of VSD, ToF, CoA, TGA, and truncus arteriosus. In contrast, PDA, ASD, and AVSD were more common in females. Conclusion: The pattern of CHDs observed in our study and age at which the diagnosis of CHDs was made were different from the other national and international studies, which points to a diagnostic issue along with problems of awareness on the part of the general population.
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Affiliation(s)
- Saad Q Khoshhal
- Department of Pathology, Faculty of Medicine, Taibah University, Al-Madinah Al-Munawwarah, Kingdom of Saudi Arabia. E-mail.
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25
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Automated image segmentation for cardiac septal defects based on contour region with convolutional neural networks: A preliminary study. INFORMATICS IN MEDICINE UNLOCKED 2021. [DOI: 10.1016/j.imu.2021.100601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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26
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Swanson L, Owen B, Keshmiri A, Deyranlou A, Aldersley T, Lawrenson J, Human P, De Decker R, Fourie B, Comitis G, Engel ME, Keavney B, Zühlke L, Ngoepe M, Revell A. A Patient-Specific CFD Pipeline Using Doppler Echocardiography for Application in Coarctation of the Aorta in a Limited Resource Clinical Context. Front Bioeng Biotechnol 2020; 8:409. [PMID: 32582648 PMCID: PMC7283385 DOI: 10.3389/fbioe.2020.00409] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 04/14/2020] [Indexed: 12/14/2022] Open
Abstract
Congenital heart disease (CHD) is the most common birth defect globally and coarctation of the aorta (CoA) is one of the commoner CHD conditions, affecting around 1/1800 live births. CoA is considered a CHD of critical severity. Unfortunately, the prognosis for a child born in a low and lower-middle income country (LLMICs) with CoA is far worse than in a high-income country. Reduced diagnostic and interventional capacities of specialists in these regions lead to delayed diagnosis and treatment, which in turn lead to more cases presenting at an advanced stage. Computational fluid dynamics (CFD) is an important tool in this context since it can provide additional diagnostic data in the form of hemodynamic parameters. It also provides an in silico framework, both to test potential procedures and to assess the risk of further complications arising post-repair. Although this concept is already in practice in high income countries, the clinical infrastructure in LLMICs can be sparse, and access to advanced imaging modalities such as phase contrast magnetic resonance imaging (PC-MRI) is limited, if not impossible. In this study, a pipeline was developed in conjunction with clinicians at the Red Cross War Memorial Children’s Hospital, Cape Town and was applied to perform a patient-specific CFD study of CoA. The pipeline uses data acquired from CT angiography and Doppler transthoracic echocardiography (both much more clinically available than MRI in LLMICs), while segmentation is conducted via SimVascular and simulation is realized using OpenFOAM. The reduction in cost through use of open-source software and the use of broadly available imaging modalities makes the methodology clinically feasible and repeatable within resource-constrained environments. The project identifies the key role of Doppler echocardiography, despite its disadvantages, as an intrinsic component of the pipeline if it is to be used routinely in LLMICs.
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Affiliation(s)
- Liam Swanson
- Department of Mechanical Engineering, University of Cape Town, Cape Town, South Africa
| | - Benjamin Owen
- Department of Mechanical, Aerospace and Civil Engineering (MACE), The University of Manchester, Manchester, United Kingdom
| | - Amir Keshmiri
- Department of Mechanical, Aerospace and Civil Engineering (MACE), The University of Manchester, Manchester, United Kingdom
| | - Amin Deyranlou
- Department of Mechanical, Aerospace and Civil Engineering (MACE), The University of Manchester, Manchester, United Kingdom
| | - Thomas Aldersley
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - John Lawrenson
- Department of Paediatrics and Child Health, Tygerberg Hospital, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Paul Human
- Christiaan Barnard Division of Cardiothoracic Surgery, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Rik De Decker
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Barend Fourie
- Department of Paediatrics and Child Health, Tygerberg Hospital, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - George Comitis
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Mark E Engel
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Bernard Keavney
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, School of Medical Sciences, The University of Manchester, Manchester, United Kingdom.,Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Liesl Zühlke
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Malebogo Ngoepe
- Department of Mechanical Engineering, University of Cape Town, Cape Town, South Africa
| | - Alistair Revell
- Department of Mechanical, Aerospace and Civil Engineering (MACE), The University of Manchester, Manchester, United Kingdom
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Outcomes of infants and children undergoing surgical repair of ventricular septal defect: a review of the literature and implications for research with an emphasis on pulmonary artery hypertension. Cardiol Young 2020; 30:799-806. [PMID: 32431266 DOI: 10.1017/s1047951120001146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Pulmonary vascular disease resulting from CHDs may be the most preventable cause of pulmonary artery hypertension worldwide. Many children in developing countries still do not have access to early closure of clinically significant defects, and the long-term outcomes after corrective surgery remain unclear. Focused on long-term results after isolated ventricular septal defect repair, our review sought to determine the most effective medical therapy for the pre-operative management of elevated left-to-right shunts in patients with an isolated ventricular septal defect. METHODS We identified articles specific to the surgical repair of isolated ventricular septal defects. Specific parameters included the pathophysiology and pre-operative medical management of pulmonary over-circulation and outcomes. RESULTS Studies most commonly focused on histologic changes to the pulmonary vasculature and levels of thromboxanes, prostaglandins, nitric oxide, endothelin, and matrix metalloproteinases. Only 2/44 studies mentioned targeted pharmacologic management to any of these systems related to ventricular septal defect repair; no study offered evidence-based guidelines to manage pulmonary over-circulation with ventricular septal defects. Most studies with long-term data indicated a measurable frequency of pulmonary artery hypertension or diminished exercise capacity late after ventricular septal defect repair. CONCLUSION Long-term pulmonary vascular and respiratory changes can occur in children after ventricular septal defect repair. Research should be directed at providing an evidenced-based approach to the medical management of infants and children with ventricular septal defects (and naturally all CHDs) to minimise consequences of pulmonary artery hypertension, particularly as defect repair may occur late in underprivileged societies.
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28
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Outcome of adult congenital heart disease patients undergoing cardiac surgery: clinical experience of dr. Sardjito hospital. BMC Proc 2019; 13:16. [PMID: 31890009 PMCID: PMC6913046 DOI: 10.1186/s12919-019-0178-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background Patients with congenital heart disease require surgery to correct the cardiac defect they had in order to prevent heart failure. Unfortunately, data regarding outcome of adult CHD in Indonesia is still limited. In contrast with developed countries, many congenital heart surgery patients in developing countries are adults. The purpose of this study was to investigate the outcomes of cardiac surgery procedures among adult congenital heart disease patients, and what factors that might influence the outcome of surgery. Methods A retrospective study was performed on adult congenital heart disease patients undergoing cardiac surgery at Dr. Sardjito Hospital between April 2018 and March 2019. Variables included in the study were demographic characteristics, laboratory test results, comorbidities, premedication, Cardiopulmonary Bypass (CPB) and ischemia duration were included in the analysis. Outcomes were in-hospital mortality, hospital length of stay, and ICU length of stay. Results A total of 25 congenital heart disease patients [19 Atrial Septeal Defect (ASD) patients, and 6 Ventricular Septal Defect (VSD) patients] underwent a cardiac surgery procedure at Dr. Sardjito Hospital during the study period. Mean age was 31 ± 14.92 years. The majority of patients had pulmonary hypertension. During the study period, none of the patients died during postoperative care in the hospital, mean hospital length of stay (LOS) was 8.35 ± 3.39 days and ICU LOS was 26.53 ± 11.33 h. Conclusion Surgery in adult patients with congenital heart disease may be successfully performed with low morbidity and mortality.
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Manuel V, Morais H, Turquetto ALR, Miguel G, Miana LA, Pedro A, Nunes MAS, Leon G, Magalhães MP, Martins T, Júnior APF. Single Ventricle Palliation in a Developing Sub-Saharan African Country: What Should be Improved? World J Pediatr Congenit Heart Surg 2019; 10:164-170. [DOI: 10.1177/2150135118822671] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Single ventricle physiology management is challenging, especially in low-income countries. Objective: To report the palliation outcomes of single ventricle patients in a developing African country. Methods: We retrospectively studied 83 consecutive patients subjected to single ventricle palliation in a single center between March 2011 and December 2017. Preoperative data, surgical factors, postoperative results, and survival outcomes were analyzed. The patients were divided by palliation stage: I (pulmonary artery banding [PAB] or Blalock–Taussig shunt [BTS]), II (Glenn procedure), or III (Fontan procedure). Results: Of the 83 patients who underwent palliation (stages I-III), 38 deaths were observed (31 after stage I, six after stage II, and one after stage III) for an overall mortality of 45.7%. The main causes of operative mortality were multiple organ dysfunction due to sepsis, shunt occlusion, and cardiogenic shock. Twenty-eight survivors were lost to follow-up (22 after stage I, six after stage II). Thirteen stage II survivors are still waiting for stage III. The mean follow-up was 366 ± 369 days. Five-year survival was 28.4 % for PAB and 30.1% for BTS, while that for stage II and III was 49.8% and 57.1%, respectively. Age (hazard ratio, 0.61; 95% confidence interval: 0.47-0.7; P = .000) and weight at surgery (hazard ratio, 0.45; 95% confidence interval: 0.31-0.64; P = .002) impacted survival. Conclusion: A high-mortality rate was observed in this initial experience, mainly in stage I patients. A large number of patients were lost to follow-up. A task force to improve outcomes is urgently required.
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Affiliation(s)
- Valdano Manuel
- Cardio-Thoracic Center, Clínica Girassol, Luanda, Angola
- Division of Cardiovascular Surgery, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Humberto Morais
- Cardiology Department, Hospital Militar Principal/Instituto Superior, Luanda, Angola
| | - Aida L. R. Turquetto
- Division of Cardiovascular Surgery, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Gade Miguel
- Cardio-Thoracic Center, Clínica Girassol, Luanda, Angola
| | - Leonardo A. Miana
- Division of Cardiovascular Surgery, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Albino Pedro
- Cardio-Thoracic Center, Clínica Girassol, Luanda, Angola
- Pediatric Cardiology Department, Cardiac Surgery Department, Portuguese Red Cross Hospital, Lisbon, Portugal
| | - Maria A. S. Nunes
- Cardio-Thoracic Center, Clínica Girassol, Luanda, Angola
- Pediatric Cardiology Department, Cardiac Surgery Department, Portuguese Red Cross Hospital, Lisbon, Portugal
| | - Gilberto Leon
- Cardio-Thoracic Center, Clínica Girassol, Luanda, Angola
| | - Manuel Pedro Magalhães
- Cardio-Thoracic Center, Clínica Girassol, Luanda, Angola
- Pediatric Cardiology Department, Cardiac Surgery Department, Portuguese Red Cross Hospital, Lisbon, Portugal
| | - Telmo Martins
- Cardio-Thoracic Center, Clínica Girassol, Luanda, Angola
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30
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Status of Pediatric Cardiac Care in Developing Countries. CHILDREN-BASEL 2019; 6:children6020034. [PMID: 30823591 PMCID: PMC6406635 DOI: 10.3390/children6020034] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 02/17/2019] [Accepted: 02/20/2019] [Indexed: 11/16/2022]
Abstract
About 1.35 million babies are born with congenital heart disease each year globally. Most of these are expected to lead normal, productive lives if they are treated in time. However, 90% of babies born with congenital heart disease live in regions where medical care is inadequate or unavailable. The privilege of early diagnosis and timely intervention is restricted to only those born in developed countries. Added to the burden of congenital heart disease is rheumatic heart disease, which remains a global health problem in many low-income and middle-income countries. Providing optimal care for all these children is a daunting task, and requires funds and proper planning at various levels of the health care system. This article describes the burden of pediatric heart disease, including lacunae in the current state, as well as challenges and opportunities for providing optimal care to this large population of children.
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Lack of access to paediatric cardiology services in the public health system in four major urban centres in Perú. Cardiol Young 2018; 28:1452-1456. [PMID: 30198453 DOI: 10.1017/s1047951118001555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
For one-third of the Peruvian population living in large cities outside the capital city Lima, there is no access to paediatric cardiology services provided by the public health care system. Children with suspected CHD living in these areas are referred to the adult cardiologist working at the regional hospitals for care and treatment. This is a consequence of the universal health care system and the heavily skewed distribution of the health care workforce towards the capital city of Lima. This imbalance has resulted in a severe shortage of paediatric cardiologists practicing outside of Lima and the adult cardiologists that remain are left to make up for this deficit.To gain a better understanding of the current model of care for children with suspected CHD within the public health care system in Peru, we surveyed adult cardiologists from four major urban centres that serve one-third of the Peruvian population outside of Lima. We determined that adult cardiologists spend a significant amount of time treating children, but lack the specialised training and equipment to provide model care. The cardiologists indicated that receiving additional training and appropriate equipment would help enable them to provide proper care for these children.
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Udink ten Cate FE, Sobhy R, Kalantre A, Sachdev S, Subramanian A, Koneti NR, Kumar RK, Hamza H, Jayranganath M, Sreeram N. Off-label use of duct occluder devices to close hemodynamically significant perimembranous ventricular septal defects: A multicenter experience. Catheter Cardiovasc Interv 2018; 93:82-88. [DOI: 10.1002/ccd.27792] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 06/15/2018] [Accepted: 06/20/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Floris E.A. Udink ten Cate
- Department of Pediatric Cardiology; Heart Center Cologne, University Hospital of Cologne; Cologne Germany
- Department of Pediatric Cardiology; Amalia Children's Hospital, Radboud University Medical Center; Nijmegen The Netherlands
| | - Rodina Sobhy
- Department of Pediatric Cardiology; Cairo University Children's Hospital; Cairo Egypt
| | - Atul Kalantre
- Department of Pediatric Cardiology; Amrita Institute of Medical Sciences; Kochi India
| | - Sakshi Sachdev
- Department of Pediatric Cardiology; CARE Hospital; Hyderabad India
| | - Anand Subramanian
- Sri Jayadeva Institute of Cardiovascular Sciences and Research; Bengaluru India
| | | | - Raman Krishna Kumar
- Department of Pediatric Cardiology; Amrita Institute of Medical Sciences; Kochi India
| | - Hala Hamza
- Department of Pediatric Cardiology; Cairo University Children's Hospital; Cairo Egypt
| | | | - Narayanswami Sreeram
- Department of Pediatric Cardiology; Heart Center Cologne, University Hospital of Cologne; Cologne Germany
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Affiliation(s)
- Anita Saxena
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi 110029, India
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Ladak LA, Hasan BS, Gullick J, Awais K, Abdullah A, Gallagher R. Health-related quality of life in congenital heart disease surgery patients in Pakistan: protocol for a mixed-methods study. BMJ Open 2017; 7:e018046. [PMID: 29084799 PMCID: PMC5665301 DOI: 10.1136/bmjopen-2017-018046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Reduced health-related quality of life (HRQOL) has been reported in postoperative patients with congenital heart disease (CHD). However, there is a paucity of data from low-income and middle-income countries (LMIC). Differences in sociodemographics and sociocultural contexts may influence HRQOL. This protocol paper describes a study exploring HRQOL in surgical patients with CHD from a tertiary hospital in Pakistan. The study findings will assist development of strategies to improve HRQOL in a resource-constrained context. METHODS AND ANALYSIS This prospective, concurrent triangulation, mixed-methods study aims to compare HRQOL of postsurgery patients with CHD with age-matched healthy siblings and to identify HRQOL predictors. A qualitative component aims to further understand HRQOL data by exploring the experiences related to CHD surgery for patients and parents. Participants include patients with CHD (a minimum of n~95) with at least 1-year postsurgery follow-up and no chromosomal abnormality, their parents and age-matched, healthy siblings. PedsQL 4.0 Generic Core Scales, PedsQL Cognitive Functioning Scale and PedsQL 3.0 Cardiac Module will measure HRQOL. Clinical/surgical data will be retrieved from patients' medical files. Student's t-test will be used to compare the difference in the means of HRQOL between CHD and siblings. Multiple regression will identify HRQOL predictors. A subsample of enrolled patients (n~20) and parents (n~20) from the quantitative arm will be engaged in semistructured qualitative interviews, which will be analysed using directed content analysis. Anticipated challenges include patient recruitment due to irregular follow-up compliance. Translation of data collection tools to the Urdu language and back-translation of interviews increases the study complexity. ETHICS AND DISSEMINATION Ethics approval has been obtained from The Aga Khan University, Pakistan (3737-Ped-ERC-15). Study findings will be published in peer-reviewed journals and presented at national and international conferences.
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Affiliation(s)
- Laila Akbar Ladak
- Charles Perkins Centre, Faculty of Nursing, The University of Sydney, Camperdown, New South Wales, Australia
| | - Babar Sultan Hasan
- Department of Pediatrics and Child health, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Janice Gullick
- Faculty of Nursing, The University of Sydney, Camperdown, New South Wales, Australia
| | - Khadija Awais
- Medical College, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Ahmed Abdullah
- Medical College, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Robyn Gallagher
- Charles Perkins Centre, Faculty of Nursing, The University of Sydney, Camperdown, New South Wales, Australia
- Faculty of Health, University of Technology, Sydney, New South Wales, Australia
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Affiliation(s)
- Raman Krishna Kumar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Center, Cochin, Kerala, India
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