Sore knee - why and when to call a cardiologist

A young girl received a diagnosis of septic arthritis of the knee unresponsive to standard medical and surgical treatment. We report the patient's clinical journey with clinical commentary throughout, underlying the importance of differential diagnosis that may open several scenarios and a different final diagnosis accordingly. Finally, we will discuss the treatment and management of the patient's final diagnosis.

Exercise prescription improves exercise tolerance in young children with CHD: a randomised clinical trial

Objective

The main objective of this study was to ascertain if a structured intervention programme can improve the biophysical health of young children with congenital heart disease (CHD). The primary end point was an increase in measureable physical activity levels following the intervention.

Methods

Patients aged 5–10 years with CHD were identified and invited to participate. Participants completed a baseline biophysical assessment, including a formal exercise stress test and daily activity monitoring using an accelerometer. Following randomisation, the intervention group attended a 1 day education session and received an individual written exercise plan to be continued over the 4-month intervention period. The control group continued with their usual level of care. After 4 months, all participants were reassessed in the same manner as at baseline.

Results

One hundred and sixty-three participants (mean age 8.4 years) were recruited, 100 of whom were male (61.3%). At baseline, the majority of the children were active with good exercise tolerance. The cyanotic palliated subgroup participants, however, were found to have lower levels of daily activity and significantly limited peak exercise performance compared with the other subgroups. One hundred and fifty-two participants (93.2%) attended for reassessment. Following the intervention, there was a significant improvement in peak exercise capacity in the intervention group. There was also a trend towards increased daily activity levels.

Conclusion

Overall physical activity levels are well preserved in the majority of young children with CHD. A structured intervention programme significantly increased peak exercise capacity and improved attitudes towards positive lifestyle changes.

Retrospective UK multicentre study of the pregnancy outcomes of women with a Fontan repair

Background

The population of women of childbearing age palliated with a Fontan repair is increasing. The aim of this study was to describe the progress of pregnancy and its outcome in a cohort of patients with a Fontan circulation in the UK.

Methods

A retrospective study of women with a Fontan circulation delivering between January 2005 and November 2016 in 10 specialist adult congenital heart disease centres in the UK.

Results

50 women had 124 pregnancies, resulting in 68 (54.8%) miscarriages, 2 terminations of pregnancy, 1 intrauterine death (at 30 weeks), 53 (42.7%) live births and 4 neonatal deaths. Cardiac complications in pregnancies with a live birth included heart failure (n=7, 13.5%), arrhythmia (n=6, 11.3%) and pulmonary embolism (n=1, 1.9%). Very low baseline maternal oxygen saturations at first obstetric review were associated with miscarriage. All eight women with saturations of less than 85% miscarried, compared with 60 of 116 (51.7%) who had baseline saturations of ≥85% (p=0.008). Obstetric and neonatal complications were common: preterm delivery (n=39, 72.2%), small for gestational age (<10th percentile, n=30, 55.6%; <5th centile, n=19, 35.2%) and postpartum haemorrhage (n=23, 42.6%). There were no maternal deaths in the study period.

Conclusion

Women with a Fontan circulation have a high rate of miscarriage and, even if pregnancy progresses to a viable gestational age, a high rate of obstetric and neonatal complications.

Removal of scatter radiation in paediatric cardiac catheterisation: a randomised controlled clinical trial

OBJECTIVE

This study sought to determine if DNA integrity was compromised by ionising radiation from paediatric cardiac catheterisations and if dose optimisation techniques allowed DNA integrity to be maintained.

MATERIALS AND METHODS

Children were imaged using either: (i) an anti-scatter grid (current departmental protocol), (ii) no anti-scatter grid or, (iii) no anti-scatter grid and a 15 cm air-gap between the child and the x-ray detector. Dose area product and image quality were assessed, lifetime attributable cancer risk estimates were calculated and DNA double-strand breakages quantified using the γH2AX assay.

RESULTS

Consent was obtained from 70 parents/guardians/children. Image quality was sufficient for each procedure performed. Removal of the anti-scatter grid resulted in dose reductions of 20% (no anti-scatter grid) and 30% (15 cm air-gap), DNA double-strand break reductions of 30% (no anti-scatter grid) and 20% (15 cm air-gap) and a reduction of radiation-induced cancer mortality risk of up to 45%.

CONCLUSION

Radiation doses received during paediatric cardiac catheterisation procedures resulted in a significant increase in DNA damage while maintaining acceptable image quality and diagnostic efficacy. It is feasible to remove the anti-scatter grid resulting in a reduction in DNA damage to the patient. The γH2AX assay may be used for assessment of dose optimisation strategies in children.

Perinatal management of major congenital heart disease

Congenital heart disease (CHD) is the most common form of congenital anomaly. Prenatal diagnosis of CHD has been associated with decreased morbidity and mortality for some forms of major CHD. As most cases of major CHD are not identified prenatally, clinical examination of the newborn and pulse oximetry are also important means of identifying more cases. Clinicians must suspect CHD as a diagnosis in a cyanosed or shocked neonate and be familiar with appropriate management, namely the commencement of prostaglandin if a duct dependent cardiac lesion is suspected. Telemedicine can aid prompt diagnosis of CHD and therefore direct appropriate management.

Survey of paediatricians' opinions on a regional paediatric telecardiology service

AIM

The aim of this study is to evaluate consultant general paediatricians' opinions of a UK paediatric telecardiology service.

METHODS

A structured questionnaire was developed and sent to all consultant paediatricians working in a district general hospital in Northern Ireland.

RESULTS

Paediatricians (n = 35) regarded the regional paediatric telecardiology service as very useful and of good value for money. Paediatricans in hospitals without access to telecardiology expressed a desire to join the network (86%, 12/14). More frequent use of the paediatric telecardiology service was associated with increased confidence in performing echocardiography and using the telemedicine equipment and a special interest in neonatology. The vast majority of paediatricians (32/35, 91%) believed that there should be a shared clinical responsibility for the patient following a teleconsultation. A total of 33/35 (94%) stated that the telephone costs of the consultation should be paid by the paediatrician but that the professional time of the cardiologist should be paid by the tertiary centre (29/35, 83%).

CONCLUSIONS

Paediatricians have consistently positive experiences of a regional paediatric telecardiology service. They believe that clinical responsibility is shared, and there should not be any professional fee for telemedicine activities.

Primitive hepatic venous plexus in a child with scimitar syndrome and pulmonary sequestration

We report a case of scimitar syndrome with pulmonary sequestration, persistent primitive hepatic venous plexus and stenosis of the inferior vena cava in a child presenting with failure to thrive. Such associations are rare but may have implications when planning interventions for patients with complex congenital heart disease.

A randomised trial of a remote home support programme for infants with major congenital heart disease

OBJECTIVES

To assess the sustainability, clinical utility and acceptability to clinicians and parents of a tele-homecare programme for infants with major congenital heart disease (CHD), and to evaluate the impact on healthcare resource use.

DESIGN

Randomised control trial.

SETTING

UK tertiary congenital cardiac centre.

PARTICIPANTS

83 infants with major CHD.

INTERVENTION

Participants were randomised to one of three groups: video-conferencing support (n=35), telephone support (n=24) and a control group (n=24). Patients in the two intervention groups received regular, standardised remote consultations. Video-conferences (VCs) were facilitated by Integrated Systems Digital Network lines and replaced by home broadband connections later in the study.

MAIN OUTCOME MEASURES

Healthcare resource use, utilisation including hospitalisation, clinicians' opinions on utility and quality of interventions, parental opinions on quality of interventions.

RESULTS

Clinicians were more confident making medical decisions following VCs compared with telephone consultations (p=0.01). Both VC and telephone support were very well received, but parents expressed significantly higher levels of satisfaction with VC support (p=0.001). Healthcare resource use was 37% lower in the video-conferencing group compared with both telephone support and control groups (p<0.001), as was the risk of hospitalisation (p=0.006). Direct health service costs were significantly lower in the video-conferencing group (p<0.05).

CONCLUSIONS

A tele-medicine home support programme for families of infants with major CHD is feasible, sustainable and effective. Home support with video-conferencing is superior to telephone consultations. Parents are highly satisfied with tele-homecare. Tele-homecare significantly reduces health service utilisation and may reduce health service costs.

A fetal telecardiology service: patient preference and socio-economic factors

OBJECTIVE

The aims of this study were to evaluate patients' opinions on a fetal cardiology telemedicine service compared with usual outpatient care, the effect of the telemedicine consultation on maternal anxiety and its impact on travel times and time absent from work.

METHODS

Prospective study over 20 months. Eligible patients attended for routine anomaly scan followed by fetal echocardiogram transmitted to the regional centre with live guidance by a fetal cardiologist, followed by parental counselling. All patients were offered a fetal cardiology appointment at the regional centre. Structured questionnaires assessing maternal satisfaction, travel times/days off and anxiety scores completed at time of both fetal echocardiograms.

RESULTS

Sixty-seven patients were recruited and 66 completed the study. Participants expressed very high satisfaction rates with fetal telecardiology, equivalent to face-to-face consultation. The telecardiology appointments were associated with significantly reduced travel times and days off work (p < 0.01). Expectant mothers expressed a clear inclination for a fetal cardiology appointment at the local hospital facilitated by telemedicine (p < 0.01).

CONCLUSIONS

Fetal telecardiology is highly acceptable to patients and is even preferred compared with travelling to a regional centre. There are additional socio-economic benefits that should encourage the development of remote fetal cardiology services.

Fetal diagnosis of congenital heart disease by telemedicine

OBJECTIVES

This study aimed to evaluate the feasibility, accuracy and user acceptability of performing remote fetal echocardiograms (FEs).

SETTING

A regional fetal cardiology unit and a district general hospital (DGH).

DESIGN

A prospective study over 20 months. An initial FE was performed by a radiographer in the DGH (D1) followed by a second FE transmitted to the regional centre, in real time, via a telemedicine link with live guidance by a fetal cardiologist (D2). A FE was performed later at the regional centre (D3, reference standard). Structured questionnaires were employed to evaluate the technical quality of each tele-link and the radiographers' confidence at performing FE.

RESULTS

69 remote FEs were performed and showed 58 normal hearts and 11 with congenital heart disease (CHD). D2 was accurate in 97% of cases compared with D3 (κ score=0.89) indicating excellent agreement. All tele-links connected at first attempt with a mean study time = 13.9 min. Overall tele-link quality was rated highly (median=4/5). In 94% of tele-links, at least 11/12 components of the FE were confidently assessed. The mean composite radiographer's questionnaire score increased significantly during the study period (p<0.05).

CONCLUSIONS

To date this is the largest study of its kind. CHD can be confidently diagnosed and excluded by remote FE. Radiographers report increased confidence and proficiency following involvement in real-time telemedicine. This application of telemedicine could improve access to fetal cardiology and support radiographers screening for CHD.

Remote diagnosis of congenital heart disease: the impact of telemedicine

OBJECTIVES

To determine the accuracy of remote diagnosis of congenital heart disease (CHD) by real-time transmission of echocardiographic images via integrated services digital network (ISDN) lines, to assess the impact on patient management and examine cost implications.

DESIGN

Prospective comparison of echocardiograms on infants with suspected significant CHD performed as follows: (1) hands-on evaluation and echocardiogram by a paediatrician at a district general hospital (DGH) followed by (2) transmission of the echocardiogram via ISDN 6 with guidance from a paediatric cardiologist and finally (3) hands-on evaluation and echocardiogram by a paediatric cardiologist. The economic analysis compares the cost of patient care associated with the telemedicine service with a hypothetical control group.

SETTING

Neonatal units of three DGH and a UK regional paediatric cardiology unit.

RESULTS

Echocardiograms were transmitted on 124 infants. In five cases scans were inadequate for diagnosis. Of the remaining 119 tele-echocardiograms, a follow-up echocardiogram was performed on 109/119 (92%). Major CHD was diagnosed in 39/109 infants (36%) and minor CHD in 45 (41%). The tele-echo diagnosis was accurate in 96% of cases (kappa=0.89). Unnecessary transfer to the regional unit was avoided in 93/124 patients (75%). Despite relatively high implementation costs, telemedicine care was substantially cheaper than standard care. Each DGH potentially saved money by utilising the telemedicine service (mean saving: pound728/patient).

CONCLUSIONS

CHD is accurately diagnosed by realtime transmission of echocardiograms performed by paediatricians under live guidance and interpretation by a paediatric cardiologist. Remote diagnosis and exclusion of CHD affects patient management and may be cost saving.

Home support for children with complex congenital heart disease using videoconferencing via broadband: initial results

We originally developed a home support service for babies with complex congenital heart disease, in which videoconferencing was delivered via three ISDN lines. We have now investigated the feasibility of using broadband (Internet protocol) transmission instead of ISDN lines. Five patients were enrolled (age range 14-58 days) and 78 videoconferences were conducted over a six-month period. In 70 videoconferences (90%), a successful connection was established at the first attempt. In the last 56 videoconferences a connection bandwidth of 256 kbit/s was consistently achieved. The clinician's opinions of the videoconferences were good. Parental opinions on the videoconferences were very high. There was also a significant reduction in parental anxiety following the video consultations: the median reduction in the STAI score was 6 points (P < 0.05) (n = 78). Home support for infants or children with complex congenital heart disease can be provided successfully by video consultations utilizing home broadband links.

Diagnosis of congenital heart disease in neonates by videoconferencing: an eight-year experience

Summary

Over an eight-year period, echocardiograms were transmitted by ISDN at 384 kbit/s for a total of 132 patients suspected of having congenital heart disease (CHD). Five transmitted scans were inadequate. Hands-on echocardiograms were performed subsequently on 116 of the remaining 127 cases (91%). Major CHD was diagnosed in 42 of the 116 infants (36%) and minor CHD in 49 (42%). The telemedicine diagnosis was accurate in 97% of the cases (kappa = 0.90). There were four diagnostic errors. Transfer to the regional unit was avoided in 95 patients (72%). The present study shows that high diagnostic accuracy is possible using a telemedicine link to transmit images obtained with the assistance of real-time guidance by a paediatric cardiologist. The results also demonstrate the importance of an expert interpreting the echocardiographic images, since the accuracy of diagnosis was considerably improved (the kappa coefficient increased from 0.14 to 0.90).

Down syndrome, achondroplasia and tetralogy of Fallot

This paper describes a female infant with achondroplasia, Down syndrome and tetralogy of Fallot. Down syndrome and achondroplasia were confirmed by karyotyping and presence of a common fibroblast growth factor receptor 3 mutation (Gly380Arg), respectively. The clinical course was complicated by pulmonary hypoplasia and subsequent intractable respiratory failure secondary to the combination of congenital conditions, which resulted in the patient's death at 5 months.

Uncorrected tetralogy of Fallot: adult presentation in the 61st year of life

Tetralogy of Fallot (TOF) is the commonest form of cyanotic congenital heart defect after infancy [Brickner ME, Hillis LD, Lange RA. Congenital Heart Disease in Adults-Second of Two Parts. NEJM 2000; 342(5):334-342.]. There are few studies assessing the risk of surgical correction in adult patients and long-term survival into the fourth decade of life is rare. The case history is described of a 61-year old female presenting with probable viral myocarditis. Subsequent investigations revealed an underlying diagnosis of tetralogy of Fallot. The patient remains asymptomatic despite persistent hypoxia. Potential factors contributing to longevity in this case are relatively good pulmonary blood flow via large branch pulmonary arteries, and the possible gradual development of right ventricular outflow tract obstruction over a long time period.

Inaccurate electrocardiographic interpretation of long QT: the majority of physicians cannot recognize a long QT when they see one

BACKGROUND

Physicians in all fields of medicine may encounter patients with long QT syndrome (LQTS). It is important to define the percentage of physicians capable of distinguishing QT intervals that are long from those that are normal because LQTS can be lethal when left untreated.

OBJECTIVES

The purpose of this study was to define the percentage of physicians in the different disciplines of medicine who can recognize a long QT when they see one.

METHODS

We presented the ECGs of two patients with LQTS and two healthy females to 902 physicians (25 world-renowned QT experts, 106 arrhythmia specialists, 329 cardiologists, and 442 noncardiologists) from 12 countries. They were asked to measure the QT, calculate the QTc (the QT interval corrected for the heart rate), and determine whether the QT is normal or prolonged.

RESULTS

For patients with LQTS, >80% of arrhythmia experts but <50% of cardiologists and <40% of noncardiologists calculated the QTc correctly. Underestimation of the QTc of patients with LQTS and overestimation of the QTc of healthy patients were common. Interobserver agreement was excellent among QT experts, moderate among arrhythmia experts, and low among cardiologists and noncardiologists (kappa coefficient = 0.82, 0.44, and < 0.3, respectively). Correct classification of all QT intervals as either "long" or "normal" was achieved by 96% of QT experts and 62% of arrhythmia experts, but by only <25% of cardiologists and noncardiologists.

CONCLUSIONS

Most physicians, including many cardiologists, cannot accurately calculate a QTc and cannot correctly identify a long QT.

Transcatheter occlusion of the patent ductus arteriosus: a comparison of two devices

BACKGROUND

Transcatheter occlusion of the arterial duct is a safe and effective alternative to surgical closure. The Rashkind umbrella occluder and the Cook coil are two established devices, although the former is no longer manufactured.

AIMS

To assess any difference in outcomes between the use of the Cook detachable coil and the Rashkind double umbrella in patent ductus arteriosus (PDA) occlusion.

METHODS

A retrospective study of 77 patients in whom PDA occlusion was attempted using the Cook detachable PDA coil from March 1996 to March 2000. A comparison was carried out with patients in whom occlusion was attempted using the Rashkind double umbrella between 1989 and 1996.

RESULTS

The rate of immediate complete occlusion was 24% compared with 29.9% for the Rashkind device. The figure for complete occlusion after 24 hours with the PDA coil was 63% compared with 61.5% in the Rashkind group (p > 0.1). The overall closure rate in the coil group was 72% versus 74.6% for umbrellas.

CONCLUSION

The outcome in terms of complete duct closure using the Cook coil is comparable with figures obtained using the Rashkind umbrella. Both devices have a good safety profile in the short and medium-terms.

Incidence and risk factors for ventricular septal defect in "low risk" neonates

AIMS

To quantify the incidence of ventricular septal defect in "low-risk" neonates; and to define any associated risk factors.

METHODS

One hundred and seventy three patients with ventricular septal defects from a scanned population of 3971 clinically normal neonates were compared with scanned controls, considered to be clinically normal. A subset of the group with defects was compared with normal infants delivered over the same period, to identify any seasonal variation.

RESULTS

Ventricular septal defects were detected in 4.36 % of the "scanned" group (173 out of 3971). Ten had perimembranous defects and the remainder apical or muscular lesions. Eleven neonates had multiple defects. The incidence of ventricular septal defect was independent of most tested risk factors. There were significantly more girls in the group with defects compared with the controls (p = 0.004). The defects group also contained fewer infants born during summer months (p = 0.04).

CONCLUSIONS

The incidence of ventricular septal defects was much higher than might be expected, given that "high risk infants" were excluded. The observations that gender and season of birth affect the rate suggest that both genetic and environmental factors may be involved in the aetiology.