Previous work has shown that virtual reality (VR) curricula can improve basic understanding of congenital heart disease. The efficacy of using VR to teach more complex cardiac anatomy and physiology, such as hypoplastic left heart syndrome (HLHS), is unknown. First-year fellows from thirteen pediatric cardiology fellowship programs participated in this study and were included in an intervention group or a control group. The intervention group completed the Michigan Anatomic Congenital Heart in 3D (MACH-3) curriculum. Both groups then completed a validated assessment tool. The total assessment score was calculated by summing the number of questions that participants answered correctly, ranging from 0 to 29. The difference in total assessment scores between the groups was examined using two-sample t-test and Cohen’s d effect size. A total of 56 fellows were included in the analysis. Participants in the intervention group achieved higher mean total assessment scores (n = 25, 23.8 ± 3.0 questions correct out of 29) than those in the control group (n = 31, 21.7 ± 3.9 questions correct) (p = 0.04), with a moderate effect size of 0.58. Most participants in the intervention group reported the curriculum was easy to use (96

This study aimed to assess the impact of a virtual reality (VR) educational curriculum on the knowledge of congenital heart disease (CHD) among medical students during their pediatric clerkship. A multi-center study was conducted involving medical students from two large academic medical centers. Participants engaged in the Stanford Virtual Heart (SVH) educational program during their pediatric clerkship from July 2020 to September 2021. The study employed a stratified approach for group assignment based on timing of enrollment, with Center 1 stratifying by the first or second half of the academic year and Center 2 by month-long rotations. A validated 27-question assessment tool focused on six common CHDs was administered, with the intervention group completing the SVH before the assessment and the control group completing the SVH after the assessment. Additionally, a qualitative survey gauging the participants’ experience was conducted. Results were compared between the intervention and control groups. A total of 373 medical students (179 intervention and 194 control) participated in the study. The intervention group exhibited significantly better performance on the assessment compared to the control group across both medical centers (P value < .0001). More than 92

OBJECTIVES:IV calcium is used frequently in the pediatric cardiovascular ICU (CVICU) for neonates and infants undergoing congenital heart surgery (CHS). Since critical illness is associated with abnormal cellular calcium handling and adverse effects induced by hypercalcemia, we aimed to: describe calcium use across three CVICUs; determine explanatory factors related to hypercalcemia and calcium administration; and evaluate associations with outcome. DESIGN:Retrospective cohort analysis from January 2020 to December 2022. SETTING:Three university affiliated CVICUs. PATIENTS:Children younger than 6 months undergoing CHS receiving postoperative monitoring of ionized calcium (iCa). INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Average iCa for every 24-hour period was calculated from tests drawn during the first 72 hours after CHS. Of 276 infants evaluated, 119 (43%) were neonates, 62 (23%) underwent The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category 4 and 5 surgery, and 44 (16%) had single ventricle physiology. Median (interquartile range) age was 50 days (8-113 d). IV calcium utilization differed between centers, with calcium administered in 21%, 62%, and 96% of cohorts ( p < 0.001) at respective hospitals. Hypercalcemia was more prevalent in neonates ( p = 0.02), patients with longer cardiopulmonary bypass times ( p = 0.02), and patients with higher postoperative Vasoactive-Inotrope Scores ( p = 0.001). Children receiving top 10% of total calcium administration (compared with those receiving some calcium and no calcium) were younger ( p < 0.001), experienced higher rates of cardiac arrest ( p = 0.02), longer CVICU length of stay (LOS; p < 0.001), and lower survival rates ( p < 0.001). In multivariable analyses, we failed to identify associations between hypercalcemia and receiving top 10% calcium administration with LOS or mechanical ventilation duration. CONCLUSIONS:In 2020-2022, post-CHS calcium management in neonates/infants varied across our three CVICUs. Increased calcium administration and hypercalcemia occurred in high-risk populations (e.g., neonates, STAT ≥ 4 category). Future experimental designs are needed to better understand these relationships and optimize CVICU postoperative calcium management.

Background: A 3-dimensional understanding of hypoplastic left heart syndrome (HLHS) and its stages of surgical palliation is crucial for pediatric cardiology trainees. Virtual reality has been used in surgical and medical fields for teaching of anatomy and physiology. An HLHS virtual reality curriculum is under development and requires a validated method to measure knowledge acquisition. Objectives: Develop and validate a multimedia assessment tool aimed at evaluating trainee knowledge of HLHS anatomy, physiology, and clinical concepts. Methods: Educational domains across each stage of HLHS palliation were identified, including anatomy, physiology, and important clinical concepts. Six cardiologists and fellows developed multiple-choice multimedia questions based on the educational domains. Six content experts took the assessment, rated question relevance to educational domains, and provided qualitative feedback. An item-level content validity index (I-CVI) was calculated for each question. Any questions with <= 50 % correct responses or I-CVI <0.78 was removed. Scale-level content validity index (S-CVI) was determined for the final assessment tool, and S-CVI >= 0.90 was deemed excellent. Results: A 33-question assessment tool was developed and distributed to the content experts. The average score was 97.0 %, with only four questions having incorrect answers. No questions had <= 50 % correct responses. I-CVI was <0.78 for two questions, and one question was removed due to repetition. The S-CVI was 0.97. Qualitative feedback revealed two themes that were subsequently addressed: marginal image and video quality for certain questions and the exclusive use of hemi-Fontan and bidirectional Glenn to describe stage II procedures. Following these changes, a final 30-question validated assessment tool was created. Conclusion: Evaluation of new curricula is aided by use of validated methods for assessment. Here, we demonstrate an effective iterative method for developing and validating an assessment tool to evaluate trainee knowledge of HLHS and its stages of surgical palliation.

AbstractObjectives:Virtual reality has emerged as a unique educational modality for medical trainees. However, incorporation of virtual reality curricula into formal training programmes has been limited. We describe a multi-centre effort to develop, implement, and evaluate the efficacy of a virtual reality curriculum for residents participating in paediatric cardiology rotations.Methods:A virtual reality software program (“The Stanford Virtual Heart”) was utilised. Users are placed “inside the heart” and explore non-traditional views of cardiac anatomy. Modules for six common congenital heart lesions were developed, including narrative scripts. A prospective case–control study was performed involving three large paediatric residency programmes. From July 2018 to June 2019, trainees participating in an outpatient cardiology rotation completed a 27-question, validated assessment tool. From July 2019 to February 2020, trainees completed the virtual reality curriculum and assessment tool during their cardiology rotation. Qualitative feedback on the virtual reality experience was also gathered. Intervention and control group performances were compared using univariate analyses.Results:There were 80 trainees in the control group and 52 in the intervention group. Trainees in the intervention group achieved higher scores on the assessment (20.4 ± 2.9 versus 18.8 ± 3.8 out of 27 questions answered correctly, p = 0.01). Further analysis showed significant improvement in the intervention group for questions specifically testing visuospatial concepts. In total, 100% of users recommended integration of the programme into the residency curriculum.Conclusions:Virtual reality is an effective and well-received adjunct to clinical curricula for residents participating in paediatric cardiology rotations. Our results support continued virtual reality use and expansion to include other trainees.

Improvement in congenital heart disease (CHD) outcomes has created a growing population of adolescents and young adults with unique health needs that require thoughtful transition planning and eventual transfer of care to an adult provider. Often, poor health literacy and limited resources can lead to interrupted care, which places them at risk for adverse health-related consequences. In 2019, the Wisconsin Adult Congenital Heart Disease transition program partnered with Stanford Virtual Heart (SVH), a virtual reality (VR) platform, to allow young adult patients to learn about their CHD in a clinic-based setting. We completed a single-center pilot study to evaluate these patients’ experience and perceptions to using VR during their transition education. At an initial transition visit, we used an immediate post-VR experience survey, scored using Likert scales of 1–5 (1 = strongly disagree, 5 = strongly agree). Twenty-two patients (13 males) between the ages of 16 and 19 participated. Lesions included pulmonary stenosis, Tetralogy of Fallot, atrial and ventricular septal defect, coarctation, aortic stenosis, hypoplastic left heart syndrome, and patent ductus arteriosus. Likert averages were 4.7 for finding VR helped with understanding their heart lesion, 4.6 for finding VR helped with understanding their heart surgery, 4.7 for enjoying the VR heart simulation, and 4.6 for finding that it was a good use of time. This study demonstrates that adolescents enjoyed using SVH and found it helpful. Clinical implementation shows promise as a plausible adjunct tool for transition education.

Blumenfeld YJ, et al. BMJ Innov 2022;0:1–3. doi:10.1136/bmjinnov-2021-000799 Obstetrics & Gynecology, Stanford University School of Medicine, Stanford, California, USA Cardiology, Stanford University School of Medicine, Stanford, California, USA Lighthaus, Inc, San Francisco, California, USA Pediatrics, Stanford University School of Medicine, Stanford, California, USA Surgery, Stanford University School of Medicine, Stanford, California, USA Neurosurgery, Stanford University School of Medicine, Stanford, California, USA Obstetrics & Gynecology, Baylor College of Medicine, Houston, Texas, USA

Abstract Background: Understanding how cardiovascular structure and physiology guide management is critically important in paediatric cardiology. However, few validated educational tools are available to assess trainee knowledge. To address this deficit, paediatric cardiologists and fellows from four institutions collaborated to develop a multimedia assessment tool for use with medical students and paediatric residents. This tool was developed in support of a novel 3-dimensional virtual reality curriculum created by our group. Methods: Educational domains were identified, and questions were iteratively developed by a group of clinicians from multiple centres to assess understanding of key concepts. To evaluate content validity, content experts completed the assessment and reviewed items, rating item relevance to educational domains using a 4-point Likert scale. An item-level content validity index was calculated for each question, and a scale-level content validity index was calculated for the assessment tool, with scores of ≥0.78 and ≥0.90, respectively, representing excellent content validity. Results: The mean content expert assessment score was 92% (range 88–97%). Two questions yielded ≤50% correct content expert answers. The item-level content validity index for 29 out of 32 questions was ≥0.78, and the scale-level content validity index was 0.92. Qualitative feedback included suggestions for future improvement. Questions with ≤50% content expert agreement and item-level content validity index scores <0.78 were removed, yielding a 27-question assessment tool. Conclusions: We describe a multi-centre effort to create and validate a multimedia assessment tool which may be implemented within paediatric trainee cardiology curricula. Future efforts may focus on content refinement and expansion to include additional educational domains.

Background: Venoarterial extracorporeal membrane oxygenation (ECMO) supports patients with advanced cardiac dysfunction; however, mortality occurs in a significant subset of patients. The authors performed a multicenter, prospective study to determine hemodynamic and echocardiographic predictors of mortality in children placed on ECMO for cardiac support.Methods: Over 8 years, six heart centers prospectively assessed echocardiographic and hemodynamic vari-ables on full and minimum ECMO flow. Sixty-three patients were enrolled, ranging in age from 1 day to 16 years. Hemodynamic measurements included heart rate, vasoactive inotropic score, arteriovenous oxygen difference, pulse pressure, and lactate. Echocardiographic variables included shortening fraction, ejection fraction (EF), right ventricular fractional area change, outflow tract Doppler-derived stroke distance (veloc-ity-time integral [VTI]), and degree of atrioventricular valve regurgitation. Patients were stratified into two groups: those who were able to wean within 48 hours of assessment and survived without ventricular assist devices or orthotopic heart transplantation (successful wean group) and those with unsuccessful weaning. For each patient, variables were compared between full and minimum ECMO flow for each group.Results: Thirty-eight patients (60%) formed the unsuccessful group (two with ventricular assist devices, four with orthotopic heart transplantation, 24 deaths), and 25 constituted the successful wean group. At minimum flow, higher EF (53 & PLUSMN; 16% vs 40 & PLUSMN; 20%, P = .0094), less mitral regurgitation (0.8 & PLUSMN; 0.9 vs 1.4 & PLUSMN; 0.9, P = .0329), and lower central venous pressure (12.0 & PLUSMN; 3.9 vs 14.7 & PLUSMN; 5.4 mm Hg), along with higher VTI (9.0 & PLUSMN; 2.9 vs 6.8 & PLUSMN; 3.7 cm, P = .0154), correlated successful weaning. A longer duration of ECMO (8 vs 5 days, P < .0002) was associated with unsuccessful weaning. Multivariate logistic regression predicted minimum-flow EF and VTI to independently predict successful weaning with cutoff values by receiver operating characteristic analysis of EF > 41% (area under the curve, 0.712; P = .0005) and VTI > 7.9 cm (area under the curve, 0.729; P = .0010). Conclusions: Diminished VTI or EF during ECMO weaning predicts the need for orthotopic heart transplanta-tion or ventricular assist device support or death in children on ECMO for cardiac dysfunction. Increased post -wean central venous pressure or mitral regurgitation along with a prolonged ECMO course also predicted these adverse outcomes. These measurements should be used to help discriminate which patients will require alternative methods of circulatory support for survival. (J Am Soc Echocardiogr 2023;36:233-41.)

BACKGROUND:The transition from residency to paediatric cardiology fellowship is challenging due to the new knowledge and technical skills required. Online learning can be an effective didactic modality that can be widely accessed by trainees. We sought to evaluate the effectiveness of a paediatric cardiology Fellowship Online Preparatory Course prior to the start of fellowship.METHODS:The Online Preparatory Course contained 18 online learning modules covering basic concepts in anatomy, auscultation, echocardiography, catheterisation, cardiovascular intensive care, electrophysiology, pulmonary hypertension, heart failure, and cardiac surgery. Each online learning module included an instructional video with pre-and post-video tests. Participants completed pre- and post-Online Preparatory Course knowledge-based exams and surveys. Pre- and post-Online Preparatory Course survey and knowledge-based examination results were compared via Wilcoxon sign and paired t-tests.RESULTS:151 incoming paediatric cardiology fellows from programmes across the USA participated in the 3 months prior to starting fellowship training between 2017 and 2019. There was significant improvement between pre- and post-video test scores for all 18 online learning modules. There was also significant improvement between pre- and post-Online Preparatory Course exam scores (PRE 43.6 ± 11% versus POST 60.3 ± 10%, p < 0.001). Comparing pre- and post-Online Preparatory Course surveys, there was a statistically significant improvement in the participants' comfort level in 35 of 36 (97%) assessment areas. Nearly all participants (98%) agreed or strongly agreed that the Online Preparatory Course was a valuable learning experience and helped alleviate some anxieties (77% agreed or strongly agreed) related to starting fellowship.CONCLUSION:An Online Preparatory Course prior to starting fellowship can provide a foundation of knowledge, decrease anxiety, and serve as an effective educational springboard for paediatric cardiology fellows.

This cross-sectional study assesses changes in views of medical scientific articles published in 3 leading medical journals since the start of the COVID-19 pandemic.

Introduction: The transition from residency to subspecialty fellowship in pediatric cardiology is challenging, with the daunting requirement to rapidly acquire a broad scope of knowledge and skill. In 2015, a pediatric cardiology boot camp was designed as an educational tool to help prepare trainees for this transition. Hypothesis: A national pediatric cardiology boot camp consistently improves knowledge and decreases anxiety for prospective fellows. Methods: In late spring each year (2015-2019), a 2.5-day intensive program was provided for trainees prior to beginning fellowship in July. Hands-on, simulation-based experiences were provided on topics including anatomy, auscultation, echocardiography, catheterization, cardiovascular intensive care, electrophysiology, heart failure, pulmonary hypertension, and cardiac surgery. Knowledge based exams and surveys were completed by each participant pre- and post-training. Pre- and post-training exam results were compared via paired t-tests and survey results were compared via Wilcoxon rank sum. Results: Over 5 years 144 participants (72 female, 50%) completed the course, representing 40 fellowship programs in the United States and Canada. In aggregate, significant improvement was seen in participants’ knowledge assessment (pre 45 ± 11% vs. post 71 ± 9%; p<0.0001). Post-intervention tests showed significant increases in knowledge every year, with a similar mean rate of improvement from year to year (25±10%; p=0.15). Participants in 2015 did score higher on both pre and post testing (pre 55±10%, post 85±7%; p<0.0001), but the improvement rate remained consistent. Pre- and post-program surveys showed significant improvement in 38 of 38 domains assessing comfort and anxiety (p<0.001 for each domain). All participants strongly agreed (97%) or agreed (3%) that the boot camp was a valuable learning experience and 98% strongly agreed (66%) or agreed (32%) that boot camp alleviated anxieties about starting fellowship. Conclusions: The Pediatric Cardiology Boot Camp provides a significant and reproducible educational benefit to participants nationwide. This intensive program simultaneously improves learners’ knowledge and alleviates anxiety as they transition to subspecialty training.

3D visualization technologies have evolved to become a mainstay in the management of congenital heart disease (CHD) with a growing presence within multiple facets. Printed and virtual 3D models allow for a more comprehensive approach to educating trainees and care team members. Computational fluid dynamics can take 3D modeling to the next level, by predicting post-procedural outcomes and helping to determine surgical approach. 3D printing and extended reality are developing resources for pre-procedural planning and intra-procedural guidance with the potential to revolutionize decision-making and procedural success. Challenges still remain within existing technologies and their applications to the CHD field. Addressing these gaps, both by those within and outside of CHD, will transform education and patient care within our field.

During kidney transplantation, the transplanted kidney undergoes ischemia reperfusion injury, with adenosine being a major mediator. This study aimed to assess whether aminophylline, an adenosine receptor antagonist, improves early graft function and reduces incidence of delayed graft function (DGF) and slow graft function (SGF). Single center, double-blinded, placebo-controlled randomized clinical trial. Pediatric patients admitted for renal transplantation from donation after brain death donors were randomized into a treatment arm receiving aminophylline and a placebo arm receiving normal saline infusions. Primary outcome was estimated glomerular filtration rate (eGFR) at 5 days post-transplant. Secondary outcomes were rates of DGF/SGF and urinary neutrophil gelatinase–associated lipocalin (NGAL) levels. Twenty-three patients were randomized to aminophylline and 27 to placebo. There was no difference in day 5 eGFR, rate of DGF/SGF, or urine NGAL/Creatinine level between aminophylline vs. placebo arm (eGFR 67.39 ± 38.9 ml/min/1.73m2 vs. 80.48 ± 52.1 ml/min/1.73m2p = 0.32; DGF/SGF 5/23 (21.7%) vs. 3/27 (11.1%) p = 0.31; urine NGAL/creatinine 300.5 ng/mg IQR 105.5–1464.5 ng/mg vs. 425.4 ng/mg IQR 140.3–1126.2 ng/mg, p = 0.95; respectively). At 12 months, there was 100% patient survival and 98% graft survival. eGFR at 12 months was similar between the two arms. There was no benefit in peri-transplant aminophylline administration. Our results are limited by small sample size, since sample calculations were based on primary outcome of day 5 eGFR and low rate of DGF/SGF, which may have precluded us from demonstrating efficacy. Further clinical studies are necessary to determine any benefit of aminophylline in kidney transplant recipients, particularly from high-risk donors.

Introduction Congenital heart disease (CHD) is the most common human birth defect. Atrial and ventricular septal defects (ASDs and VSDs) account for >30% of CHD. Three-dimensional (3D) Virtual Reality (VR) heart models convey more spatial information than standard 2D drawings and may enhance a learners understanding of these CHD lesions. We hypothesized that using an innovative approach to teaching CHD anatomy and physiology, supplementing traditional didactic teaching with simulation of ASDs and VSDs in an interactive VR heart model, is both feasible and beneficial to the learner's comprehension and retention of CHD knowledge. Methods This was a prospective, blinded randomized-controlled, crossover study. Pediatric residents were assigned to two groups and completed knowledge tests before and after the teaching sessions. Each group received one-on-one teaching for the 2 CHD lesions: one with VR (interventional session) and one didactic only (control session). Group A received VR teaching for ASDs and lecture only for VSDs, while group B had the opposite. VR sessions incorporated a lecture during guided use of interactive VR heart model using the Oculus Rift TM. Control sessions entailed a didactic lecture supplemented by 2D drawings of the lesion. Residents completed demographic surveys indicating year of training, previous cardiology exposure, and Likert style learner satisfaction questionnaires to evaluate their experience with the VR intervention. To assess retention, the knowledge test was repeated 3-6 months following the study. Analysis of the average percentage correct and average change in percentage correct between the pre-test, post-test, and delayed post-test was performed across the control and intervention groups to assess the efficacy of VR vs. traditional didactic education. We used the non-parametric 2-tailed Student's t-test to assess for statistical difference across groups. Results Of the 20 pediatric residents who participated in the study, 70% were interns. 15% had completed a cardiology rotation during medical school and 30% had completed a cardiology rotation during residency. Average pre-intervention scores were 22 +/- 17% and 31 +/- 8% for the control and VR groups respectively (p=0.38). Average post-intervention scores rose significantly across groups (p = 2.2 × 10-8) but were similar comparing control and VR exposures (83+/-17% and 93+/-8% respectively; p=0.23). Retention test scores were also similar across exposures: 67+/-11% and 57+/-21%, respectively (p=0.27). All residents rated the overall quality of using VR to educate pediatric residents about CHD as excellent. Residents were more likely to feel "very confident" after VR based sessions. Residents also described VR as an engaging educational experience that increased their ability to visualize and describe CHD lesions. Conclusions Using VR is an engaging and effective way to teach residents about CHD and results in knowledge acquisition and retention similar to traditional didactic teaching methods. Future studies with larger number of participants are needed to further explore the use of VR.

PURPOSE OF REVIEW In the field of pediatric cardiology, a sub-specialty that relies on an understanding of complex three-dimensional structures, virtual reality technology may represent a new and exciting tool for both practitioners and patients. Here, the current medical and surgical applications of virtual reality are reviewed and the potential for future applications explored. RECENT FINDINGS Multiple centers have begun to develop software designed to bring virtual reality technology to bear on congenital heart disease. These efforts have focused on surgical preparation, on education of medical providers, and on preparation of patients and their family members for cardiac interventions. Though relatively little statistical evidence for benefit has been generated to date, those studies currently available suggest that virtual reality may provide a significant benefit in all three of these aspects of medical care. SUMMARY The immersive nature of virtual reality meshes well with the learning styles of adult practitioners and promises to be a powerful tool for both pediatric cardiologists and the patients with whose care they are entrusted. Though additional studies are clearly needed, this technology promises to improve the field's ability to prepare providers and patients alike for challenge of treating congenital heart disease.

Background. Previous studies suggest that birth before 39 weeks' gestational age (GA) is associated with higher perioperative mortality and morbidity after congenital heart surgery. The optimal approach to timing of cardiac operation in premature infants remains unclear. We investigated the impact of GA at birth and corrected GA at surgery on postoperative outcomes using the Pediatric Cardiac Critical Care Consortium (PC4) database. Methods. Infants undergoing selected index cardiac operations before the end of the neonatal period were included (n = 2298). GA at birth and corrected GA at the time of the index cardiac operation were used as categorical predictors and fitted as a cubic spline to assess nonlinear relationships. The primary outcome was hospital mortality. Multivariable logistic regression models assessed the association between predictors and outcomes while adjusting for confounders. Results. Late-preterm (34-36 weeks) birth was associated with increased odds of mortality compared with fullterm (39-40 weeks) birth, while early-term (37-38 weeks) birth was not associated with increased mortality. Corrected GA at surgery of 34 to 37 weeks compared with 40 to 44 weeks was associated with increased mortality. When analyzing corrected GA at surgery as a continuous predictor of outcome, odds of survival improve as patients approach 39 weeks corrected GA. Conclusions. Contrary to previous literature, we did not find an association between early-term birth and hospital mortality at PC4 hospitals. Our analysis of the relationship between corrected GA and mortality suggests that operating closer to full-term corrected GA may improve survival. (C) 2021 by The Society of Thoracic Surgeons

Purpose: Pediatric cardiology requires a clear understanding of how cardiovascular structure and physiology guide therapeutic decisions. Pediatric residents have limited exposure to pediatric cardiology during training, and outside of standard clinical oversight, there is a paucity of methods available for assessing trainee knowledge despite the need for trainees to recognize and properly refer these patients in a general pediatric setting after graduation. Here we describe a multicenter collaborative effort to develop and validate a multimedia assessment tool for assessing pediatric residents’ knowledge of key concepts of …

This cross-sectional study examines the association between article citations, Altmetric attention scores, and cumulative page views of pediatric research articles from 4 high-impact medical journals.