Cross-sectional cardiac imaging including cardiac computed tomography (CCT) and cardiac magnetic resonance imaging (CMR) allows three-dimensional imaging of intracardiac and extracardiac structures. This study was undertaken to better understand current European practice of pediatric cardiology cross-sectional imaging, in addition to how training is undertaken in different centers. A structured detailed 64-question survey focusing on cross-sectional imaging was circulated to all Imaging Working Group members of the 95 AEPC affiliated centers. Consultants from 42 centers (44

Lead strangulation is a dangerous complication of epicardial pacemaker insertion. This complication has been increasingly highlighted lately. Our institution has recently identified four cases over the past five years. This study’s aim was to 1) identify risk factors for strangulation and 2) prospectively screen existing epicardial pacemaker patients for unrecognized strangulation or features that would prompt closer review. Patients known to the pacemaker clinic with epicardial pacemakers inserted from 2005 to 2023 were included. Electronic health records were used to locate all subjects and gather data. Risk factors were identified using Firth’s penalized method of logistic regression. Forty-five patients were included, of which four (8.8

In Northern Ireland, approximately 200 babies per year are born with congenital heart disease. Although the incidence of congenital heart disease and other pediatric cardiac pathology remains largely static, there is anecdotal evidence to suggest that the number of referrals for specialist assessment continues to increase. The general impression is that nonspecialists are increasingly reluctant to provide reassurance or take responsibility for patients presenting with symptoms of possible cardiac etiology, and such increased demand has obvious implications for allocation of limited resources. We aimed to determine the volume and range of outpatient referrals to tertiary pediatric cardiology services.

Clinical introduction A young man attended the adult congenital heart disease clinic for routine follow-up. He had a diagnosis of transposition of the great arteries (TGA) and underwent a Senning procedure at 10 months of age. He had remained well over the intervening years, was fully saturated, with a normal exercise tolerance, no cardiovascular symptoms and no history of arrhythmia or symptoms suggesting thromboembolic events. Transthoracic echocardiogram is shown in figure 1A and cardiac MRI image in figure 1B. Question Which of the following is the most likely diagnosis? Intact atrial pathways Secundum atrial septal defect Baffle leak Primum atrial septal defect Baffle obstruction

Background There is a significant body of adult congenital patients born with transposition of the great arteries (TGA) who have undergone Mustard or Senning procedures requiring follow up. Long-term complications relating to the intra atrial baffles are frequent and baffle leaks may cause significant desaturation, exercise intolerance and increased risk of paradoxical emboli. However the clinical consequence of a baffle leak is often poorly understood and in some cases their presence may prove beneficial to the patient. We describe four cases in whom the decision to eliminate an atrial baffle leak was not clear-cut. Findings Four male patients, mean age 27 years, with a history of TGA underwent a Senning procedure in infancy (mean age 8 months). All patients were NYHA class 1, in sinus rhythm with no history of embolic events. Significant baffle leaks were identified on MRI and confirmed at cardiac catheterisation. Calculated Qp:Qs ranged from 1.5–3:1. Pulmonary artery pressure was normal in all cases. All 4 patients had a dilated left ventricle with well-preserved function and, interestingly, had a systemic right ventricle of relatively normal size with good function. Discussion A significant baffle leak, which behaves like an atrial septal defect, places a volume load on the posterior subpulmonary left ventricle. We postulate that this may actually be beneficial in supporting systemic right ventricular function. For a subset of patients intervention to abolish the leak could potentially precipitate right ventricular dysfunction. This must be offset against the potential implications of a significant left to right shunt. Careful investigation is required to appropriately diagnose, counsel and follow this patient group.

A Cost Analysis of a Remote Home Support Programme for Infants with Major Congenital Heart Disease: Evidence from a Randomized Controlled Trial Objective: Paediatric cardiology is a highly centralised subspecialty with patients living often living large distances from the tertiary care centre. A tele homecare programme for infants with major congenital heart disease (CHD) was devised to support patients and families during the stressful and vulnerable period following discharge from hospital. This study aimed to describe the costs and potential savings of a telemedicine home support programme for infants with major congenital heart disease (CHD). Methods: A randomized controlled trial was performed at a UK tertiary paediatric cardiology centre. Infants with major CHD discharged home were randomized to one of three groups: Two intervention groups (Video support and Telephone support) and one control group (standard care). Patients in the two intervention groups received regular, standardised remote consultations. Video support initially provided by ISDN lines and later by a home broadband (IP) connection. The main outcome measure was a comparison of total cost to NHS of participants including cost of study interventions and health service utilisation.

Editor, In the present era, demands on the specialist services provided in paediatric cardiology centres have increased dramatically1, 2 . We aimed to determine the frequency and basis for inpatient consultation with the paediatric cardiology service in a tertiary teaching hospital. Information regarding new patient referral activity in the Department of Paediatric Cardiology, RBHSC was collected prospectively Monday to Friday from 9am to 5pm during a 3-month period using a proforma Ninety-six new patient referrals were made, 77 were formally reviewed. The mean age at referral was 2 years (range birth to 17 years). The most common reasons for referral were identification of a murmur (33.3%) or for assessment of a condition likely to be associated with congenital heart disease (31.3%). Reasons for referral are illustrated in Figure 1. Almost two thirds (65.6%) of referrals were made from the RBHSC site, significantly more than any other peripheral hospital site (p < 0.05). However, there were no significant differences in the reason for referral between RBHSC and non-RBHSC sites (Chi-squared 0.21). Fig 1 Indications for referral to Paediatric Cardiology. Of all the patients formally reviewed (n = 77), only five (7%) had major congenital heart disease (CHD) with diagnoses of hypoplastic left heart x2, coarctation, pulmonary atresia VSD and a large primum ASD. Eighteen patients (23%) had minor CHD not likely to require any intervention (e.g. small muscular VSD), 10% had features of normal transition from foetal circulation such as patent ductus arteriosus (PDA). Diagnoses reached are shown in Figure 2. A large number of patients (66.7%) were referred with incomplete first line investigations (i.e. CXR, ECG, measurement of saturations and blood pressure). Fig 2 Paediatric Cardiology diagnoses. Triaging and managing of referrals represents a significant burden for junior medical staff on the paediatric cardiology ward and can potentially impact on level of care provided to inpatients. Proximity to the service appears to inappropriately increase number of referrals made although there is no difference in actual reason for referral. Similar to the current literature, few referrals yield significant pathology and the most frequent reason for referral remains evaluation of a murmur2. 3. Limited information available at time of referral makes it difficult to prioritise the patient in a proper fashion and may make the whole process more time consuming. We believe there is a requirement for further education of paediatric trainees regarding appropriate work-up of patients and which conditions require inpatient consultation.

In 2003, the paediatric cardiology department at the Royal Belfast Hospital for Sick Children (RBHSC) piloted home support for infants with major congenital heart disease based on videoconference consultations. The videoconferencing used an ISDN 6 link (3 ISDN lines aggregated to provide a bandwidth of 384 kbit/s) installed in each family’s home. Following the success of this pilot trial, a randomised controlled trial of the home support programme was initiated in 2005 using ISDN 6. During the 2000s, Internet provision in the community accelerated, both in terms of availability and increasing bandwidths. We therefore began pilot tests using an ADSL connection, ultimately switching from ISDN to ADSL transmission for the telecardiology work. The present study compared the quality of remote consultations achieved with the two modalities.

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: 728 pound/patient).Conclusions CHD is accurately diagnosed by real-time 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.

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).

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.

BACKGROUND:Centralization of pediatric cardiology services into a small number of tertiary centers and the particular stress that accompanies diagnosis and surgical management of severe congenital heart disease (CHD) renders psychological support for families and clinical monitoring of patients following discharge increasingly important. Telemedicine has an increasing role in clinical and academic medicine. Improvements in quality and reliability of videoconferencing systems have allowed this to become a useful diagnostic tool.OBJECTIVE:This study aimed to assess the benefits of home monitoring by videoconferencing compared with contacting by telephone only, in terms of decreasing anxiety levels and clinical monitoring in the postdischarge period.METHODS:We performed a prospective, controlled study of children with a recent diagnosis of severe CHD and those recovering from palliative or corrective surgery for severe CHD. We used standardized anxiety scores to assess anxiety after discharge in families followed up by home videoconferencing or telephone calls and assessed the clinical information available through videoconferencing or telephone calls by structured questionnaires.RESULTS:Videoconferencing decreased anxiety levels compared with telephone calls (P < .05). Improved clinical information was available in the videoconferencing group, resulting in more appropriate and timely hospital attendance.CONCLUSION:Videoconferencing is acceptable to parents and physicians and provides a more effective form of follow-up in terms of clinical observation and parental anxiety levels.