Background Early echocardiographic indicators of cardiac remodeling may enhance cardiomyopathy risk prediction in childhood cancer survivors (CCS). Objectives The objective of the study was to assess whether influential echocardiographic measures can be combined to develop a robust cardiomyopathy risk prediction model in CCS. Methods Multicenter retrospective study of ≥1-year CCS with digitally archived surveillance echocardiograms, enrolled cardiomyopathy cases (left ventricular [LV] fractional shortening ≤28% or LV ejection fraction ≤50% on ≥2 occasions) and noncases (≥5-year CCS who maintained fractional shortening ≥ 30% and ejection fraction ≥55% without initiation of cardiac medications). Echocardiograms were centrally quantitated in a blinded fashion. Least absolute shrinkage and selection operator regression identified the most influential 2-year predictors of cardiomyopathy among 27 echocardiographic parameters. Logistic regression was used to generate ORs with 95% CIs. Estimates were applied to the training and test data sets to generate area under the receiver operating characteristic curves (AUC). Results Data from 146 CCS (52 cases; 94 noncases) with a median follow-up of 9.3 years post-cancer diagnosis and a total of 281 echocardiograms were included. A set of 7 echocardiographic measures were identified as the most influential predictors, with AUC of 0.82 (95% CI: 0.74-0.89) and 0.85 (95% CI: 0.74-0.95) in the training and test data sets, respectively. LV end-systolic dimension (ORmm: 1.2; 95% CI: 1.1-1.4), apical 4-chamber longitudinal strain (OR%: 1.2; 95% CI: 1.0-1.3), and septal A’ velocity (ORcm/s: 1.3; 95% CI: 1.1-1.6) were strongly predictive of cardiomyopathy. AUCs were similar if cancer treatment exposures were included. Conclusions Early abnormalities in echocardiographic parameters of structure and function predict subsequent cardiomyopathy in CCS and can identify high-risk survivors who warrant early intervention.

The American College of Cardiology’s Adult Congenital and Pediatric Cardiology Quality Network has developed a metric for assessing comprehensive transthoracic echocardiographic (TTE) exam. This study evaluates the relationship between the study comprehensiveness score (CS) and diagnostic errors in patients undergoing congenital heart surgery. The echocardiography lab quality database at a single-center identified preoperative TTEs with diagnostic errors when compared with transesophageal echocardiograms or direct surgical inspection from 1/1/2018 to 8/1/2023. TTEs without diagnostic errors served as controls (similar age, gender, and surgical risk score). TTEs were assigned a CS by a single blinded reviewer. Diagnostic errors were characterized by types of errors, primary contributors to errors (procedural/conditional, cognitive, technical, patient-and-disease-related factors), severity, and preventability. Of the 2448 TTEs, 159 (6.5

ObjectiveImage quality of fetal echocardiography (FE) has improved in the recent era, but few recent studies have reported the accuracy of FE, specifically in single ventricle (SV) congenital heart disease (CHD). This study aimed to assess the ability of FE to correctly predict SV-CHD postnatal anatomy and physiology in a contemporary cohort.MethodsThe contemporary clinical reports of patients with SV-CHD, in which FE was performed between July 2017 and July 2021, were compared with postnatal echocardiograms from a formal quality assurance program. SV fetuses were grouped by anatomical subtype. Diagnostic errors were designated as major if the error would have caused significant alteration in parental counseling or postnatal management. The remaining errors were classified as minor. Physiological discrepancies, including prostaglandin-E (PGE) dependency, atrioventricular valve regurgitation (AVVR), pulmonary venous obstruction, and restrictive atrial septum (RAS) were assessed by chart review of the postnatal course.ResultsA total of 119 subjects were analyzed. SV subtypes in the cohort included hypoplastic left heart syndrome (HLHS) (n = 68), tricuspid atresia (n = 16), double-inlet left ventricle (n = 12), unbalanced atrioventricular canal (UAVC) (n = 11), heterotaxy (n = 9) and other (n = 3). The rate of major anatomical and physiological errors was low (n = 6 (5.0%)). A higher proportion of minor errors was noted in HLHS and tricuspid atresia, but the differences were not statistically significant. Physiological discrepancies were uncommon, with three major discrepancies, including underestimation of the degree of venous obstruction in one non-HLHS fetus with total anomalous pulmonary venous return, overestimation of RAS in one HLHS fetus and incorrect prediction of PGE dependency in one case false-negative for pulmonary blood flow. No discrepancy in degree of AVVR or RAS affected postnatal care. Minor physiological discrepancies included two false-positive predictions of PGE dependency with one false-positive for ductal-dependent systemic flow and one false-positive for pulmonary blood flow.ConclusionsIn this contemporary review of FE at our center, there was high accuracy in describing anatomical and physiological findings in SV-CHD. Major physiological discrepancies were uncommon but included important cases of false-negative prediction of PGE dependency and underestimation of obstruction of total anomalous pulmonary venous return. These data can inform more accurate counseling of families with SV-CHD fetuses and guide diagnostic improvement efforts. (c) 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Abstract Background Despite routine echocardiographic surveillance for childhood cancer survivors, the ability to predict cardiomyopathy risk in individual patients is limited. We explored the feasibility and optimal processes for machine learning-enhanced cardiomyopathy prediction in survivors using serial echocardiograms from five centers. Methods We designed a series of deep convolutional neural networks (DCNNs) for prediction of cardiomyopathy (shortening fraction ≤ 28% or ejection fraction ≤ 50% on two occasions) for at-risk survivors ≥ 1-year post initial cancer therapy. We built DCNNs with four subsets of echocardiographic data differing in timing relative to case (survivor who developed cardiomyopathy) index diagnosis and two input formats (montages) with differing image selections. We used holdout subsets in a 10-fold cross-validation framework and standard metrics to assess model performance (e.g., F1-score, area under the precision-recall curve [AUPRC]). Performance of the input formats was compared using a combined 5 × 2 cross-validation F-test. Results The dataset included 542 pairs of montages: 171 montage pairs from 45 cases at time of cardiomyopathy diagnosis or pre-diagnosis and 371 pairs from 70 at-risk survivors who didn’t develop cardiomyopathy during follow-up (non-case). The DCNN trained to distinguish between non-case and time of cardiomyopathy diagnosis or pre-diagnosis case montages achieved an AUROC of 0.89 ± 0.02, AUPRC 0.83 ± 0.03, and F1-score: 0.76 ± 0.04. When limited to smaller subsets of case data (e.g., ≥ 1 or 2 years pre-diagnosis), performance worsened. Model input format did not impact performance accuracy across models. Conclusions This methodology is a promising first step toward development of a DCNN capable of accurately differentiating pre-diagnosis versus non-case echocardiograms to predict survivors more likely to develop cardiomyopathy. Graphical Abstract

Objectives: To examine the probability of left ventricular outflow tract (LVOT) reintervention following interrupted aortic arch (IAA) repair in neonates with LVOT obstruction (LVOTO) risk. Methods: This retrospective multicenter study included 150 neonates who underwent IAA repair (2003-2017); 100 of 150 (67%) had isolated IAA repair (with ventricular septal defect closure) and 50 of 150 (33%) had concomitant LVOT intervention: conal muscle resection (n = 16), Ross-Konno (n = 7), and Yasui operation (n = 27: single-stage n = 8, staged n = 19). Demographic and morphologic characteristics were reviewed. Factors associated with LVOT reoperation were explored using multivariable analysis. Results: Concomitant LVOT intervention was more likely in neonates with type B IAA, bicuspid aortic valve, aberrant right subclavian artery, smaller aortic valve annulus, and ascending aorta dimensions. On follow-up, five-year freedom from LVOT reoperation was highest following Ross-Konno (100%), 77% following Yasui (mainly for neo-aortic regurgitation), 77% following isolated IAA repair (mainly for LVOTO), and 47% following IAA repair with concomitant conal resection, P = .033. While all patients had low peak LVOT gradient at time of discharge, those who had conal resection developed higher gradients on follow-up ( P = .007). Ross-Konno and Yasui procedures were associated with higher right ventricular outflow tract (RVOT) reoperation. In the cohort following isolated IAA repair, aortic sinus Z score was associated with LVOT reoperation. Conclusions: Both Yasui and Ross-Konno operations effectively mitigate late LVOTO risk. The highest risk of reintervention for LVOTO was associated with conal muscle resection while the lowest risk is associated with Ross-Konno. The RVOT reoperation risk in patients who had Ross-Konno or Yasui does not seem to affect survival.

Objective Risk stratification of fetuses diagnosed with congenital heart disease (CHD) helps provide a delivery plan and prepare families and medical teams on expected course in the delivery room. Our aim was to assess the accuracy of echocardiographically determined risk-stratification assignments in predicting postnatal cardiac outcomes beyond the delivery room. Study Design This was a retrospective study at a single center evaluating all fetuses with CHD who were risk-stratified by echocardiographically determined level of care (LOC) assignment, ranging from 1a (lowest risk) to 4 (highest risk). All data were collected from January 1, 2017, to November 1, 2021. Outcomes included any unexpected cardiac interventions and neonatal clinical outcomes including in-hospital mortality, the need for prostaglandins or inotropes, and defined critical illness. These outcomes were assessed for each LOC assignment by Fisher's exact test. Results Out of 817 patients assigned a LOC, a total of 747 fetuses were included in our final cohort with a separate subanalysis of 70 fetuses diagnosed with coarctation of the aorta. The sensitivity and specificity were high for all LOC levels in predicting delivery room needs (93–100%). Higher LOC levels (3–4) had a lower positive predictive value (66–67%) indicating a high false-positive rate. Subjects with higher LOC assignments had a greater frequency of critical illness, hospital mortality, need for inotropes, need for neonatal surgical or catheterization interventions, and need for prostaglandins (p < 0.001 for all outcomes). A post-hoc analysis reviewing LOC assignments revealed a greater tendency to over-assign LOC at higher assignments (19% for LOC 3 and 4) compared to lower assignments (4% for LOC 1 and 2). Conclusion Risk stratification based on fetal echocardiography can predict neonatal clinical outcomes and acuity of postnatal management needs. However, there is greater variability in expected clinical events and an expected degree of false positives for those with higher LOC assignments. Key Points

BACKGROUND:A previous multicenter study showed that longitudinal changes in standard cardiac functional parameters were associated with the development of cardiomyopathy in childhood cancer survivors (CCS). Evaluation of the relationship between global longitudinal strain (GLS) changes and cardiomyopathy risk was limited, largely due to lack of quality apical 2- and 3-chamber views in addition to 4-chamber view. We sought to determine whether apical 4-chamber longitudinal strain (A4LS) alone can serve as a suitable surrogate for GLS in this population. METHODS:A4LS and GLS were measured in echocardiograms with acceptable apical 2-, 3-, and 4-chamber views. Correlation was evaluated using Pearson and Spearman coefficients, and agreement was evaluated with Bland-Altman plots. The ability of A4LS to identify normal and abnormal values compared to GLS as the reference was evaluated. RESULTS:Among a total of 632 reviewed echocardiograms, we identified 130 echocardiograms from 56 patients with adequate views (38% female; mean age at cancer diagnosis 8.3 years; mean follow-up 9.4 years). Correlation coefficients between A4LS and GLS were .89 (Pearson) and .85 (Spearman), with Bland-Altman plot of GLS-A4LS showing a mean difference of -.71 ± 1.8. Compared with GLS as the gold standard, A4LS had a sensitivity of 86% (95% CI 79%-93%) and specificity of 82% (69%-95%) when using normal range cutoffs and 90% (82%-97%) and 70% (58%-81%) when using ±2 standard deviations. CONCLUSION:A4LS performs well when compared with GLS in this population. Given the more recent adoption of apical 2- and 3-chamber views in most pediatric echocardiography laboratories, A4LS is a reasonable stand-alone measurement in retrospective analyses of older study cohorts and echocardiogram biorepositories.

Health care providers are at risk of emotional distress and Second Victim Syndrome (SVS). We sought to evaluate the effectiveness of improvements in a system-wide peer support program in reducing emotional distress after an unanticipated adverse event, poor patient outcome, medical error, or patient-related injury. The Second Victim Experience and Support Tool was sent to all intensive care (intensive care unit [ICU]) providers ( n = 900) in our health care system. The current survey results were compared with the same survey from 2020. The period between the surveys included increased peer supporters and awareness of peer support programs, rapid deployment of unit-based support, and the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. The response rate in 2022 increased to 40% ( n = 364) from 28% ( n = 266) in 2020. Respondents did not differ in age, gender, home unit, role, or years of experience. The number of providers who experienced psychological distress (42% to 33%; p = 0.02) and physical distress (26% to 17%; p = 0.01) decreased between surveys. Significant decreases occurred primarily in nurses and respiratory therapists. Consideration of turnover increased from 25% to 33% ( p = 0.01). Desired support did not change between survey periods with "the ability to take time away" (74% and 73%), "a peaceful location to recover" (64% and 70%), and "a respected peer to discuss the details of what happened" (83% and 78%) being most desired. We demonstrate results consistent with the positive impact of a peer support program on staff and provider emotional distress and SVS in our pediatric health care system. A multidisciplinary peer support program is crucial to staff well-being and resilience in high-stress ICU and inpatient environments.

Purpose For patients with congenital heart disease (CHD), the most common birth defect, genetic evaluation is not universally accepted, and current practices are anecdotal. Here, we analyzed genetic evaluation practices across centers, determined diagnostic yield of testing, and identified phenotypic features associated with abnormal results. Methods This is a multicenter cross-sectional study of 5 large children's hospitals, including 2899 children ≤14 months undergoing surgical repair for CHD from 2013 to 2016, followed by multivariate logistics regression analysis. Results Genetic testing occurred in 1607 of 2899 patients (55%). Testing rates differed highly between institutions (42%-78%, P < .001). Choice of testing modality also differed across institutions (ie, chromosomal microarray, 26%-67%, P < .001). Genetic testing was abnormal in 702 of 1607 patients (44%), and no major phenotypic feature drove diagnostic yield. Only 849 patients were seen by geneticists (29%), ranging across centers (15%-52%, P < .001). Geneticist consultation associated with increased genetic testing yield (odds ratio: 5.7, 95% CI 4.33-7.58, P < .001). Conclusion Genetics evaluation in CHD is diagnostically important but underused and highly variable, with high diagnostic rates across patient types, including in infants with presumed isolated CHD. These findings support recommendations for comprehensive testing and standardization of care.

Background Chromosomal microarray analysis (CMA) provides an opportunity to understand genetic causes of congenital heart disease (CHD). The methods for describing cardiac phenotypes in patients with CMA abnormalities have been inconsistent, which may complicate clinical interpretation of abnormal testing results and hinder a more complete understanding of genotype-phenotype relationships. Methods and Results Patients with CHD and abnormal clinical CMA were accrued from 9 pediatric cardiac centers. Highly detailed cardiac phenotypes were systematically classified and analyzed for their association with CMA abnormality. Hierarchical classification of each patient into 1 CHD category facilitated broad analyses. Inclusive classification allowing multiple CHD types per patient provided sensitive descriptions. In 1363 registry patients, 28% had genomic disorders with well-recognized CHD association, 67% had clinically reported copy number variants (CNVs) with rare or no prior CHD association, and 5% had regions of homozygosity without CNV. Hierarchical classification identified expected CHD categories in genomic disorders, as well as uncharacteristic CHDs. Inclusive phenotyping provided sensitive descriptions of patients with multiple CHD types, which occurred commonly. Among CNVs with rare or no prior CHD association, submicroscopic CNVs were enriched for more complex types of CHD compared with large CNVs. The submicroscopic CNVs that contained a curated CHD gene were enriched for left ventricular obstruction or septal defects, whereas CNVs containing a single gene were enriched for conotruncal defects. Neuronal-related pathways were over-represented in single-gene CNVs, including top candidate causative genes NRXN3, ADCY2, and HCN1. Conclusions Intensive cardiac phenotyping in multisite registry data identifies genotype-phenotype associations in CHD patients with abnormal CMA.

BackgroundPediatric acute myeloid leukemia (AML) therapy is associated with substantial short- and long-term treatment-related cardiotoxicity mainly due to high-dose anthracycline exposure. Early left ventricular systolic dysfunction (LVSD) compromises anthracycline delivery and is associated with inferior event-free and overall survival in de novo pediatric AML. Thus, effective cardioprotective strategies and cardiotoxicity risk predictors are critical to optimize cancer therapy delivery and enable early interventions to prevent progressive LVSD. While dexrazoxane-based cardioprotection reduces short-term cardiotoxicity without compromising cancer survival, liposomal anthracycline formulations have the potential to mitigate cardiotoxicity while improving antitumor efficacy. This overview summarizes the rationale and methodology of cardiac substudies within AAML1831, a randomized Children's Oncology Group Phase 3 study of CPX-351, a liposomal formulation of daunorubicin and cytarabine, in comparison with standard daunorubicin/cytarabine with dexrazoxane in the treatment of de novo pediatric AML.Methods/designChildren (age <22 years) with newly diagnosed AML were enrolled and randomized to CPX-351-containing induction 1 and 2 (Arm A) or standard daunorubicin and dexrazoxane-containing induction (Arm B). Embedded cardiac correlative studies aim to compare the efficacy of this liposomal anthracycline formulation to dexrazoxane for primary prevention of cardiotoxicity by detailed core lab analysis of standardized echocardiograms and serial cardiac biomarkers throughout AML therapy and in follow-up. In addition, AAML1831 will assess the ability of early changes in sensitive echo indices (e.g., global longitudinal strain) and cardiac biomarkers (e.g., troponin and natriuretic peptides) to predict subsequent LVSD. Finally, AAML1831 establishes expert consensus-based strategies in cardiac monitoring and anthracycline dose modification to balance the potentially competing priorities of cardiotoxicity reduction with optimal leukemia therapy.DiscussionThis study will inform diagnostic, prognostic, preventative, and treatment strategies regarding cardiotoxicity during pediatric AML therapy. Together, these measures have the potential to improve leukemia-free and overall survival and long-term cardiovascular health in children with AML. Clinical trial registration:https://clinicaltrials.gov/, identifier NCT04293562

Objective: To characterise transesophageal echocardiography practice patterns among paediatric cardiac surgical centres in the United States and Canada. Methods: A 42-question survey was sent to 80 echocardiography laboratory directors at paediatric cardiology centres with surgical programmes in the United States and Canada. Question domains included transesophageal echocardiography centre characteristics, performance and reporting, equipment use, trainee participation, and quality assurance. Results: Fifty of the 80 centres (62.5%) responded to the survey. Most settings were academic (86.0%) with 42.0% of centres performing > 350 surgical cases/year. The median number of transesophageal echocardiograms performed/cardiologist/year was 50 (26, 73). Pre-operative transesophageal echocardiography was performed in most surgical cases by 91.7% of centres. Transesophageal echocardiography was always performed by most centres following Norwood, Glenn, and Fontan procedures and by < 10% of centres following coarctation repair. Many centres with a written guideline allowed transesophageal echocardiography transducer use at weights below manufacturer recommendations (50.0 and 61.1% for neonatal and paediatric transducers, respectively). Most centres (36/37, 97.3%) with categorical fellowships had rotations which included transesophageal echocardiography participation. Large surgical centres (>350 cases/year) had higher median number of transesophageal echocardiograms/cardiologist/year (75.5 [53, 86] versus 35 [20, 52], p < 0.001) and more frequently used anaesthesia for diagnostic transesophageal echocardiography ≥ 67% of time (100.0 versus 62.1%, p = 0.001). Conclusions: There is significant variability in transesophageal echocardiography practice patterns and training requirements among paediatric cardiology centres in the United States and Canada. Findings may help inform programmatic decisions regarding transesophageal echocardiography expectations, performance and reporting, equipment use, trainee involvement, and quality assurance.

Vascular rings are increasingly identified on fetal echocardiography. The purpose of this study is to analyze clinical outcomes and patterns of diagnostic testing in fetuses with vascular rings diagnosed by echocardiography. A retrospective cohort study was performed of fetuses with postnatally confirmed vascular rings from 2017 to 2022. Clinical outcomes included type and timing of symptoms, and timing of surgical intervention. Freedom from symptoms and/or surgery was assessed by Kaplan-Meier analysis. Frequency of genetic and diagnostic testing (barium esophagogram, CT/MRI angiogram, and bronchoscopy) was also assessed. Overall, 46 patients were evaluated (91% with a right aortic arch/left ductus and 4% with a double aortic arch). A vascular ring was isolated in 59%, associated with structural heart lesions in 33%, and associated with noncardiac anomalies in 8%. Prenatal diagnoses increased over time. Symptoms developed in 24% (11/46); 82% (9/11) had respiratory and 45% (5/11) had gastroesophageal complaints. Surgery was performed in 17% (11/46). Symptoms presented bimodally, prior to 100 or after 400 days of life. There was no difference in the type of symptoms for early (< 100 days) or late (> 400 days) presenters. Symptomatic patients received more diagnostic testing. Genetic testing was obtained in 46% and positive in 33%, with 22q11 deletion and Trisomy 21 being identified. Prenatal diagnoses of vascular rings increased over time, with subjects developing symptoms bimodally in early or late infancy. The frequency of genetic testing was suboptimal given the prevalence of genetic abnormalities seen in this population.

10012 Background: Many childhood cancer patients receive cardiotoxic therapies and need surveillance for therapy-related cardiomyopathy (CM). (Echo)cardiography is used to screen for cardiac dysfunction but has relatively poor discriminatory ability to predict who will develop CM. We sought to identify combinations of echo parameters that can better predict which patients subsequently develop CM. Methods: Longitudinal echos (obtained per routine care) of patients diagnosed with cancer < 21y who subsequently met CM criteria (left ventricular [LV] ejection fraction ≤50% / fractional shortening ≤28%, ≥2 times, with ≥1 time after completion of cancer therapy) plus clinical data were collated from COG sites. Echos and data from patients without CM were also collated. All echos were centrally remeasured for 42 routinely reported parameters in blinded fashion. We applied least absolute shrinkage and selection operator (LASSO) to fit logistic models to identify the most influential predictors for CM development within 2 and 5y of echo, plus age and sex. Data were randomly split into training (85%) and test (15%) sets with 10-fold cross validation. Prediction accuracy was calculated using area under the ROC curve (AUC), based on the model that provided the minimum mean cross-validated error. Results: Echos from 88 CM cases (248 echos predating CM) and 126 non-cases (518 echos) were available. Patients (n = 214) were diagnosed at mean age 7.7±5.2y with mean 9.5±4.0y follow-up. Mean doxorubicin equivalent doses for cases and non-cases were 350±188 and 272±199 mg/m 2 , respectively. For 2y CM prediction, models achieved training AUC 0.85 (95%CI 0.78-0.92; 261 echos) and test AUC 0.74 (95% CI 0.74-0.90; 46 echos). Factors selected included age, 2-dimensional (2D) measurements of LV geometry (LV systolic and end-systolic dimensions, and posterior wall thickness), systolic function (M-mode fractional shortening), diastolic function (mitral inflow E wave, septal E’, septal A’), and a measurement of combined systolic and diastolic function (myocardial performance index). For 5y CM prediction, models achieved training AUC 0.90 (95%CI 0.85-0.95; 175 echos) and test AUC 0.89 (95%CI 0.78-0.99; 30 echos). Age, LV end-systolic dimension (2D and M-mode), M-mode LV posterior wall thickness, 2D wall thickness-dimension ratio, mitral inflow E, septal E’, septal A’, and the myocardial performance index were selected. At both times 2D end-systolic dimension was the most influential parameter. Inclusion of anthracycline and chest radiotherapy dose did not meaningfully improve the AUCs. Conclusions: Prediction models that incorporate conventional echo data may be able to accurately identify childhood cancer patients at high risk of developing CM 2-5y prior to CM diagnosis. This may provide a window of opportunity to introduce interventions that may arrest or slow CM progression.

Background:The COVID pandemic necessitated an altered approach to transthoracic echocardiography, especially in COVID cases. Whether this has effected echocardiography lab quality is unknown. Objectives:We sought to determine whether echocardiography lab quality measures during the COVID pandemic were different from those prior to the pandemic and whether quality and comprehensiveness of echocardiograms performed during the pandemic was different between COVID and non-COVID patients. Methods:The four quality measures (diagnostic errors, appropriateness of echocardiogram, American College of Cardiology Image Quality metric and Comprehensive Exam metric in structurally normal hearts) reported quarterly in our lab were compared between two quarters during COVID (2020) and pre-COVID (2019). Each component of these metrics was also assessed in randomly selected echocardiograms in COVID patients and compared to non-COVID echocardiograms. Results:For non-COVID echocardiograms, the image quality metric did not change between 2019 and 2020 and the comprehensive exam metric improved. Diagnostic error rate did not change, and appropriateness of echocardiogram indications improved. When COVID and non-COVID echocardiograms were compared, the image quality metric and comprehensiveness exam metric were lower for COVID cases (image quality mean 21.3/23 for non-COVID, 18.6/23 for COVID, p < 0.001 and comprehensive exam mean 29.5/30 for non-COVID, 27.7/39 for COVID, p < 0.001). In particular, systemic and pulmonary veins, pulmonary arteries and aortic arch were not adequately imaged in COVID patients. For studies in which a follow-up echocardiogram was available, no new pathology was found. Conclusions:At our center, though diagnostic error rate did not change during the pandemic and the proportion of echocardiograms ordered for appropriate indications increased, imaging quality in COVID patients was compromised, especially for systemic and pulmonary veins, pulmonary arteries and arch. Though no new pathology was noted on the small number of patients who had follow-up studies, we are paying careful attention to these structures to avoid diagnostic errors going forward.

Introduction: Childhood cancer survivors require life-long surveillance for treatment-related cardiomyopathy/heart failure (CHF). Ultimately, we aim to use machine learning to aid in echocardiographic discrimination of survivors more likely to develop future CHF. For this feasibility pilot, we built two proof-of-concept deep convolutional neural networks (DCNNs) tasked with binary classification of present/future CHF versus no CHF with the aim of assessing optimal data input format and model architecture. Methods: From a robust multi-institutional surveillance echo dataset, we selected pilot data comprising 171 parasternal short axis echo clips, 52 from 5 CHF+ (present and future CHF) and 119 from 21 CHF- patients. We built two DCNN models differing in frame selection for input data (Fig. 1), both tasked with binary classification of CHF+ vs. CHF-. We used holdout subsets in a 10-fold cross-validation framework to test model performance and Student’s t test (paired) to compare model performance. Results: Classification performance was similar, with mean AUROC values of 0.59 ± 0.09 and 0.53 ± 0.11 (p=0.14) for the models trained on Type I and Type II montages, respectively (Fig. 2). Conclusions: The DCNN framework is feasible for a model tasked with classifying CHF status, and we are optimistic that a similar model can be trained with pre-CHF diagnosis (case) vs control patient images to facilitate machine learning-assisted identification of childhood cancer survivors more likely to develop CHF in the future.

Introduction: Burnout among physicians may impact productivity and result in suboptimal patient care. Studies looking at burnout in a specific pediatric subspecialty are extremely limited. In a previous study, the authors evaluated the work–life balance and burnout among pediatric cardiology attending at our institution. This demonstrated early signs of reduced work engagement and possible burnout in the near future. To address this, the authors implemented a number of targeted interventions and conducted a follow-up survey to assess the effects of such changes. The objective of this study was to evaluate the current status of work–life balance and burnout among pediatric cardiologists at the author's institution compared to the general population and to the prior survey.Materials and Methods: Pediatric cardiology attending physicians were surveyed at the author's institution to assess their perception of burnout and work–life balance using the Maslach burnout inventory and the areas of work–life survey.Results: Forty-seven of the 52 pediatric cardiologists responded to the survey. They were divided into groups by their respective subspecialty: interventional/electrophysiology (n = 2), cardiac intensive care unit/inpatient (n = 9), noninvasive imaging (n = 6), outpatient (n = 22), and other (n = 8). When compared to the previous survey, the Maslach burnout inventory scores were significantly lower in the area of emotional exhaustion. However, most scores in the areas of work–life survey were lower than the prior survey.Conclusion: This follow-up study focusing on pediatric cardiology attending physicians demonstrated worsening burnout and signs of reduced work engagement compared to the previous survey 4 years ago. Interventions did not include bolstering our physician support systems and developing resiliency training for our physicians, which is an area the authors are going to focus on going forward.The following core competencies are addressed in this article: Medical knowledge, Practice-based learning, Systems-based practice.

•Cardiac interdependence in conjoined twins is a rare phenomenon.•Presence of congenital heart disease may be an important prognostic factor.•There is high risk of high-output heart failure and pulmonary hypertension in the donor twin.•If reconstruction is feasible, early separation may improve the chance of survival.