Behaviour and emotions of children and young people with congenital heart disease: A literature review

Congenital heart disease (CHD) is one of the common types of birth defects. Children and young people (CYP) with CHD might exhibit behavioural and emotional changes related to undergoing different medical treatments and hospitalization. Therefore, a literature review was conducted from January 2000 to June 2017 that aimed to understand and evaluate current international literature focusing on CYP's behavioural and emotional status as patients with CHD. A comprehensive search of Medline, PsycINFO and CINAHL databases was undertaken. Eight quantitative studies were reviewed following strict eligibility criteria. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of the reviewed studies. Parents provided proxy reports on their children's behaviour and emotions in all studies. Half of the reviewed studies presented the self-perceptions of children who were over seven years old. CYP with CHD exhibited internalizing and externalizing behavioural problems, withdrawal, depression, social, and attention problems. CYP with more severe CHD reported greater behavioural and emotional problems than CYP with less severe CHD. Moreover, younger children developed more problems than older children. Future more depth research using qualitative designs is required to explore the personal views of children younger than seven years old on the impact of CHD on their behaviour and emotions.

Benefit of vessel closure with the Azur CX Peripheral Coil System in small children with complex CHD

Vessel occlusion is a frequently used procedure to close congenital or acquired collaterals or communications. We report two cases of successful vessel closure, in small infants with CHD, using the Azur CX Peripheral Coil System. The low profile of the device, the controlled delivery of the coils, and the delivery through a microcatheter make it particularly interesting for the occlusion of highly tortuous vessels in children.

Persistent Left Superior Vena Cava Suggested by an Unusual Central Venous Pressure Waveform

Background  A persistent left superior vena cava (PLSVC) is the most common congenital anomaly of the thoracic venous return. Case Description  During atrial septal defect repair, a pulmonary artery (PA) catheter was placed via the left internal jugular vein. Although placement of the PA catheter in the main PA was confirmed by transesophageal echocardiography, the central venous pressure (CVP) waveform was abnormal. Intraoperatively, the PA catheter was seen exiting the coronary sinus with the CVP port within the coronary sinus. Conclusions  The diagnosis of PLSVC is discussed and the differential diagnosis of the abnormal "ventricular" pattern of the CVP waveform is reviewed.

Interaction between Coffee Drinking and TRIB1 rs17321515 Single Nucleotide Polymorphism on Coronary Heart Disease in a Taiwanese Population

A complex interplay of several genetic and lifestyle factors influence coronary heart disease (CHD). We determined the interaction between coffee consumption and the tribbles pseudokinase 1 (TRIB1) rs17321515 variant on coronary heart disease (CHD). Data on CHD were obtained from the National Health Insurance Research Database (NHIRD) while genotype data were collected from the Taiwan Biobank (TWB) Database. From the linked electronic health record data, 1116 individuals were identified with CHD while 7853 were control individuals. Coffee consumption was associated with a lower risk of CHD. The multivariate-adjusted odds ratio (OR) and 95% confidence interval (CI) was 0.84 (0.72-0.99). Association of CHD with the TRIB1 rs17321515 variant was not significant. The OR (95% CI) was 1.01 (0.72-0.99). There was an interaction between TRIB1 rs17321515 and coffee consumption on CHD risk (p for interaction = 0.0330). After stratification by rs17321515 genotypes, coffee drinking remained significantly associated with a lower risk of CHD only among participants with GG genotype (OR, 0.62; 95% CI, 0.45-0.85). In conclusion, consumption of coffee was significantly associated with a decreased risk of CHD among Taiwanese adults with the TRIB1 GG genotype.

Combined hybrid pulmonary valve placement and atrial septal defect closure: case report and literature review

We report a case of a 15-year-old female who underwent combined hybrid pulmonary valve replacement and transcatheter atrial septal defect device closure, which was performed due to severe volume overload of the right side of the heart secondary to pulmonary regurgitation and atrial septal defect.

Exercise capacity, physical activity, and health-related quality of life in adults with CHD

OBJECTIVES

The aim of this study was to assess exercise capacity, physical activity, and health-related quality of life within a broad and unselected group of adults with CHD.

DESIGN

From April 2009 to February 2014, 1310 patients were assessed for suitability to participate in this single-centre cross-sectional study. Seven hundred and forty-seven (57%) patients were included, performed a submaximal bicycle test, and answered questionnaires regarding physical activity and health-related quality of life. Exercise capacity, physical activity, and health-related quality of life were compared with reference values and correlations were studied.

RESULTS

The exercise capacities of men and women with CHD were 58.7 and 66.3%, respectively, of reference values. Approximately, 20-25% of the patients did not achieve the recommended amount of physical activity. In addition, men scored significantly less points on 7 out of 10 scales of health-related quality of life and women in 6 out of 10 scales, compared with reference values. The strongest correlation was between exercise capacity and the Short Form-36 (physical function).

CONCLUSIONS

Exercise capacity was impaired in all adults with CHD, including those with less complicated CHD. One-quarter of the patients did not achieve the recommended levels of physical activity. Exercise tests followed by individualised exercise prescriptions may be offered to all patients with CHD aiming to increase exercise capacity, levels of physical activity, improve health-related quality of life, and reduce the risk of acquired life-style diseases.

Influenza associated with circulatory collapse and atrioventricular block in an unvaccinated child with repaired CHD

Symptomatic, circulatory collapse occurred in an unvaccinated child with repaired congenital heart and a backup pacemaker during an Influenza B viral infection with complete atrioventricular block and pacemaker non-capture. Ventricular arrhythmias occurred during her collapse. Atrioventricular conduction recovered within 24 hours. Influenza-associated cardiac inflammation can adversely affect patients with repaired CHD. Proactive immunisation is strongly recommended.

Faecal calprotectin concentrations in neonates with CHD: pilot study

Neonates with CHD are at increased risk of developing necrotising enterocolitis due to mesenteric hypoperfusion. Necrotising enterocolitis results in repeated feed interruptions contributing to poor growth during the early post-operative phase. Poor weight gain and longer hospital stay are risk factors for death in neonates with CHD. Abdominal radiography is used as a diagnostic tool for necrotising enterocolitis; however, its utility is limited in the early stages of necrotising enterocolitis when pneumatosis intestinalis is absent. Calprotectin is a neutrophil activation biomarker, and elevated levels are evident in inflammatory diseases such as necrotising enterocolitis. The aim of this study was to determine whether there is a correlation between faecal calprotectin concentration and gut inflammation in neonates with CHD. This prospective single-centre study recruited newly diagnosed term patients with duct-dependent CHD between March 2018 and March 2019. Faecal calprotectin concentrations were measured in post-surgical patients using enzyme-linked immunosorbent assay methods. A total of 30 patients were included in the analysis. Calprotectin concentration for patients who developed necrotising enterocolitis was 3528 µg/g compared with 390 µg/g without, compared with 1339 µg/g in patients with suspected necrotising enterocolitis (p = 0.0001). Patients with suspected necrotising enterocolitis had a significantly longer length of hospital stay, on average 18 days longer compared to patients without necrotising enterocolitis (p = 0.03). Faecal calprotectin concentrations may reflect severity of gut inflammation in neonates with CHD. Suspected necrotising enterocolitis contributes to longer days nil by mouth and an increase in length of hospital stay.

Treatment of severe pulmonary insufficiency with bilateral branch pulmonary artery Melody valve implantation

Branch pulmonary artery valve implantation has been reported in larger patients with dysfunctional right ventricular outflow tracts via routine femoral access. Here, we report treatment of severe pulmonary insufficiency with bilateral branch pulmonary artery Melody valve implantation (Medtronic, Minneapolis, Minnesota). To the best of our knowledge, this is the first report of bilateral valve implantation utilising the hybrid approach in a small-size patient.

Fetal CHD and perinatal outcomes

OBJECTIVE

To evaluate delivery management and outcomes in fetuses prenatally diagnosed with CHD.

STUDY DESIGN

A retrospective cohort study was conducted on 6194 fetuses (born between 2013 and 2016), comparing prenatally diagnosed with CHD (170) to those with non-cardiac (234) and no anomalies (5790). Primary outcomes included the incidence of preterm delivery and mode of delivery.

RESULTS

Gestational age at delivery was significantly lower between the CHD and non-anomalous cohorts (38.6 and 39.1 weeks, respectively). Neonates with CHD had a significantly lower birth weights (p < 0.001). There was an approximately 1.5-fold increase in the rate of primary cesarean sections associated with prenatally diagnosed CHD with an odds ratio of 1.49 (95% CI 1.06-2.10).

CONCLUSIONS

Our study provides additional evidence that the prenatal diagnosis of CHD is associated with a lower birth weight, preterm delivery, and with an increased risk of delivery by primary cesarean section.

A low threshold for neonatal intervention yields a high rate of biventricular outcomes in pulmonary atresia with intact ventricular septum

AIMS

Management strategies for pulmonary atresia with intact ventricular septum are variable and are based on right ventricular morphology and associated abnormalities. Catheter perforation of the pulmonary valve provides an alternative strategy to surgery in the neonatal period. We sought to assess the long-term outcome in terms of survival, re-intervention, and functional ventricular outcome in the setting of a 26-year single-centre experience of low threshold inclusion criteria for percutaneous valvotomy.

METHODS AND RESULTS

Retrospective analysis of patients diagnosed with pulmonary atresia with intact ventricular septum from 1990 to 2016 at a tertiary referral centre, was performed. Of 71 patients, 48 were brought to the catheterisation laboratory for intervention. Catheter valvotomy was successful in 45 patients (94%). Twenty-three patients (51%) also underwent ductus arteriosus stenting. The length of intensive care and hospital stay was significantly shorter, and early re-interventions were significantly reduced in the catheterisation group. There were eight deaths (17%); all within 35 days of the procedure. Of the survivors, only one has required a Fontan circulation. Twenty-eight patients (74%) have undergone biventricular repair and nine patients (24%) have one-and-a-half ventricle circulation. Following successful valvotomy, 80% of patients required further catheter-based or surgical interventions.

CONCLUSIONS

A low threshold for initial interventional management yielded a high rate of successful biventricular circulations. Although mortality was low in patients who survived the peri-procedural period, the rate of re-intervention remained high in all groups.

Distinct Distress Symptom Trajectories Over 3 Years Are Associated With Baseline Illness Perceptions in Individuals With Coronary Heart Disease

BACKGROUND

Depression and anxiety symptoms (termed distress) are common among coronary heart disease (CHD) patients and associated with poor outcomes. Illness perceptions predict distinct outcome trajectories in other long-term conditions, yet it is not known how they relate to distress trajectories in CHD.

PURPOSE

This study aimed to examine whether baseline illness perceptions are associated with distress symptom trajectories among primary care CHD patients.

METHODS

This is a secondary analysis of 803 CHD patients from the UPBEAT-UK study, who completed the Hospital Anxiety and Depression Scale every 6 months for 3 years. Baseline assessments included the Brief Illness Perception Questionnaire. Using latent class growth analysis, Palacios et al. (2018) identified five distinct distress symptom trajectories ("stable low," "chronic high," "improving," "worsening," and "fluctuating") in this cohort. Adjusted multinomial logistic regression analyses were used to test the association between baseline illness perceptions and distress symptom trajectories.

RESULTS

Compared with the stable low distress trajectory, stronger illness identity (odds ratio [OR] = 1.31, p < .01), higher perceived consequences (OR = 1.47, p < .01), illness-related emotion (OR = 1.66, p < .01), and illness concerns (OR = 1.36, p < .01) increased the odds of having chronic high distress. Stronger illness coherence (OR = 0.89, p < .05) and personal (OR = 0.77, p < .01) and treatment control (OR = 0.75, p < .01) reduced the odds of chronic high distress. Worsening distress symptoms were associated with weaker perceptions of treatment control, higher perceived consequences, and greater illness-related concerns and emotions.

CONCLUSIONS

Illness perceptions of CHD are associated with distress symptom trajectories. Therapeutically modifying unhelpful illness perceptions in CHD patients who experience high levels of distress could potentially improve mental health outcomes.

Diagnostic and predictive values of plasma connective tissue growth factor in children with pulmonary hypertension associated with CHD

OBJECTIVE

To evaluate the diagnostic and predictive values of plasma connective tissue growth factor in children with pulmonary hypertension (PH)-related CHD.

PATIENTS AND METHODS

Forty patients with PH-related CHD were enrolled as group I, and 40 patients with CHD and no PH served as group II. Forty healthy children of matched age and sex served as a control group. Echocardiographic examinations and plasma connective tissue growth factor levels were performed for all included children. Cardiac catheterisation was performed for children with CHD only.

RESULTS

Plasma connective tissue growth factor levels were significantly higher in children with PH-related CHD compared to CHD-only patients and to control group and this elevation went with the severity of PH. There was a significant positive correlation between connective tissue growth factor levels and mean pulmonary pressure, pulmonary vascular resistance, and right ventricular diameter. A significant negative correlation was noticed between connective tissue growth factor levels, oxygen saturation, and right ventricular diastolic function. The sensitivity of plasma connective tissue growth factor as a diagnostic biomarker for PH was 95%, and the specificity was 90% at a cut-off value ≥650 pg/mL. The predictive value of plasma connective tissue growth factor for adverse outcome had a sensitivity of 88% and a specificity of 83% at a cut-off value ≥1900 pg/mL.

CONCLUSION

Connective tissue growth factor is a promising biomarker with good diagnostic and predictive values in children with PH-related CHD.

Peritoneal dialysis during congenital heart surgery admissions: insights from a large database

BACKGROUND

The management of fluid overload after congenital heart surgery has been limited to diuretics, fluid restriction, and dialysis. This study was conducted to determine the association between peritoneal dialysis and important clinical outcomes in children undergoing congenital heart surgery.

METHODS

A retrospective review was conducted to identify patients under 18 years of age who underwent congenital heart surgery. The data were obtained over a 16-year period (1997-2012) from the Kids' Inpatient Database. Data analysed consisted of demographics, diagnoses, type of congenital heart surgery, length of stay, cost of hospitalisation, and mortality. Logistic regression was performed to determine factors associated with peritoneal dialysis.

RESULTS

A total of 46,176 admissions after congenital heart surgery were included in the study. Of those, 181 (0.4%) utilised peritoneal dialysis. The mean age of the peritoneal dialysis group was 7.6 months compared to 39.6 months in those without peritoneal dialysis. The most common CHDs were atrial septal defect (37%), ventricular septal defect (32.6%), and hypoplastic left heart syndrome (18.8%). Univariate analyses demonstrated significantly greater length of stay, cost of admission, and mortality in those with peritoneal dialysis. Regression analyses demonstrated that peritoneal dialysis was independently associated with significant decrease in cost of admission (-$57,500) and significant increase in mortality (odds ratio 1.5).

CONCLUSIONS

Peritoneal dialysis appears to be used in specific patient subsets and is independently associated with decreased cost of stay, although it is associated with increased mortality. Further studies are needed to describe risks and benefit of peritoneal dialysis in this population.

Heart University: a new online educational forum in paediatric and adult congenital cardiac care. The future of virtual learning in a post-pandemic world?

Online learning has become an increasingly expected and popular component for education of the modern-day adult learner, including the medical provider. In light of the recent coronavirus pandemic, there has never been more urgency to establish opportunities for supplemental online learning. Heart University aims to be "the go-to online resource" for e-learning in CHD and paediatric-acquired heart disease. It is a carefully curated open access library of paedagogical material for all providers of care to children and adults with CHD or children with acquired heart disease, whether a trainee or a practising provider. In this manuscript, we review the aims, development, current offerings and standing, and future goals of Heart University.

"Why and how did this happen?": development and evaluation of an information resource for parents of children with CHD

BACKGROUND

The causes of CHD are complex and often unknown, leading parents to ask how and why this has happened. Genetic counselling has been shown to benefit these parents by providing information and support; however, most parents currently do not receive this service. This study aimed to develop a brochure to determine whether an information resource could improve parents' knowledge about CHD causation and inheritance and increase psychosocial functioning.

METHODS

In development, the resource was assessed against several readability scales and piloted. Parents of children attending preadmission clinic for surgery were included. Assessments occurred pre- and post-receiving the information resource using a purpose-designed knowledge measure and validated psychological measures.

RESULTS

Participant's (n = 52) knowledge scores increased significantly from the pre-questionnaire ( ${\overline x}\, = \,5/10$ , sd = 2.086) to post-questionnaire ( $\overline x\, = \,7.88/10$ , sd = 2.094, p < 0.001), with all aware that CHD can be caused by genetic factors after reading the brochure. Perceived personal control also increased from pre- ( $\overline x\, = \,11.856/18$ , sd = 4.339) to post-brochure ( $\overline x\, = \,14.644/18$ , sd = 3.733, p < 0.001), and many reported reduced feelings of guilt. No negative emotional response to the brochure was reported. The information provided was considered relevant (88%), reassuring (86%), and 88% would recommend the brochure to other parents. However, some wanted more emotional support and assistance in what to tell their child.

CONCLUSIONS

Use of the information resource significantly enhanced parents' knowledge of CHD causation and increased their psychosocial functioning. It is a valuable resource in the absence of genetic counselling; however, it should not replace formal genetic counselling when required.

Early and late outcomes of surgical repair of double-chambered right ventricle: a single-centre experience

OBJECTIVE

Double-chambered right ventricle is characterised by division of the outlet portion of the right ventricle by hypertrophy of the septoparietal trabeculations into two parts. We aim to report our experiences regarding the presenting symptoms of double-chambered right ventricle, long-term prognosis, including the recurrence rate and incidence of arrhythmias after surgery.

METHODS

We retrospectively investigated 89 consecutive patients who were diagnosed to have double-chambered right ventricle and underwent a surgical intervention from 1995 to 2016. The data obtained by echocardiography, cardiac catheterisation, and surgical findings as well as post-operative follow-up, surgical approaches, post-operative morbidity, mortality, and cardiac events were evaluated.

RESULTS

Median age at the time of diagnosis was 2 months and mean age at the time of operation was 5.3 years. Concomitant cardiac anomalies were as follows: perimembranous ventricular septal defect (78 patients), atrial septal defect (9 patients), discrete subaortic membrane (32 patients), right aortic arch (3 patients), aortic valve prolapse and/or mild aortic regurgitation (14 patients), and left superior caval vein (2 patients). The mean follow-up period was 4.86 ± 4.6 years. In these patients, mean systolic pressure gradient in the right ventricle by echocardiography before, immediately, and long-term after surgical intervention was 66.3, 11.8, and 10.4 mmHg, respectively. There were no deaths during the long-term follow-up period. Surgical reinterventions were performed for residual ventricular septal defect (2), residual pulmonary stenosis (1), and severe tricuspid insufficiency (1).

CONCLUSION

The surgical outcomes and prognosis of double-chambered right ventricle are favourable, recurrence and fatal arrhythmias are unlikely in long-term follow-up.

A Tribute to the Pioneers of Right Heart Bypass: An Historical Review

Cavopulmonary anastomosis was first described by Carlon, Mondini, De Marchi in a canine model in 1951 and later, in the clinical practice, by Glenn in 1958. Total right heart bypass was first introduced by Fontan and Kreutzer in 1971, in each instance as treatment for tricuspid atresia. Several modifications of such a procedure followed the initial concept of the right atrium as a pumping chamber, including modifications aimed to minimize energy loss at the anastomotic level and arrhythmias. Tribute is given to our pioneers who developed such an operation aimed to treat any child with functionally univentricular hearts.

Prevalence and RIsk factors for Silent Myocardial ischemia (PRISM): A clinico observational study in patients of type 2 diabetes

Objectives

To estimate the prevalence and to identify potential risk factors of silent myocardial ischemia in a cohort of patients with asymptomatic type 2 Diabetes (diabetes) for early detection of coronary risk by employing objective noninvasive clinical screening tools for Subclinical Atherosclerosis.

Methods

The study is a clinic-based observational study on 338 consecutive diabetes patients attending an urban health center from Eastern India. The response rate was 96.57% out of 350 eligible subjects, comprising 176 (52.1%) males and 162 (47.9%) females. Clinical, anthropometric, biochemical parameters were collected in all participants. Both tools, i.e., treadmill test (TMT) to identify subjects with silent myocardial ischemia, and carotid imaging to detect subclinical atherosclerosis by evaluating carotid intima-media thickness (CIMT), were assessed. Significant determinants were predicted by multivariable logistic regression.

Results

The study group was divided into a TMT negative (n = 260), and a TMT positive group (n = 78). These 78 TMT positive subjects (23.1%) were identified to have silent myocardial ischemia. The prevalence of silent myocardial ischemia was more common in males (28.4%) than in females (17.3%). The mean CIMT in our study group was 0.6741 ± 0.034 mm (males – 0.684 ± 0.034 mm and females – 0.663 ± 0.032 mm). Age ≥50 years, CIMT ≥0.70 mm, hypercholesterolemia, and hypertriglyceridemia were significant determinants for identifying asymptomatic diabetics at risk for silent myocardial ischemia.

Conclusion

Silent myocardial ischemia is highly prevalent at about one in four asymptomatic diabetic patients. An increased CIMT can be a surrogate marker of higher coronary risk amongst these asymptomatic diabetics.

Recurrent coarctation in Williams syndrome: novel approach of drug-eluting stent implantation

Patients with Williams syndrome often present with abnormalities of the vascular wall of the aorta and/or the pulmonary artery. Surgery may result in restenosis of the affected vessel. Herein, we report a case of an infant with multiple recurrences of aortic coarctation successfully treated with Zotarolimus drug-eluting stent.

Epidemiological analysis of neonatal CHD near Petrochemical Complex

OBJECTIVE

To study the incidence, types, and characteristics of CHD in all live births delivered in Jinshan Hospital from 1 January, 2016 to 31 December, 2017, and to analyse the correlation between CHD and the distance between maternal residence and Shanghai Petrochemical Complex.

METHODS

All live births, delivered in Jinshan Hospital in 2016 and 2017, have received CHD screening and neonatal follow-up after delivery. For those both positive for CHD screening and negative for CHD screening but with heart murmur found during physical examination on neonatal follow-up after delivery, echocardiography was performed to confirm CHD diagnosis. All maternal residential addresses have been grouped for analysis according to the distance between maternal residence and Shanghai Petrochemical Complex.

RESULTS

There were 5544 live births in total, and a total of 79 children with CHD were confirmed by CHD screening and echocardiography, of which the types of diseases with high incidence, in descending order of incidence, are atrial septal defect (48/79), ventricular septal defect (25/79), patent ductus arteriosus (21/79), and pulmonary artery stenosis (9/79). There was no statistically significant difference in the incidence of CHD among the groups divided by the distance between maternal residence and Shanghai Petrochemical Complex. The incidence of neonatal CHD near Shanghai Petrochemical Complex is 1.42%.

CONCLUSIONS

Most of the children with CHD can be screened out through CHD screening and physical examination in neonatal period and early infancy stage. The distance between maternal residence and Shanghai Petrochemical Complex has no significant direct effect on the incidence of CHD in neonates near Shanghai Petrochemical Complex.

The Benefits and Bias in Neurodevelopmental Evaluation for Children with Congenital Heart Disease

Neurodevelopmental (ND) impairment is common in children with congenital heart disease (CHD). While routine ND surveillance and evaluation of high-risk patients has become the standard-of-care, capture rate, barriers to referral, and potential patient benefits remain incompletely understood. Electronic data warehouse records from a single center were reviewed to identify all eligible and evaluated patients between July 2015 and December 2017 based on current guidelines for ND screening in CHD. Diagnoses, referring provider, and payor were considered. Potential benefit of the evaluation was defined as receipt of new diagnosis, referral for additional evaluation, or referral for a new service. Contingencies were assessed with Fisher's exact test. In this retrospective, cohort study, of 3434 children identified as eligible for ND evaluation, 135 were evaluated (4%). Appropriate evaluation was affected by diagnostic bias against coarctation of the aorta (CoArc) and favoring hypoplastic left heart syndrome (HLHS) (1.8 vs. 11.9%, p<0.01). Referrals were disproportionally made by a select group of cardiologists, and the rate of ND appointment non-compliance was higher in self-pay compared to insured patients (78% vs 27%, p<0.01). Potential benefit rate was 70-80% amongst individuals with the three most common diagnoses requiring neonatal surgery (CoArc, transposition of the great arteries, and HLHS). Appropriate ND evaluation in CHD is impacted by diagnosis, provider, and insurance status. Potential benefit of ND evaluation is high regardless of diagnosis. Strategies to improve access to ND evaluations and provider understanding of the at-risk population will likely improve longitudinal ND surveillance and clinical benefit.

Transcatheter closure of elongated and pulmonary hypertensive patent arterial duct in infants using Amplatzer vascular plug II

OBJECTIVE

To evaluate the feasibility, efficacy, and safety of Amplatzer vascular plug II in large and elongated ducts in infants.

INTRODUCTION

Patent arterial duct device closure is technically challenging in infants with large and elongated ducts because Amplatzer duct occluder and Amplatzer duct occluder II have high chances of causing aortic coarctation and left pulmonary artery stenosis, respectively. The Amplatzer vascular plug II being soft with no retention discs on either sides helps in mitigating these problems.

METHOD

This is a prospective, observational study involving infants with clinical, echocardiographic and angiographic evidence of large left to right shunt. All the children underwent duct closure using Amplatzer vascular plug II.

RESULTS

Eighteen infants qualified for the study. Mean age and weight were 8.63 ± 3.84 months and 6.3 ± 1.7 kg, respectively. The angiographic mean duct diameter at the pulmonary artery end was 4.66 ± 0.92 mm, and the mean duct length was 9.4 ± 2.48 mm. The size of Amplatzer vascular plug II used varied from 6 mm to 10 mm. Technical success was achieved in 16/18 cases. One patient had device embolisation, and in the other, the device was found to be unstable. The ratio of Amplatzer vascular plug II size to the duct diameter was 1.65 ± 0.27, while the ratio of ductal length to device length was 1.48 ± 0.46 in those with successful outcome.

CONCLUSIONS

Amplatzer vascular plug II is a safe and effective option in appropriately selected infants with elongated ducts. Diameter and length of Amplatzer vascular plug II vis-a-vis those of the ductus are important determinants of the successful outcome.

Emotional quality-of-life and patient-reported limitation in sports participation in children with uncorrected congenital and acquired heart disease in healthcare-restricted settings in low- and middle-income countries

BACKGROUND

Little is known about emotional quality-of-life in paediatric heart disease in low- and middle-income countries where the prevalence of uncorrected lesions is high. Research on emotional quality-of-life and its predictors in these settings is key to planning interventions.

METHODS

Ten-year retrospective cross-sectional study of children aged 6-17 years with uncorrected congenital or acquired heart disease in 12 low- and middle-income countries was conducted. Emotional functioning score of the PedsQL TM 4.0 generic core scale and data on patient-reported limitation in sports participation were collected via in-person interview and analysed using regression analyses.

RESULTS

Ninety-four children reported mean emotional functioning scores of 71.94 (SD 25.32) [95% CI 66.75-77.13] with lower scores independently associated with having a parent with a chronic illness or who had died (p = 0.005), having less than three siblings (p = 0.007), and reporting a subjective limitation in carrying an item equivalent to a 4 lb load (p = 0.021). Patient-reported limitation in sports participation at least "sometimes" was present in 69% and was independently associated with experiencing symptoms at least once a month (p < 0.001).

CONCLUSION

Some of the factors which were associated with better emotional quality-of-life were similar to those identified in previous studies in patients with corrected defects. Patient-reported limitation in sports participation is common. In addition to corrective surgery and exercise, numerous other interventions which are practicable during surgical missions might improve emotional quality-of-life.

Shorter Leukocyte Telomere Lengths in Healthy Relatives of Patients with Coronary Heart Disease

Telomere length (TL), sirtuin (SIRT) 1, growth differentiation factor (GDF) 11, as well as inflammaging have been related to age-related diseases. In healthy subjects, we aimed to investigate whether leukocyte TL (LTL) associated with family history of coronary heart disease (CHD), age, sex, and lifestyle, and further potential covariations between LTL, GDF11, SIRT1 and selected proinflammatory markers. In 118 healthy subjects (18-81 years, 58% females), whole blood was collected for DNA and RNA isolation and polymerase chain reaction relative quantification of LTLs and gene-expression of SIRT1, GDF11, interleukin (IL)-18, and interferon (IFN)ƴ, respectively, and serum SIRT1 and IL-18 analyses. Shorter LTLs were associated with a seven-fold higher frequency of hereditary CHD in subjects with LTLs in quartile (Q)1 compared with Q2-4 (odds ratio = 7.5, 95% confidence interval: 2.5-21.6, p < 0.001, adjusted). We also observed that LTLs in Q4 compared with Q1-3 associated with higher leukocyte expression of SIRT1 and GDF11 (p = 0.052 and p = 0.058), lower IFNƴ expression (p = 0.009), and lower circulating IL-18 levels (p = 0.027). SIRT1 and GDF11 expression were strongly intercorrelated (Spearman's rho = 0.85, p < 0.001). Overall, smoking, snus, and alcohol consumption were not associated with LTLs. The observed shorter LTLs in association with elevated expression of SIRT1 and GDF11 and dampened inflammation in hereditary CHD subjects, suggest impending risk of disease. More research are warranted to shed light on early lifestyle interventions targeting these mechanisms, to promote healthier aging in individuals with hereditary burden. Graphical Abstract [Figure: see text].