Healthcare needs and Quality of Life in Youths with Congenital Heart Disease: Health-Promoting Behaviors as a Mediator

PURPOSE

The aims of this study were to examine the relationship between healthcare needs, health-promoting behaviors and quality of life (QoL) of youths with congenital heart disease (CHD), and to determine whether health-promoting behaviors were a mediating variable.

DESIGN AND METHODS

This cross-sectional descriptive study was conducted recruiting 205 youths aged 15 to 24 with either ventricular septal defect (VSD) or tetralogy of Fallot (TOF). A self-reported questionnaire was used to collect demographic information; furthermore, the thickness of the triceps skinfold was measured. The Healthcare Needs Scale for Youth with CHD, Adolescent Health Promotion-short form scale, and World Health Organization QoL-BREF scale were administered, and Pearson's correlation, multiple regressions, and the Sobel test were conducted.

RESULTS

The triceps skinfold of participants with VSD was significantly thicker than that of participants with TOF (p < 0.05). Healthcare needs, health-promoting behaviors, and QoL were positively correlated. The overall health-promoting behaviors served as a partial mediator between overall healthcare needs and QoL, accounting for 40.1% of the total variation.

CONCLUSIONS

The study illustrates that health-promoting behaviors have an impact on healthcare needs and QoL of youths with CHD. The development of tailored health consulting interventions to fulfill healthcare needs is required to improve physical and psychosocial wellness among youths with CHD.

PRACTICE IMPLICATIONS

Targeting individual and public health strategies for enhancing health-promoting behaviors should be integrated in CHD care planning.

Cardiac manifestations and gene mutations of patients with RASopathies in Taiwan

RASopathies are developmental diseases caused by mutations in rat sarcoma-mitogen-activated protein kinase pathway genes. These disorders, such as Noonan syndrome (NS) and NS-related disorders (NSRD), including cardio-facio-cutaneous (CFC) syndrome, Costello syndrome (CS), and NS with multiple lentigines (NSML; also known as LEOPARD syndrome), have a similar systemic phenotype. A wide spectrum of congenital heart disease and hypertrophic cardiomyopathy (HCMP) can exhibit major associated characteristics. A retrospective study was conducted at the Mackay Memorial Hospital, National Taiwan University Hospital, Buddhist Tzu-Chi General Hospital, Chang-Gung Memorial Hospital, Taichung Veterans General Hospital, and Chung Shan Medical University Hospital from January 2007 to December 2018. We reviewed the clinical records of 76 patients with a confirmed molecular diagnosis of RASopathies, including NS, CS, CFC syndrome, and NSML. We evaluated the demographic data and medical records with clinical phenotypes of cardiac structural anomalies using cross-sectional and color Doppler echocardiography, electrocardiographic findings, and follow-up data. A total of 47 (61.8%) patients had cardiac abnormalities. The prevalence of cardiac lesions according to each syndrome was 62.7, 50.0, 60.0, and 66.7% in patients with NS, CFC syndrome, CS, and NSML, respectively. An atrial septal defect was usually combined with other cardiac abnormalities, such as pulmonary stenosis (PS), HCMP, ventricular septal defect, or patent ductus arteriosus. Patients with NS most commonly showed PS. In patients with NSRD and cardiac abnormalities, HCMP (29.4%) was the most commonly observed cardiac lesion. PTPN11 was also the most frequently detected mutation in patients with NS and NSRD. Cardiac abnormalities were the most common symptoms observed in patients with RASopathies at the time of their first hospital visit. Performing precise analyses of genotype-cardiac phenotype correlations in a larger cohort will help us accurately diagnose RASopathy as soon as possible.

Zero Fluoroscopy During Ablation of Right-Sided Supraventricular Tachycardia Substrates in a Pediatric Population - Initial Experience in Taiwan

Background

Zero fluoroscopy during ablation of arrhythmias has been introduced to reduce radiation exposure. However, the safety, feasibility and efficacy of the technique in pediatric populations have yet to be delineated.

Objectives

To investigate the safety, feasibility and effectiveness of zero fluoroscopic-guided transcatheter ablation of right-sided supraventricular tachycardia substrates in a pediatric population.

Methods

Patients < 20 years of age who received ablation of right-sided accessory pathway-mediated arrhythmia and atrioventricular nodal reentrant tachycardia at our hospital between January 2014 and July 2018 were enrolled, and their medical records were reviewed. Patients undergoing ablations with conventional fluoroscopic guidance were enrolled as the control group, and those undergoing ablations with zero fluoroscopic guidance were enrolled as the study group. Repaired or complex congenital heart disease patients were excluded.

Results

One hundred and two patients (55 male; 47 female) received a total of 109 ablation procedures: 68 procedures in the control group and 41 in the study group. The mean procedure duration was 104.7 ± 65.1 minutes in the control group and 98.6 ± 57.6 minutes in the study group (p = 0.62). The mean fluoroscopy time was 30.9 ± 23.9 minutes in the control group, while all procedures in the study group were performed without fluoroscopy (p < 0.001). In subgroup analysis, the results were similar. Acute procedural success rates were high in both groups (98.5% vs. 97.6%, p = 1.0). The recurrence rate was 11.5% (7/61) in the control group and 7.5% (3/40) in the study group (p = 0.78) at mid-term follow-up.

Conclusions

Using the zero fluoroscopy technique during pediatric ablation procedures for right-sided supraventricular tachycardia substrates is safe and significantly reduces radiation exposure.

Differential impact of physical activity type on depression in adults with congenital heart disease: A multi-center international study

OBJECTIVE

This study aimed to examine the association between physical activity (PA) and depression in a large international cohort of adults with congenital heart disease (ACHD) as data about the differential impact of PA type on depression in this population are lacking.

METHODS

In 2018, we conducted a cross-sectional assessment of 3908 ACHD recruited from 24 ACHD-specialized centers in 15 countries between April 2013 to March 2015. The Hospital Anxiety and Depression Scale was used to assess self-reported depressive symptoms and the Health-Behavior Scale-Congenital Heart Disease was used to collect PA information. Cochran-Armitage tests were performed to assess trends between depressive symptom levels and PA participation. Chi-Square and Wilcoxon Rank Sum tests were utilized to examine relations between depressive symptom levels and patient characteristics. Stepwise multivariable models were then constructed to understand the independent impact of PA on depressive symptoms.

RESULTS

The overall prevalence of elevated depressive symptoms in this sample was 12% with significant differences in rates between countries (p < .001). Physically active individuals were less likely to be depressed than those who were sedentary. Of the 2 PA domains examined, sport participation rather than active commute was significantly associated with reduced symptoms of depression. After adjustment in multivariable analysis, sport participation was still significantly associated with 38% decreased probability of depressive symptoms (p < .001).

CONCLUSIONS

Sport participation is independently associated with reduced depressive symptoms. The development and promotion of sport-related exercise prescriptions uniquely designed for ACHD may improve depression status in this unique population.

Outcomes of Kawasaki Disease Children With Spontaneous Defervescence Within 10 Days

Background: Kawasaki disease (KD) is one of the most common vasculitis in childhood. Intravenous γ-immunoglobulin (IVIG) is recommended to be administrated within 10 days after fever onset. However, some patients didn't have IVIG therapies because of atypical disease presentations or spontaneous defervescence. We aimed to evaluate the coronary outcomes of the KD patients who didn't receive IVIG and had defervescence within 10 days. Methods: We retrospectively reviewed the KD patients in NTUCH between 2008 and 2015. The patients with a diagnosis of KD and had a febrile length between 5 and 10 days were enrolled. Days of fever, clinical symptoms, laboratory data at the acute stage, and series of coronary artery measurements within a minimum of 3 months after disease onset were recorded. Risk factors associated with coronary lesions 1 month after KD onset were also analyzed. Results: Two hundred ninety-three eligible KD patients were enrolled (Male: 55.1%, mean age of onset: 1.8 years old). Thirty-seven patients had spontaneous defervescence without IVIG treatment. The incidence of coronary aneurysms at the 4th week after disease onset was higher in spontaneously defervesced KD patients than those treated with IVIG (18.9% vs. 5.1%, p = 0.002). Interestingly, of the 238 KD patients without coronary lesions at their acute phase, percentages of emerging coronary aneurysms became significantly higher if they didn't have IVIG therapies due to spontaneous defervescence (4/31), compared with those who received IVIG (3/208). Further analysis showed the development of coronary lesions at 1 month after disease onset was associated with younger age (<12 months old, p = 0.024), and leukocytosis (WBC > 17,000/cumm, p = 0.031). Conclusions: 18.9% of KD patients with spontaneous defervescence had coronary aneurysms. Even without initial coronary lesions, such patients were still riskier to develop coronary aneurysms, compared with KD patients who received IVIG therapies. Such findings address the importance of refining the strategy for use of IVIG in the spontaneously defervesced KD patients within 10 days after fever onset, at least in those with age younger than 1 year and those with leukocytosis.

Different endosperm structures in wheat and corn affected in vitro rumen fermentation and nitrogen utilization of rice straw-based diet

Starchy grain is usually supplemented to diets containing low-quality forage to provide sufficient energy for ruminant animals. Ruminal degradation of grain starch mainly depends on the hydrolysis of the endosperm, which may be variable among grain sources. This study was conducted to investigate the influence of endosperm structure of wheat and corn on in vitro rumen fermentation and nitrogen (N) utilization of rice straw. The 3×4 factorial design included three ratios of concentrate to forage (35:65, 50:50 and 65:35) and four ratios of wheat to corn starch (20:80, 40:60, 60:40 and 80:20). The endosperm structure was detected by scanning electronic microscopy and a confocal laser scanning microscopic. An in vitro gas test was performed to evaluate the rumen fermentation characteristics and N utilization. Starch granules were embedded in the starch-protein matrix in corn, but more granules were separated from the matrix in the wheat endosperm. With the increasing ratio of wheat, rate and extent of gas production, total volatile fatty acids, and ammonia N increased linearly (P<0.01), but microbial protein concentration decreased (quadratic, P<0.01), with the maximum value at a ratio of 40% wheat. The efficiency of N utilization decreased linearly (P<0.01). Rumen fermentation and N utilization were significantly affected by the concentrate-to-forage ratio (P<0.01). Significant interactions between the concentrate-to-forage ratio and the wheat-to-corn ratio were detected in total volatile fatty acids and the efficiency of N utilization (P<0.01). In summary, the starch-protein matrix and starch granules in the wheat and corn endosperm mixture play an important role in the regulation of rumen fermentation and N utilization under low-quality forage.

State-of-the-art acute phase management of Kawasaki disease after 2017 scientific statement from the American Heart Association

Kawasaki disease (KD) has become the most common form of pediatric systemic vasculitis. Although patients with KD received intravenous immunoglobulin (IVIG) therapy, coronary arterial lesions (CALs) still occurred in 5%-10% of these patients during the acute stage. CALs may persist and even progress to stenosis or obstruction. Therefore, CALs following KD are currently the leading cause of acquired heart diseases in children. The etiology of CALs remains unknown despite more than four decades of research. Two unsolved problems are IVIG unresponsiveness and the diagnosis of incomplete KD. The two subgroups of KD patients with these problems have a high risk of CAL. In April 2017, the American Heart Association (AHA) updated the guidelines for the diagnosis, treatment, and long-term management of KD. Compared with the previous KD guidelines published in 2004, the new guidelines provide solutions to the aforementioned two problems and emphasize risk stratification by using coronary artery Z score systems, as well as coronary severity-based management and long-term follow-up. Therefore, in this study, we merged the AHA Scientific Statement in 2017 with recent findings for Taiwanese KD patients to provide potential future care directions for Taiwanese patients with KD.

Physical Activity-Related Drivers of Perceived Health Status in Adults With Congenital Heart Disease

Data on the differential impact of physical activity on perceived health status (PHS) in a large adult congenital heart disease (ACHD) patient population are lacking. We conducted a cross-sectional assessment of 4,028 ACHD patients recruited from 24 ACHD-specialized centers in 15 countries across 5 continents to examine the association between physical activity and PHS in a large international cohort of ACHD patients. A linear analog scale of the EuroQol-5D 3 level version and the 12-item Short Form Health Survey-version 2 were used to assess self-reported health status and the Health-Behavior Scale-Congenital Heart Disease was used as a subjective measurement of physical activity type, participation, and level. Correlation analyses and Wilcoxon Rank Sum tests examined bivariate relations between sample characteristics and PHS scores. Then, multivariable models were constructed to understand the impact of physical activity on PHS. Only 30% of our sample achieved recommended physical activity levels. Physically active patients reported better PHS than sedentary patients; however, the amount of physical activity was not associated with PHS. Further statistical analyses demonstrated that specifically sport participation regardless of physical activity level was a predictor of PHS. In conclusion, the majority of ACHD patients across the world are physically inactive. Sport participation appears to be the primary physical activity-related driver of PHS. By promoting sport-related exercise ACHD specialists thus may improve PHS in ACHD patients.

[Association between serum lipid level and depression in patients with chronic heart failure]

Objective: To investigate the association between serum lipid level and depression in patients with chronic heart failure (CHF). Methods: A total of 348 patients with CHF from the First department of Cardiology of the people's hospital of Shaanxi province from September 2016 to June 2017 were included.The Hamilton Depression Scale (HAMD) was used to evaluate the degree of depression and some related clinical data were tested.The serum lipid level and depression scores in the patients were analyzed using Pearson correlation analysis, and Logistic regression analysis was used to analyze the confounding factors of depression. Results: There was significant difference in the proportion of depression between normal serum lipid group and dyslipidemia group (P=0.044). Pearson correlation analysis showed that depression score was linearly related to total cholesterol (r=0.326, P<0.001) and low density lipoprotein cholesterol (r=0.354, P<0.001), and Logistic regression analysis showed that after adjusting for age, BMI, triglyceride, low density lipoprotein cholesterol, creatinine, total bilirubin, albumin, B type natriuretic peptide, total cholesterol (OR=3.523, P=0.007) and high density lipoprotein cholesterol (OR=0.205, P=0.041) were associated with depression in CHF patients. Conclusion: Total cholesterol can increase the risk of depression, and high density lipoprotein cholesterol can reduce the risk of depression in CHF patients.

Efficacy of a Novel Palivizumab Prophylaxis Protocol for Respiratory Syncytial Virus Infection in Congenital Heart Disease: A Multicenter Study

OBJECTIVE

To analyze the efficacy of a novel palivizumab protocol for hemodynamically significant congenital heart disease (hsCHD) in subtropical areas without clear respiratory syncytial virus seasonality.

STUDY DESIGN

Since July 2013, the National Health Insurance program has provided reimbursement for palivizumab prophylaxis with a novel monthly protocol in selected patients with hsCHD under 1 year of age. We performed a multicenter study to assess the trend of respiratory syncytial virus hospitalizations in patients with hsCHD from 2010 to 2016 during the prepalivizumab, transition, and postpalivizumab periods, and compared treatment and propensity-matched control groups.

RESULTS

A total of 747 patients were enrolled in the study group and 809 in the control group. The male:female was 836:720. Cyanotic CHD was observed in 42.9% of patients. The mean age at diagnosis of CHD was 32.9 days. After 516 685 patient-days of follow-up and a mean of 3.9 doses of palivizumab in the treatment group, respiratory syncytial virus hospitalization rates decreased by 53% and 49% before and after match compared with the control group (P = .009 and .029, respectively). Hospitalization days and intensive care unit admission rate also decreased similarly in the treatment group. The efficacy of this protocol was more prominent in patients with cyanotic hsCHD. The annual respiratory syncytial virus-associated hospitalization rates also decreased significantly from the prepalivizumab to the palivizumab period (from 4.8% to 2.0%; P = .038).

CONCLUSION

Palivizumab prophylaxis through the novel monthly protocol for patients with hsCHD is effective in reducing respiratory syncytial virus-related hospitalizations.

Primary ventricular tachycardia in paediatric population in a tertiary centre

OBJECTIVE

To delineate the outcome of ventricular tachycardia (VT) in the paediatric population.

METHODS

Patients who developed sustained VT between the ages of 0 and 18 years in a referral centre from 1991 to 2015 were enrolled.

RESULTS

A total of 116 patients (67 male/49 female) had documented VT, and 53 (46%) had associated heart disease, namely cardiomyopathy in 20 (17%), structural heart disease in 19 (16%) and channelopathy in 14 (12%), and some of them presented with two types of associated heart disease. Idiopathic VT (63 patients), which presents without associated heart disease, was the most common type. Forty-one patients received catheter ablation, with 37 being successful (90%) and 6 of 37 recurrence (16%). None of the patients died during the 5.8±5.9 year follow-up. VT with cardiomyopathy was associated with the highest mortality rate, particularly in those with hypertrophic and restrictive cardiomyopathy. Among 16 patients initially presenting VT and heart failure, seven exhibited improved heart function after VT control, which could be predicted by benign onset symptoms, monomorphic QRS morphology and the presentation of VT at the initial diagnosis of cardiomyopathy. VT associated with structural heart disease was also associated with a high risk of mortality, but this risk decreased after aggressive intervention in the recent years. VT with channelopathy can be often controlled with medication, except for those with prenatal onset.

CONCLUSIONS

Although VT may carry high mortality when associated with structural anomaly or cardiomyopathy, VT presenting to tertiary referral centre often has a favourable outcome after prompt intervention.

A positive perspective of knowledge, attitude, and practices for health-promoting behaviors of adolescents with congenital heart disease

Background:

Health-promoting behaviors could serve as a major strategy to optimize long-term outcomes for adolescents with congenital heart disease. The associations assessed from a positive perspective of knowledge, attitudes, and practice model would potentially cultivate health-promoting behaviors during adolescence.

Aim:

The purpose of this study was to examine the relationships between disease knowledge, resilience, family functioning, and health-promoting behaviors in adolescents with congenital heart disease.

Methods:

A total of 320 adolescents with congenital heart disease who were aged 12–18 years were recruited from pediatric cardiology outpatient departments, and participated in a cross-sectional survey. The participants completed the Leuven Knowledge Questionnaire for Congenital Heart Disease; Haase Adolescent Resilience in Illness Scale; Family Adaptability, Partnership, Growth, Affection, and Resolve; and Adolescent Health Promotion scales. The collected data were analyzed using descriptive statistics and three multiple regression models.

Results:

Greater knowledge of prevention of complications and higher resilience had a more powerful effect in enhancing health-promoting behaviors. Having symptoms and moderate or severe family dysfunction were significantly more negatively predictive of health-promoting behaviors than not having symptoms and positive family function. The third model explained 40% of the variance in engaging in health-promoting behaviors among adolescents with congenital heart disease.

Conclusion:

The findings of this study provide new insights into the role of disease knowledge, resilience, and family functioning in the health-promoting behavior of adolescents with congenital heart disease. Continued efforts are required to plan family care programs that promote the acquisition of sufficient disease knowledge and the development of resilience for adolescents with congenital heart disease.

Pneumococcal vaccination and efficacy in patients with heterotaxy syndrome

BackgroundPneumococcal vaccines, including pneumococcal polysaccharide vaccine (PPV) and pneumococcal conjugated vaccine (PCV), are crucial in preventing invasive pneumococcal diseases. We analyzed the pneumococcal vaccination rate, efficacy, and durability in patients with heterotaxy.MethodsAll patients with heterotaxy and CCHD who were followed up at our institution between 2010 and 2015 were included. Pneumococcal vaccine status and geometric mean concentration (GMC) of serotypes 6B, 14, 19F, and 23F were analyzed. Splenic function was considered abnormal when the percentage of IgM memory B cell was less than 1%.ResultsThe GMCs of the four serotypes did not differ significantly between patients with heterotaxy and those with CCHD; the GMCs were also not affected by abnormal splenic function. Most patients had GMCs >0.35 μg/ml (protection level) 4-5 years after either PPV or PCV injection; however, it may decay gradually in some serotypes. In addition, 21.4% of 42 patients with heterotaxy did not receive pneumococcal vaccine, and none completely adhered to the vaccine guidelines.ConclusionsVaccine efficacy was acceptable, even in patients with abnormal splenic function. In some patients, the durability of PPV and PCV decreased with time, highlighting the importance of booster doses. Vaccination rate in patients with heterotaxy is unsatisfactory.

[The research progress of CO(2) laser in the treatment of oral lichen planus]

Oral lichen planus (OLP) is a common oral mucosal disease. The etiology of OLP is not clear. The treatment of OLP is difficult as some of the OLP patients have little effects to the conventional mucosal treatments. In recent years, laser therapy has been adopted to treat patients with OLP. The CO(2) laser therapy has drawn much attention of doctors and scholars because of its advantages in treating the OLP. This review article mainly discusses the principle, effects and some state-of-the-art progresses in OLP treatment using CO(2) laser.

Risk factors and implications of progressive coronary dilatation in children with Kawasaki disease

Background

Kawasaki disease (KD) is an acute systemic vasculitis that occurs in children and may lead to cardiovascular morbidity and mortality. Progressive coronary dilatation for at least 2 months is associated with worse late coronary outcomes in patients with KD having medium or giant aneurysms. However, the risk factors and occurrence of progressive coronary dilatation in patients with KD but without medium or giant aneurysms have been insufficiently explored.

Methods

We retrospectively enrolled 169 patients with KD from a tertiary medical center in Taiwan during 2009–2013. Medical records of all patients were reviewed. Echocardiography was performed during the acute KD phase and at 3–4 weeks, 6–8 weeks, 6 months, and 12 months after KD onset. Progressive coronary dilatation was defined as the progressive enlargement of coronary arteries on three consecutive echocardiograms. Logistic regression analysis was conducted to evaluate the potential risk factors for coronary aneurysms and progressive coronary dilatation.

Results

Of a total of 169 patients with KD, 31 (18.3%) had maximal coronary Z-scores of ≥ + 2.5 during the acute KD phase, 16 (9.5%; male/female: 9/7) had coronary aneurysms at 1 month after KD onset, and 5 (3.0%) satisfied the definition of progressive coronary dilatation. Multivariate logistic regression analysis revealed that an initial maximal coronary Z-score of ≥ + 2.5 [odds ratio (OR): 5.24, 95% confidence interval (CI): 1.31–21.3, P = 0.020] and hypoalbuminemia (OR: 4.83, 95% CI: 1.11–20.9, P = 0.035) were independent risk factors for coronary aneurysms and were significantly associated with progressive coronary dilatation. However, the association between intravenous immunoglobulin unresponsiveness and the development of coronary aneurysms at 1 month after KD onset didn’t reach the level of significance (P = 0.058).

Conclusions

In the present study, 3% (5/169) of patients with KD had progressive coronary dilatation, which was associated with persistent coronary aneurysms at 1 year after KD onset. Initial coronary dilatation and hypoalbuminemia were independently associated with the occurrence of progressive coronary dilatation. Therefore, such patients may require intensive cardiac monitoring and adjuvant therapies apart from immunoglobulin therapies.

Characterization of miRNAs involved in response to poly(I:C) in porcine airway epithelial cells

MicroRNAs (miRNA) have been implicated in a variety of pathological conditions including infectious diseases. Knowledge of the miRNAs affected by poly(I:C), a synthetic analog of viral double-stranded RNA, in porcine airway epithelial cells (PAECs) contributes to understanding the mechanisms of swine viral respiratory diseases, which bring enormous economic loss worldwide every year. In this study, we used high throughput sequencing to profile miRNA expression in PAECs treated with poly(I:C) as compared to the untreated control. This approach revealed 23 differentially expressed miRNAs (DEMs), five of which have not been implicated in viral infection before. Nineteen of the 23 miRNAs were down-regulated including members of the miR-17-92 cluster, a well-known polycistronic oncomir and extensively involved in viral infection in humans. Target genes of DEMs, predicted using bioinformatic methods and validated by luciferase reporter analysis on two representative DEMs, were significantly enriched in several pathways including transforming growth factor-β signaling. A large quantity of sequence variations (isomiRs) were found including a substitution at position 5, which was verified to redirect miRNAs to a new spectrum of targets by luciferase reporter assay together with bioinformatics analysis. Twelve novel porcine miRNAs conserved in other species were identified by homology analysis together with cloning verification. Furthermore, the expression analysis revealed the potential importance of three novel miRNAs in porcine immune response to viruses. Overall, our data contribute to clarifying the mechanisms underlying the host immune response against respiratory viruses in pigs, and enriches the repertoire of porcine miRNAs.

Paradoxical Hypertension after Successful Cheatham Platinum Stent Implantation in an Adolescent with Coarctation of the Aorta

Stent implantation using a Cheatham Platinum (CP) stent for coarctation of the aorta (CoA) is a promising treatment alternative to traditional surgical repair. However, there are no earlier reports in the literature focusing on use of this stent in a Taiwanese patient. Herein we report a 16-year-old boy with CoA presenting with heart murmur and exercise intolerance who underwent successful CP stent placement. However, severe hypertension with arterial blood pressure increasing to 207/104 mmHg occurred four hours after stent implantation. There was no abdominal pain, nausea or vomiting. The patient's hypertension was controlled by intravenous nitroglycerin infusion, followed by an oral antihypertensitve agent for the following 7 days. Experience from this case highlighted the usefulness of CP stent implantation for native CoA, and the importance of early recognition and management of paradoxical hypertension after CoA stenting.

Electrophysiology Study for Complex Supraventricular Tachycardia in Congenital Heart Disease Patients With Single-Ventricle Physiology

BACKGROUND

Supraventricular tachycardia (SVT) is common in complex congenital heart disease (CCHD) patients with single-ventricle physiology and may cause hemodynamic deterioration. We reported the outcomes of catheter ablation for such complex SVT in these single-ventricle CCHD patients.

METHODS AND RESULTS

Patients with single-ventricle physiology (defined as CCHD patients) who received electrophysiology studies and catheter ablation between 1995 and 2015 were studied. We enrolled 30 CCHD patients (18 with right atrial isomerism, 5 with left atrial isomerism, and 7 with other CCHDs; 17 male, 13 female). The age of onset of clinical SVT was 6.7 years (±4.7 years). Electrophysiology studies and ablation were performed at age 7.1 years (±3.9 years); body weight was 20.7 kg (±10.0 kg). Twin atrioventricular nodes were present in 60% of patients (right atrial isomerism, 72.2%; left atrial isomerism, 40%; other CCHDs, 42.9%). Manifested preexcitation was noted in 10% of patients. SVT was induced in 21 patients. Twin atrioventricular nodal reentrant tachycardia was the most common (57.1%), followed by atrioventricular reentrant tachycardia (28.6%), junctional tachycardia (14.3%), and atrioventricular nodal reentrant tachycardia (9.5%). Multiple arrhythmias were common (33.3%), particularly in patients with atrioventricular reentrant tachycardia (50%). Ablation successfully eliminated SVT in 12 of 14 patients (85.7%), with a recurrence rate of 16.7% during 6 years of follow-up.

CONCLUSIONS

Transcatheter ablation of complex SVT substrates, including minor atrioventricular node of twin atrioventricular nodal reentrant tachycardia, accessory pathways of atrioventricular reentrant tachycardia, and a slow pathway of atrioventricular nodal reentrant tachycardia, is effective in CCHD patients. The limitations are limited vascular access and the risk of atrioventricular block.

Early supplementation of starter pellets with alfalfa improves the performance of pre- and postweaning Hu lambs

This study aims to determine the effects of alfalfa supplementation on the pre- and postweaning performance, rumen development, and feed transition in starter diet-fed lambs. Six of 66 male Hu lambs were slaughtered at the age of 10 d to serve as a control. The other 60 lambs were randomly allocated to 2 dietary treatments: milk replacer and starter pellets without (STA) or with free-choice chopped alfalfa (S-ALF). The animals were offered 300 g/d of the concentrate mixture and had free access to alfalfa after weaning at the end of wk 4 (age 38 d). The alfalfa inclusion in the S-ALF group tended to increase the starter intake before weaning, significantly increased the concentrate intake soon after weaning ( < 0.05), and increased the BW ( < 0.01) and ADG ( < 0.10) in pre- and postweaning lambs. The S-ALF group had heavier carcasses ( < 0.05), rumens ( < 0.05), reticula ( < 0.05), omasums ( < 0.10), abomasums ( < 0.05), and visceral organs ( < 0.10) than the STA lambs after weaning. Alfalfa supplementation increased ( < 0.05) the rumen papillae length and the ratio of the duodenal villus height to the crypt depth; it also decreased ( < 0.05) the concentration and molar proportion of propionate in wk 1 and 5. The STA lambs had higher ( < 0.01) blood concentrations of globulin and blood urea nitrogen and lower β-hydroxybutyrate after weaning. The STA group also had a higher incidence of feed plaque. From the above results, we infer that the free-choice addition of chopped alfalfa to starter diets is beneficial to rumen development, relieves weaning stress, and improves the performance of lambs.

Assessing utility of exercise test in determining exercise prescription in adolescent and adult patients with repaired tetralogy of fallot

Parameters from cardiopulmonary exercise test (CPET) are useful prognostic factors for patients with repaired tetralogy of fallot (TOF). Its application in exercise prescription remains unclear. This study sought to define its role. We made current exercise recommendations in repaired TOF patients according to European Society of Cardiology (ESC) guideline, which were based on ventricular function, pressure/volume load, pulmonary artery pressure, hypoxemia and arrhythmic burden both at rest and during exercise. CPET parameters (peak oxygen consumption, oxygen uptake efficiency plateau, and E/CO₂ slope), along with cardiothoracic ratio, ventricular arrhythmia, QRS duration and NYHA functional status, were used to calculate "score to exercise". 112 repaired TOF adolescent and adult aged 32.6 ± 10.8 (14.05- to 56.99-year-old, median 30.1) years received exercise recommendations by ESC guideline, which suggested high, moderate and low intensity sports for 45 (40.2 %), 45 (40.2 %), and 22 (19.6 %) patients, respectively. The optimal cut-off values were 67 and 77 % for peak VO₂, 86 and 100 % for OUEP, 22 and 28 for E/CO₂ slope to correlate to the exercise intensity recommendation. But, individual CPET parameter had low consistency (41-46 %) in making decisions of exercise intensity compared to ESC recommendations. Using the "score to exercise", the consistency rate could be increased to 74.1 %. With "score to exercise" recommended exercise intensity, follow-up result revealed no adverse event related to sports. Individual CPET parameter did not correlate well to the exercise recommendation from ESC. We proposed a scoring system, "score to exercise", which incorporates three CPET parameters with cardiothoracic ratio, ventricular arrhythmia, QRS duration and NYHA functional status. Score to exercise is easy to be assessed and provides useful information for exercise recommendation in patients with repaired TOF.

Assessing Late Cardiopulmonary Function in Patients with Repaired Tetralogy of Fallot Using Exercise Cardiopulmonary Function Test and Cardiac Magnetic Resonance

BACKGROUND

Patients with repaired tetralogy of Fallot (TOF) usually experience progressive right ventricle (RV) dysfunction due to pulmonary regurgitation (PR). This could further worsen the cardiopulmonary function. This study aimed to compare the changes in patient exercise cardiopulmonary test and cardiac magnetic resonance imaging, and consider the implication of these changes.

METHODS

Our study examined repaired TOF patients who underwent cardiopulmonary exercise test (CPET) to obtain maximal (peak oxygen consumption, peak VO2) and submaximal parameters (oxygen uptake efficiency plateau, oxygen uptake efficiency plateau (OUEP), and ratio of minute ventilation to carbon dioxide production, VE/VCO2 slope). Additionally, the hemodynamic status was assessed by using cardiac magnetic resonance. Criteria for exclusion included TOF patients with pulmonary atresia, atrioventricular septal defect, or absence of pulmonary valve syndrome.

RESULTS

We enrolled 158 patients whose mean age at repair was 7.8 ± 9.1 years (range 0.1-49.2 years) and the mean patient age at CPET was 29.5 ± 12.2 years (range 7.0-57.0 years). Severe PR (PR fraction ≥ 40%) in 53 patients, moderate in 55, and mild (PR fraction < 20%) in 50 patients were noted. The mean RV end-diastolic volume index (RVEDVi) was 113 ± 35 ml/m(2), with 7 patients observed to have a RVEDVi > 163 ml/m(2). The mean left ventricular ejection fraction (LVEF) was 63 ± 8%, left ventricular end-diastolic volume index (LVEDVi) was 65 ± 12 ml/m(2), and LVESVi was 25 ± 14 ml/m(2). CPET revealed significantly decreased peak VO2 (68.5 ± 14.4% of predicted), and fair OUEP (90.3 ± 14.1% of predicted) and VE/VCO2 slope (27.1 ± 5.3). PR fraction and age at repair were negatively correlated with maximal and submaximal exercise indicators (peak VO2 and OUEP). Left ventricular (LV) function and size were positively correlated with peak VO2 and OUEP.

CONCLUSIONS

The results of CPET showed that patients with repaired TOF had a low maximal exercise capacity (peak VO2), but a fair submaximal exercise capacity (OUEP and VE/VCO2 slope), suggesting limited exercise capability in high intensity circumstances. PR, LV function and age at total repair were the most important determinants of CPET performance.

KEY WORDS

Cardiac magnetic resonance; Cardiopulmonary exercise function; Pulmonary regurgitation; Surgical age; Tetralogy of Fallot.

Preconception Counseling for Women with Congenital Heart Disease

With advances that have been made over the recent decades in transcatheter and surgical interventions, most patients with congenital heart disease (CHD) can survive into adulthood. Overall, probably half of these surviving patients are female. When these female CHD patients reach childbearing age, however, pregnancy management will be a major issue. In order to meet the demands of fetal growth, the maternal cardiovascular system starts a series of adaptations beginning in early pregnancy. These adaptations include: decreased systemic and pulmonary vascular resistances, decreased blood pressure, expansion of the blood volume, increased heart rate and increased cardiac output. For women with CHD, this hemodynamic alteration may increase the risks of adverse cardiovascular events as well as the fetal and neonatal complications. Therefore, proper risk stratification and effective counseling for women with CHD who are planning their pregnancies is an important undertaking.

KEY WORDS

Congenital heart disease; Pregnancy.

Six-Minute Walking Test: Normal Reference Values for Taiwanese Children and Adolescents

BACKGROUND

The 6-minute walking test (6MWT) is a simple method used to evaluate exercise capacity in adults and children with cardiac diseases. Normal reference values in pediatric populations have been reported, but significant variations in the walking distance (6MWD) were noted among different studies. We aimed to provide and validate normal reference values of the 6MWD for healthy Taiwanese pediatric population between 7 and 17 years of age.

METHODS

Healthy children and adolescents were recruited from 13 randomly selected schools in Kaohsiung City. From that recruitment effort, 762 participants (50.1% male) were included, and the 6MWT was conducted using standardized protocols. The main outcome measure utilized was the 6MWD, which was used to construct centile charts and Z score equations. Data from additional 64 healthy volunteers recruited from the National Taiwan University Children's Hospital were used to validate these standards.

RESULTS

There was an overall linear trend of increase in the 6MWD between 7 and 17 years of age (p < 0.001). Males covered significantly more distance than females after the age of 14 years, when the 6MWD essentially plateaued in female adolescents. Upon multivariate analysis, height was the most significant positive predictor of the 6MWD, while body mass index negatively correlated with the 6MWD. The height-based normal reference values of the 6MWD, derived from the 6MWT conducted in the school settings, were validated by a second cohort who received 6MWT inside the hospital.

CONCLUSIONS

Normal reference values of the 6MWD in healthy Taiwanese children and adolescents may serve as useful references for future clinical and research studies.

KEY WORDS

Adolescents; Children; Six-minute walking test; Taiwan.

High Sensitivity C Reactive Protein (hs-CRP) in Adolescent and Young Adult Patients with History of Kawasaki Disease

BACKGROUND

For children with a history of Kawasaki disease (KD), low grade inflammation was generally reported to be associated with persistent coronary artery lesions (CAL). However, this association has not been clearly demonstrated to hold true in KD adolescents and young adults (10-25 years of age).

METHODS

We enrolled 104 subjects into our study, who were separated into the following 3 groups and controls: 1): 22 KD patients with angiography-confirmed CAL which persisted for an average of 12.5 years after onset of KD; 2) 38 KD patients with regressed aneurysms; 3) 44 KD patients without any coronary complications from the disease onset; and 4) 31 age-matched (18.7 ± 1.88 years old) healthy controls. Plasma levels of high-sensitivity C reactive protein (hs-CRP) were measured for all participants.

RESULTS

Plasma levels of hs-CRP were significantly higher in KD patients than in the controls, regardless of their coronary severity. However, there was no significant difference in hs-CRP levels among KD patients with different severities of CAL. Of the candidate risk factors of elevated hs-CRP such as body mass index, gender, coronary severity, and levels of high-density lipoprotein-cholesterol, linear regression analysis showed the only independent predictor of hs-CRP levels was BMI (β = 0.306, p = 0.01), rather than patient grouping (p = 0.091).

CONCLUSIONS

Our study found that levels of hs-CRP are significantly higher in adolescent and young adult patients with a history of KD, compared with age-matched controls. Low grade inflammation may play a minor role when KD patients enter into adulthood. body mass index (BMI), rather than coronary severity, was independently associated with the elevation of hs-CRP levels, one of biomarkers for further cardiovascular event. Therefore, ongoing control and management of BMI may be one of beneficial strategies that can be employed to help avoid elevation of hs-CRP levels in KD patients.

KEY WORDS

Adolescents; High sensitivity-C reactive protein; Kawasaki disease; Young adult.

Progressive Coronary Dilatation Predicts Worse Outcome in Kawasaki Disease

OBJECTIVE

To explore the implication of serial coronary changes on the late coronary outcomes in patients with Kawasaki disease (KD) with coronary aneurysms ≧ 4 mm.

STUDY DESIGN

We performed a retrospective review of 78 patients with KD with large coronary aneurysms (1980-2013, male: 76.9%; 792 patient-years). Progressive coronary dilatation was defined for those with progressive enlargement of coronary arteries in 3 consecutive echocardiograms.

RESULTS

We studied 27 patients with KD with giant aneurysms (≧ 8 mm) and 51 patients with KD with medium aneurysms (4-8 mm). All the giant and 43.1% of medium aneurysms persisted during the study period. For the patients with giant aneurysms, their 10-year freedom from acute myocardial infarction/cardiovascular death and all ischemia was 66% and 52%, respectively. The median intervals for the aneurysm diameters reaching their peak were 3.3 months (giant) and 0.25 months (medium), respectively. In patients with giant aneurysms, the 10-year freedom from ischemia was much lower in those with progressive coronary dilatation (28% vs 59%, P = .021). In patients with medium aneurysms, the probability of 5-year persistence of aneurysm was much greater (67.2% vs 14.8%, P < 10(-3)) in those with progressive coronary dilatation. Male sex and intravenous immunoglobulin therapy were not associated with the late outcomes in the patients with KD who had aneurysms larger than 4 mm.

CONCLUSIONS

In addition to coronary diameters 1 month after the onset of KD, progressive coronary dilatation at 2 or more months after diagnosis may be an indicator of duration, and the severity of vasculitis and adverse dilative remodeling were associated with worse late coronary outcomes.

Low immunoglobulin M memory B-cell percentage in patients with heterotaxy syndrome correlates with the risk of severe bacterial infection

BACKGROUND

Patients with heterotaxy syndrome, commonly associated with complex congenital heart disease (CHD), exhibit a higher risk of severe bacterial infection (SBI). We sought to define the change of a novel immunologic marker, the immunoglobulin M (IgM) memory B-cell percentage, and its association with SBI.

METHODS

We enrolled 46 (M/F 29/17) heterotaxy syndrome patients (42 right atrial isomerism (RAI) and 4 left atrial isomerism (LAI)) aged > 1 y during the period 2010-2012 in a tertiary care center. We analyzed IgM(+)CD27(+) memory B-cell percentages. Patients with simple and complex CHD served as controls.

RESULTS

The mean IgM memory B-cell percentages were the lowest in the heterotaxy syndrome group, compared with those in complex and simple CHD groups (1.8 ± 2.1 vs. 3.9 ± 3.2 vs. 5.1 ± 4.7, P < 0.001). In the heterotaxy syndrome group, 41.3% had low IgM memory B-cell percentages (<1% of B cells). Seven had a history of community-acquired SBI and 85.7% of these had low IgM memory B-cell percentages, which was the only significant factors related to community-acquired SBI (P = 0.028).

CONCLUSION

The memory B cell and IgM memory B-cell percentages are low in patients with heterotaxy syndrome, and the presence of IgM memory B-cell percentage < 1% correlates with community-acquired SBI.

Telmisartan inhibited angiotensin II-induced collagen metabolic imbalance without directly targeting TGF-β 1/Smad signaling pathway in cardiac fibroblasts

AIM

Cardiac fibrosis is an important pathological process of cardiac remodeling. A large number of studies have shown that telmisartan can attenuate cardiac fibrosis through acting on angiotensin II 1 receptor (AT1R), and TGF-β 1/Smad signaling molecule is an important pathway to achieve this effect. The aim of the study was to clarify whether, with excessive activation of RAAS system, telmisartan could also directly target TGF-β 1/Smad signaling pathway to have the function of anti-cardiac fibrosis.

METHODS

In this study, neonatal rat cardiac fibroblasts were cultured and AngII or TGF-β 1 was administered for treatment or pre-incubation, and then telmisartan was used for 24 hours' incubation. Western blot and enzyme-linked immunosorbent assay (ELISA) tests were performed to detect protein expressions.

RESULTS

The results showed that telmisartan could inhibit collagen synthesis and collagen metabolic imbalance under the effect of Ang II, but telmisartan could not have such function in TGF-β 1-induced cardiac fibroblasts. It was further confirmed by western blot method that telmisartan could inhibit TGF-β 1/Smad signaling molecule expression under the effect of Ang II, but telmisartan had no effect on TGF-β 1-induced Smad signaling molecule expression.

CONCLUSION

According to the present study telmisartan played a role of anticardiac fibrosis without directly targeting TGF-β 1/Smad signaling pathway molecule.

Effects of Supplemental Levels of Saccharomyces cerevisiae Fermentation Product on Lactation Performance in Dairy Cows under Heat Stress

The objectives of this study were to evaluate the effects of different supplemental levels of Saccharomyces cerevisiae fermentation product (SCFP; Original XP; Diamond V) on lactation performance in Holstein dairy cows under heat stress. Eighty-one multiparous Holstein dairy cows were divided into 27 blocks of 3 cows each based on milk yield (23.6±0.20 kg/d), parity (2.88±0.91) and day in milk (204±46 d). The cows were randomly assigned within blocks to one of three treatments: 0 (control), 120, or 240 g/d of SCFP mixed with 240, 120, or 0 g of corn meal, respectively. The experiment was carried out during the summer season of 2014, starting from 14 July 2014 and lasting for 9 weeks with the first week as adaption period. During the experimental period, average daily temperature-humidity index (measured at 08:00, 14:00, and 20:00) was above 68, indicating that cows were exposed to heat stress throughout the study. Rectal temperatures tended to decrease linearly (p = 0.07) for cows supplemented with SCFP compared to the control cows at 14:30, but were not different at 06:30 (p>0.10). Dry matter intake was not affected by SCFP supplementation (p>0.10). Milk yield increased linearly (p<0.05) with increasing levels of SCFP. Feed efficiency (milk yield/dry matter intake) was highest (p<0.05) for cows fed 240 g/d SCFP. Cows supplemented with SCFP gained (p<0.01) body weight, while cows in the control lost body weight. Net energy balance also increased linearly (p<0.01) with increasing levels of SCFP. Concentrations of milk urea nitrogen (p<0.01) decreased linearly with increasing levels of SCFP, while no difference (p>0.10) was observed among the treatments in conversion of dietary crude protein to milk protein yield. In summary, supplementation of SCFP alleviated the negative effect of heat stress in lactating Holstein dairy cows and allowed cows to maintain higher milk production, feed efficiency and net energy balance. Effects of SCFP were dose-dependent and greater effects were observed from higher doses.

Effects of Replacement of Concentrate Mixture by Broccoli Byproducts on Lactating Performance in Dairy Cows

The objective of the present study was to determine the effects of feeding pelletized broccoli byproducts (PBB) on milk yield and milk composition in dairy cows. In Trial 1, an in vitro gas test determined the optimal replacement level of PBB in a concentrate mixture in a mixed substrate with Chinese wild ryegrass hay (50:50, w/w) at levels of 0, 10%, 20%, 30%, or 40% (dry matter basis). When the concentrate was replaced by PBB at a level of 20%, no adverse effects were found on the gas volume or its rate constant during ruminal fermentation. In trial 2, 24 lactating cows (days in milk = 170.4±35; milk yield = 30±3 kg/d; body weight = 580 ±13 kg) were divided into 12 blocks based on day in milk and milk yield and randomly allocated to two dietary treatments: a basic diet with or without PBB replacing 20% of the concentrate mixture. The feeding trial lasted for 56 days; the first week allowed for adaptation to the diet. The milk composition was analyzed once a week. No significant difference in milk yield was observed between the two groups (23.5 vs 24.2 kg). A significant increase was found in milk fat content in the PBB group (p<0.05). Inclusion of PBB did not affect milk protein, lactose, total solids or solids-not-fat (p>0.05). These results indicated that PBB could be included in dairy cattle diets at a suitable level to replace concentrate mixture without any adverse effects on dairy performance.

Acute and late coronary outcomes in 1073 patients with Kawasaki disease with and without intravenous γ-immunoglobulin therapy

OBJECTIVE

To explore acute and late coronary outcomes and their risk/modifiers in patients with Kawasaki disease (KD).

DESIGN

Retrospective study.

SETTING AND PATIENTS

1073 patients with KD identified from a tertiary care medical centre (1980-2012; 8677 patient-years).

MAIN OUTCOME MEASURES

The acute coronary severities and late outcomes (survival free of coronary aneurysm persistence and ischaemia) were assessed.

RESULTS

Coronary arterial lesions occurred in 40.6% of cases at their acute febrile stages, and persisted beyond 1 month in 196 (18.3%, M/F=138/58) patients: 125 (11.6%) had small aneurysms, 44 (4.1%) had medium aneurysms, and 27 (2.5%) had giant aneurysms. At follow-up (1-46 years), coronary aneurysms persisted in all with giant aneurysms, in 55% of those with medium aneurysms (18% with stenosis), and in 9% of those with small aneurysms. Ischaemia events occurred in 14 patients (M/F=13/1) and caused four deaths. Among the patients with KD with coronary aneurysms, 10-year ischaemia event-free and aneurysm persistence probability was 87.5% and 20.6%, respectively. The only independent risk for aneurysm persistence was the aneurysm severity 1 month after KD onset (χ(2)=80.73, p<10(-3)). Male patients and intravenous γ-immunoglobulin (IVIG) therapy were independent risk factors of initial coronary severity but were not associated with the late coronary outcomes, even in severity stratified subgroups.

CONCLUSIONS

The coronary severity 1 month after KD onset is most crucial to the late coronary outcomes. Although IVIG use improves the initial severity of coronary lesions, it does not further modify the long-term fate of coronary aneurysms.

Risk factors and derived formosa score for intravenous immunoglobulin unresponsiveness in Taiwanese children with Kawasaki disease

BACKGROUND/PURPOSE

Kawasaki disease (KD) is the most common pediatric vasculitis. The study aimed to identify the risk factors of intravenous immunoglobulin (IVIG) unresponsiveness from the initial clinical parameters of the Taiwanese KD patients.

METHODS

We enrolled 248 KD (development dataset: 181, validation: 67) patients who received IVIG within 10 days after fever onset. IVIG unresponsiveness was defined by persistent fever beyond 24 hours after IVIG or recrudescent fever with KD symptoms.

RESULTS

From the development dataset (181 patients), IVIG unresponsiveness was noted in 22 patients (12.1%). The preIVIG levels of albumin, percentage of neutrophils, and positive lymphadenopathy were identified with highest risk for IVIG unresponsiveness. These three variables were used to construct a three-variable logistic regression model, which yielded an area under the receiver-operating-characteristics curve of 0.87. These three variables were further used to generate a composite scoring model (Formosa score) which yielded a sensitivity of 90.9% and specificity of 81.3% for a cut-off point of three or more. Validation in an independent cohort (67 KD patients) yielded sensitivity and specificity of 71.4% and 81.0%, respectively.

CONCLUSION

We have established a simple three-variable Formosa score for KD patients to identify early those at risk of IVIG unresponsiveness for timely aggressive immunomodulation initially.

Assessment of Patterns of Patient-Reported Outcomes in Adults with Congenital Heart disease - International Study (APPROACH-IS): rationale, design, and methods

BACKGROUND

Data on patient-reported outcomes (PROs) in adults with congenital heart disease (CHD) are inconsistent and vary across the world. Better understanding of PROs and their differences across cultural and geographic barriers can best be accomplished via international studies using uniform research methods. The APPROACH-IS consortium (Assessment of Patterns of Patient-Reported Outcomes in Adults with Congenital Heart disease - International Study) was created for this purpose and investigates PROs in adults with CHD worldwide. This paper outlines the project rationale, design, and methods.

METHODS/DESIGN

APPROACH-IS is a cross-sectional study. The goal is to recruit 3500-4000 adults with CHD from 15 countries in five major regions of the world (Asia, Australia, Europe, North and South America). Self-report questionnaires are administered to capture information on PRO domains: (i) perceived health status (12-item Short-form Health Survey & EuroQOL-5D); (ii) psychological functioning (Hospital Anxiety and Depression Scale); (iii) health behaviors (Health-Behavior Scale-Congenital Heart Disease); and (iv) quality of life (Linear Analog Scale & Satisfaction With Life Scale). Additionally, potential explanatory variables are assessed: (i) socio-demographic variables; (ii) medical history (chart review); (iii) sense of coherence (Orientation to Life Questionnaire); and (iv) illness perceptions (Brief Illness Perception Questionnaire). Descriptive analyses and multilevel models will examine differences in PROs and investigate potential explanatory variables.

DISCUSSION

APPROACH-IS represents a global effort to increase research understanding and capacity in the field of CHD, and will have major implications for patient care. Results will generate valuable information for developing interventions to optimize patients' health and well-being.

REGISTRATION

ClinicalTrials.gov: NCT02150603.

Between invisible defects and visible impact: the life experiences of adolescents and young adults with congenital heart disease

AIM

To describe the life experiences of adolescents and young adults with congenital heart disease.

BACKGROUND

Owing to medical advances, most children with congenital heart disease are expected to survive into adulthood. The transitional development from adolescence to adult is the critical period for fostering self-care.

DESIGN

Descriptive phenomenological study.

METHODS

Thirty-five patients of 15-24 years old with congenital heart disease were recruited from paediatric cardiology clinics by purposive sampling. They were individually interviewed between October 2012-February 2013 using a semi-structured interview guideline and joined adult congenital heart disease clinics at two medical centres in northern Taiwan. The data were analysed using descriptive phenomenological method developed by Giorgi.

FINDINGS

The essence of the life experience of adolescents and young adults with congenital heart disease involves a dynamic process of moving between invisible defects and coexistence with the disease. Six themes emerged: (1) invisible defects: the existence of imperfect understanding; (2) conflict: interpersonal frustrations; (3) imbalance: the loss of self-balance; (4) suffering: increasing anxiety; (5) encounters: meeting needs; and (6) coexistence: positive coping strategies.

CONCLUSION

As patients with congenital heart disease transition from adolescence into adulthood, they must learn about their disease, overcome frustration and anxiety and develop self-care strategies for coexisting with congenital heart disease. Results of this study may serve as clinical care guidelines for adolescents and young adults with congenital heart disease and give a reference for developing transitional intervention strategies.

Trends in the utilization of computed tomography and cardiac catheterization among children with congenital heart disease

Background/Purpose

Pediatric cardiac computed tomography (CT) is a noninvasive imaging modality used to clearly demonstrate the anatomical detail of congenital heart diseases. We investigated the impact of cardiac CT on the utilization of cardiac catheterization among children with congenital heart disease.

Methods

The study sample consisted of 2648 cardiac CT and 3814 cardiac catheterization from 1999 to 2009 for congenital heart diseases. Diagnoses were categorized into 11 disease groups. The numbers of examination, according to the different modalities, were compared using temporal trend analyses. The estimated effective radiation doses (mSv) of CT and catheterization were calculated and compared.

Results

The number of CT scans and interventional catheterizations had a slight annual increase of 1.2% and 2.7%, respectively, whereas that of diagnostic catheterization decreased by 6.2% per year. Disease groups fell into two categories according to utilization trend differences between CT and diagnostic catheterization. The increased use of CT reduces the need for diagnostic catheterization in patients with atrioventricular connection disorder, coronary arterial disorder, great vessel disorder, septal disorder, tetralogy of Fallot, and ventriculoarterial connection disorder. Clinicians choose either catheterization or CT, or both examinations, depending on clinical conditions, in patients with semilunar valvular disorder, heterotaxy, myocardial disorder, pericardial disorder, and pulmonary vein disorder. The radiation dose of CT was lower than that of diagnostic cardiac catheterization in all age groups.

Conclusion

The use of noninvasive CT in children with selected heart conditions might reduce the use of diagnostic cardiac catheterization. This may release time and facilities within the catheterization laboratory to meet the increasing demand for cardiac interventions.

Coronary Diameters in Taiwanese Children Younger than 6 Years Old: Z-Score Regression Equations Derived from Body Surface Area

BACKGROUND

The measurements of coronary diameters, usually obtained by 2-dimentsional echocardiography, play important roles oin the management and follow-up of Kawasaki disease (KD). However, in Taiwan, domestic normgrams and a Z-score calculator for coronary artery diameters are still not available.

METHODS

Echocardiography was performed on 412 healthy children younger than 6 years of age. The appropriate exponential regression model was fitted to correspond with body surface area (BSA). The computed Z-scores of all subjects were also tested for normal distribution.

RESULTS

Using the model ln (measurement) = β1 + β2 × ln (BSA), the adjusted R(2) values were 0.611 and 0.484 for the models of the left main coronary artery (LMCA) and the right (RCA), respectively. Analysis of computed Z-score distribution showed acceptable goodness of fit for a normal distribution [p = 0.90 (LMCA); p = 0.17 (RCA)].

CONCLUSIONS

We have established reference ranges for the coronary artery diameters in Taiwanese children younger than 6 years of age. The regression equations and Z-score calculators for the LMCA and RCA provide an objective determination of coronary dilatation in a large population, which is important for the care and medical management of KD patients in Taiwan.

KEY WORDS

Coronary diameter; Kawasaki disease; Taiwan; Z-score.