Arrhythmogenic forms of heart failure in children

Accuracy of the Apple Watch iECG in Children With and Without Congenital Heart Disease

The development of smart technologies paves the way for new diagnostic modalities. The Apple Watch provides an FDA approved iECG function for users from 22 years of age. Yet, there are currently no data on the accuracy of the Apple Watch iECG in children. While arrhythmias are a frequent phenomenon in children, especially those with congenital heart disease, the increasing spread of smart watches provides the possibility to use a smart watch as mobile event recorder in case of suspected arrhythmia. This may help to provide valuable information to the treating physician, without having the patient to come to the hospital. Necessary treatment adjustments might be provided without timely delay. The aim of this study was therefore to evaluate the agreement of measured values of rate, interval, and amplitude with those obtained by a diagnostic quality ECG recording to an Apple Watch iECG in children with and without congenital heart disease. In this prospective, single-arm study, consecutive patients aged 0-16 years presenting to the Heart Center Leipzig, Department for pediatric cardiology were included. After obtaining informed consent from participants' parents, a 12-lead ECG and an iECG using an Apple Watch were performed. Cardiac rhythm was classified, amplitudes and timing intervals were measured and analyzed in iECG and 12-lead ECG for comparability. These measurements were performed blinded to the patients' history by two experienced pediatric cardiologists. Patient demographic data, medical and cardiac history were assessed. 215 children between 0 and 16 years were enrolled. Comparison of amplitudes and timing intervals between ECG and iECG showed excellent correlation (K > 0.7, p < 0.01) in all parameters except for the p-waves. Automatic rhythm classification was inferior to manual interpretation of ECG / iECG, while iECG interpretation was reliable in 94.86% of cases. The study demonstrates equal quality of the Apple Watch derived iECG compared to a lead I in 12-lead ECG in children of all age groups and independent from cardiac anatomy.

Critical care for paediatric patients with heart failure

This review offers a critical-care perspective on the pathophysiology, monitoring, and management of acute heart failure syndromes in children. An in-depth understanding of the cardiovascular physiological disturbances in this population of patients is essential to correctly interpret clinical signs, symptoms and monitoring data, and to implement appropriate therapies. In this regard, the myocardial force-velocity relationship, the Frank-Starling mechanism, and pressure-volume loops are discussed. A variety of monitoring modalities are used to provide insight into the haemodynamic state, clinical trajectory, and response to treatment. Critical-care treatment of acute heart failure is based on the fundamental principles of optimising the delivery of oxygen and minimising metabolic demands. The former may be achieved by optimising systemic arterial oxygen content and the variables that determine cardiac output: heart rate and rhythm, preload, afterload, and contractility. Metabolic demands may be decreased by a number of ways including positive pressure ventilation, temperature control, and sedation. Mechanical circulatory support should be considered for refractory cases. In the near future, monitoring modalities may be improved by the capture and analysis of complex clinical data such as pressure waveforms and heart rate variability. Using predictive modelling and streaming analytics, these data may then be used to develop automated, real-time clinical decision support tools. Given the barriers to conducting multi-centre trials in this population of patients, the thoughtful analysis of data from multi-centre clinical registries and administrative databases will also likely have an impact on clinical practice.

A rare cause of vomiting in a 5-year-old girl

A 5-year-old previously healthy girl presented to the emergency department (ED) with vomiting for 6 days. Her activity level was normal but her parents described progressive exercise intolerance with frequent recreational breaks approximately 2 days prior to presentation. In addition, the child complained of mild abdominal discomfort that began 24 hours prior to her presentation. She had no diarrhea or changes in her diet or oral intake; she had no dysuria or changes in urination. She had no cough, shortness of breath, dizziness, vision changes, falls, or decreased coordination.

Recurrent congestive heart failure in a child due to probable myocarditis

Recurrent congestive heart failure (CHF) attributable to myocarditis is a seldom-discussed entity in the scientific literature. This report describes the case of an 8-year-old girl who had three clinically identical episodes of CHF, beginning at the age of 5 years, with each episode preceded by a viral prodrome. The clinical features and the echocardiography and electrocardiogram findings were most supportive of myocarditis. Symptoms and investigations completely normalized between episodes. The third episode, associated with influenza A (strain H1N1) infection, led to cardiac arrest and death on day 2 after admission. Autopsy showed mild cardiomegaly with microscopic foci of myocardial fibrosis and extensive contraction band necrosis. This report is the first to describe recurrent CHF due to probable myocarditis in a pediatric patient.