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Hellström Schmidt S, Smedenmark J, Jeremiasen I, Sigurdsson B, Eklund EA, Pronk CJ. Overuse of EEG and ECG in children with breath-holding spells and its implication for the management of the spells. Acta Paediatr 2024; 113:317-326. [PMID: 37905418 DOI: 10.1111/apa.17020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/15/2023] [Accepted: 10/19/2023] [Indexed: 11/02/2023]
Abstract
AIM Breath-holding spells (BHS) are common in children, but evidence-based clinical guidelines are lacking. We investigated a large population-based cohort of BHS patients, to propose a refined description of typical BHS and guidelines for its management. METHODS In a cross-sectional retrospective study, patients diagnosed with BHS in Southern Sweden 2004-2018 were recruited. Disease characteristics and diagnostic data were collected from patient medical records. RESULTS In total, 519 patients, mean age at diagnosis 19.8 ± 13.8 months with equal gender distribution, were included. In 48.3%, BHS had already been diagnosed after one spell. During spells, 78.0% of patients were unresponsive. For 71.5%, atonic, tonic, tonic-clonic or myoclonic seizures were reported, and 78.0% of patients had a spell lasting less than 1 min. Electroencephalography was conducted in 30.4% and Electrocardiography in 45.1%. Six children (3.8%) had a pathological electroencephalogram, four of which had concomitant epilepsy and only 0.9% of children had electrocardiogram findings suggesting pathology, none showing long QT syndrome. CONCLUSION Children with BHS were frequently subjected to unnecessary diagnostic interventions. We characterise a typical presentation of BHS and propose a management-algorithm, which is expected to reduce unnecessary usage of electroencephalography and electrocardiography.
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Affiliation(s)
- Sanna Hellström Schmidt
- Department of Paediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
- Chilhood Cancer Center, Skåne University Hospital, Lund, Sweden
| | - Julia Smedenmark
- Department of Paediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Ida Jeremiasen
- The Paediatric Heart Center, Skåne University Hospital, Lund, Sweden
| | - Björn Sigurdsson
- Department of Paediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Paediatric Neurology, Skåne University Hospital, Lund, Sweden
| | - Erik A Eklund
- Department of Paediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Paediatric Neurology, Skåne University Hospital, Lund, Sweden
| | - Cornelis Jan Pronk
- Department of Paediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
- Chilhood Cancer Center, Skåne University Hospital, Lund, Sweden
- Wallenberg Centre Molecular Medicine and Division Molecular Haematology, Lund University, Lund, Sweden
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Jeremiasen I, Tran-Lundmark K, Dolk M, Naumburg E. Outpatient prescription of pulmonary vasodilator therapy to preterm children with bronchopulmonary dysplasia. Acta Paediatr 2023; 112:409-416. [PMID: 36478302 PMCID: PMC10108203 DOI: 10.1111/apa.16615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/28/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022]
Abstract
AIM The use of pulmonary vasodilator therapy in children born preterm is largely unknown. Our aim was to map prescription patterns in children with bronchopulmonary dysplasia in Sweden. METHODS This was a descriptive national registry-based study of children <7 years who had been prescribed a pulmonary vasodilator during 2007-2017, were born preterm and classified as having bronchopulmonary dysplasia. Information on prescriptions, patient characteristics and comorbidities were retrieved from the Swedish Prescribed Drug Register and linked to other national registers. RESULTS The study included 74 children, 54 (73%) born at 22-27 weeks' gestation and 20 (27%) at 28-36 weeks. Single therapy was most common, n = 64 (86.5%), and sildenafil was prescribed most frequently, n = 69 (93%). Bosentan, iloprost, macitentan and/or treprostinil were used mainly for combination therapies, n = 10 (13.5%). Patent ductus arteriosus or atrial septal defect were present in 29 (39%) and 25 (34%) children, respectively, and 20 (69%) versus 3 (12%) underwent closure. Cardiac catheterisation was performed in 19 (26%) patients. Median duration of therapy was 4.6 (1.9-6.8, 95% CI) months. Mortality was 9%. CONCLUSION Preterm children with bronchopulmonary dysplasia were prescribed pulmonary vasodilators, often without prior catheterisation. Sildenafil was most commonly used. Diagnostic tools, effects, and drug safety need further evaluation.
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Affiliation(s)
- Ida Jeremiasen
- Department of Experimental Medical Science, Lund University, Lund, Sweden.,The Paediatric Heart Centre, Skåne University Hospital, Lund, Sweden
| | - Karin Tran-Lundmark
- Department of Experimental Medical Science, Lund University, Lund, Sweden.,The Paediatric Heart Centre, Skåne University Hospital, Lund, Sweden.,Wallenberg Centre for Molecular Medicine, Lund University, Lund, Sweden
| | - Mikaela Dolk
- Department of Experimental Medical Science, Lund University, Lund, Sweden.,The Paediatric Heart Centre, Skåne University Hospital, Lund, Sweden
| | - Estelle Naumburg
- Department of Clinical Sciences, Paediatrics, Umeå University, Umeå, Sweden
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Jeremiasen I, Naumburg E, Westöö C, G Weismann C, Tran-Lundmark K. Vasodilator therapy for pulmonary hypertension in children: a national study of patient characteristics and current treatment strategies. Pulm Circ 2021; 11:20458940211057891. [PMID: 34925762 PMCID: PMC8671688 DOI: 10.1177/20458940211057891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 10/19/2021] [Indexed: 02/06/2023] Open
Abstract
Pulmonary vasodilator therapy is still often an off-label treatment for pulmonary hypertension in children. The aim of this nationwide register-based study was to assess patient characteristics and strategies for pulmonary vasodilator therapy in young Swedish children. Prescription information for all children below seven years of age at treatment initiation, between 2007 and 2017, was retrieved from the National Prescribed Drug Register, and medical information was obtained by linkage to other registers. All patients were categorized according to the WHO classification of pulmonary hypertension. In total, 233 patients had been prescribed pulmonary vasodilators. The treatment was initiated before one year of age in 61% (N = 143). Sildenafil was most common (N = 224 patients), followed by bosentan (N = 29), iloprost (N = 14), macitentan (N = 4), treprostinil (N = 2) and riociguat (N = 2). Over the study period, the prescription rate for sildenafil tripled. Monotherapy was most common, 87% (N = 203), while 13% (N = 20) had combination therapy. Bronchopulmonary dysplasia (N = 82, 35%) and/or congenital heart defects (N = 156, 67%) were the most common associated conditions. Eight percent (N = 18) of the patients had Down syndrome. Cardiac catheterization had been performed in 39% (N = 91). Overall mortality was 13% (N = 30) during the study period. This study provides an unbiased overview of national outpatient use of pulmonary vasodilator therapy in young children. Few cases of idiopathic pulmonary arterial hypertension were found, but a large proportion of pulmonary hypertension associated with congenital heart defects or bronchopulmonary dysplasia. Despite treatment, mortality was high, and additional pediatric studies are needed for a better understanding of underlying pathologies and evidence of treatment effects.
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Affiliation(s)
- Ida Jeremiasen
- Department of Experimental Medical Science and Wallenberg Centre for Molecular Medicine, Lund University, Lund, Sweden.,The Paediatric Heart Center, Skane University Hospital, Lund, Sweden
| | - Estelle Naumburg
- Institution of Clinical Sciences, Paediatrics, Umeå University, Umeå, Sweden
| | - Christian Westöö
- Department of Experimental Medical Science and Wallenberg Centre for Molecular Medicine, Lund University, Lund, Sweden
| | | | - Karin Tran-Lundmark
- Department of Experimental Medical Science and Wallenberg Centre for Molecular Medicine, Lund University, Lund, Sweden.,The Paediatric Heart Center, Skane University Hospital, Lund, Sweden
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Westöö C, Norvik C, Peruzzi N, van der Have O, Lovric G, Jeremiasen I, Tran PK, Mokso R, de Jesus Perez V, Brunnström H, Bech M, Galambos C, Tran-Lundmark K. Distinct types of plexiform lesions identified by synchrotron-based phase-contrast micro-CT. Am J Physiol Lung Cell Mol Physiol 2021; 321:L17-L28. [PMID: 33881927 DOI: 10.1152/ajplung.00432.2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
In pulmonary arterial hypertension, plexiform lesions are associated with severe arterial obstruction and right ventricular failure. Exploring their structure and position is crucial for understanding the interplay between hemodynamics and vascular remodeling. The aim of this research was to use synchrotron-based phase-contrast micro-CT to study the three-dimensional structure of plexiform lesions. Archived paraffin-embedded tissue samples from 14 patients with pulmonary arterial hypertension (13 idiopathic, 1 with known BMPR2-mutation) were imaged. Clinical data showed high-median PVR (12.5 WU) and mPAP (68 mmHg). Vascular lesions with more than 1 lumen were defined as plexiform. Prior radiopaque dye injection in some samples facilitated 3-D rendering. Four distinct types of plexiform lesions were identified: 1) localized within or derived from monopodial branches (supernumerary arteries), often with a connection to the vasa vasorum; 2) localized between pulmonary arteries and larger airways as a tortuous transformation of intrapulmonary bronchopulmonary anastomoses; 3) as spherical structures at unexpected abrupt ends of distal pulmonary arteries; and 4) as occluded pulmonary arteries with recanalization. By appearance and localization, types 1-2 potentially relieve pressure via the bronchial circulation, as pulmonary arteries in these patients were almost invariably occluded distally. In addition, types 1-3 were often surrounded by dilated thin-walled vessels, often connected to pulmonary veins, peribronchial vessels, or the vasa vasorum. Collaterals, bypassing completely occluded pulmonary arteries, were also observed to originate within plexiform lesions. In conclusion, synchrotron-based imaging revealed significant plexiform lesion heterogeneity, resulting in a novel classification. The four types likely have different effects on hemodynamics and disease progression.
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Affiliation(s)
- Christian Westöö
- Department of Experimental Medical Science, Lund University, Lund, Sweden
| | - Christian Norvik
- Department of Experimental Medical Science, Lund University, Lund, Sweden
| | - Niccolò Peruzzi
- Department of Clinical Sciences, Division of Medical Radiation Physics, Lund University, Lund, Sweden
| | - Oscar van der Have
- Department of Experimental Medical Science, Lund University, Lund, Sweden
| | - Goran Lovric
- Centre d'Imagerie BioMédicale, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland.,Swiss Light Source, Paul Scherrer Institute, Villigen, Switzerland
| | - Ida Jeremiasen
- Department of Experimental Medical Science, Lund University, Lund, Sweden.,Children's Heart Center, Skåne University Hospital, Lund, Sweden
| | - Phan-Kiet Tran
- Children's Heart Center, Skåne University Hospital, Lund, Sweden
| | - Rajmund Mokso
- Max IV Laboratory, Lund University, Lund, Sweden.,Institute for Biomedical Engineering, University and ETH Zürich, Zurich, Switzerland
| | | | - Hans Brunnström
- Department of Clinical Sciences Lund, Division of Pathology, Lund University, Lund, Sweden.,Department of Genetics and Pathology, Division of Laboratory Medicine, Lund University, Lund, Sweden
| | - Martin Bech
- Department of Clinical Sciences, Division of Medical Radiation Physics, Lund University, Lund, Sweden
| | - Csaba Galambos
- Department of Pathology and Laboratory Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Karin Tran-Lundmark
- Department of Experimental Medical Science, Lund University, Lund, Sweden.,Children's Heart Center, Skåne University Hospital, Lund, Sweden.,Wallenberg Centre for Molecular Medicine, Lund University, Lund, Sweden
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Jeremiasen I, Tran-Lundmark K, Idris N, Tran PK, Moledina S. Pulmonary Vasodilator Therapy in Children with Single Ventricle Physiology: Effects on Saturation and Pulmonary Arterial Pressure. Pediatr Cardiol 2020; 41:1651-1659. [PMID: 32734529 PMCID: PMC7695650 DOI: 10.1007/s00246-020-02424-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/21/2020] [Indexed: 11/30/2022]
Abstract
In children with single ventricle physiology, increased pulmonary vascular resistance may impede surgical progression or result in failing single ventricle physiology. The use of pulmonary vasodilators has been suggested as a potential therapy. However, knowledge on indication, dosage, and effect is limited. A retrospective case notes review of all (n = 36) children with single ventricle physiology, treated with pulmonary vasodilators by the UK Pulmonary Hypertension Service for Children 2004-2017. Therapy was initiated in Stage 1 (n = 12), Glenn (n = 8), or TCPC (n = 16). Treatment indications were high mean pulmonary arterial pressure, cyanosis, reduced exercise tolerance, protein-losing enteropathy, ascites, or plastic bronchitis. Average dose of sildenafil was 2.0 mg/kg/day and bosentan was 3.3 mg/kg/day. 56% had combination therapy. Therapy was associated with a reduction of the mean pulmonary arterial pressure from 19 to 14 mmHg (n = 17, p < 0.01). Initial therapy with one or two vasodilators was associated with an increase in the mean saturation from 80 to 85%, (n = 16, p < 0.01). Adding a second vasodilator did not give significant additional effect. 5 of 12 patients progressed from Stage 1 to Glenn, Kawashima, or TCPC, and 2 of 8 from Glenn to TCPC during a mean follow-up time of 4.7 years (0-12.8). Bosentan was discontinued in 57% and sildenafil in 14% of treated patients and saturations remained stable. Pulmonary vasodilator therapy was well tolerated and associated with improvements in saturation and mean pulmonary arterial pressure in children with single ventricle physiology. It appears safe to discontinue when no clear benefit is observed.
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Affiliation(s)
- Ida Jeremiasen
- Department of Experimental Medical Science, Lund University, BMC C12, 221 84, Lund, Sweden. .,The Pediatric Heart Center, Skane University Hospital, Lund, Sweden.
| | - Karin Tran-Lundmark
- Department of Experimental Medical Science, Lund University, BMC C12, 221 84 Lund, Sweden ,The Pediatric Heart Center, Skane University Hospital, Lund, Sweden
| | - Nikmah Idris
- Great Ormond Street Hospital for Children, London, UK
| | - Phan-Kiet Tran
- The Pediatric Heart Center, Skane University Hospital, Lund, Sweden
| | - Shahin Moledina
- Great Ormond Street Hospital for Children, London, UK ,University College London, London, UK
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Norvik C, Westöö CK, Peruzzi N, Lovric G, van der Have O, Mokso R, Jeremiasen I, Brunnström H, Galambos C, Bech M, Tran-Lundmark K. Synchrotron-based phase-contrast micro-CT as a tool for understanding pulmonary vascular pathobiology and the 3-D microanatomy of alveolar capillary dysplasia. Am J Physiol Lung Cell Mol Physiol 2019; 318:L65-L75. [PMID: 31596108 DOI: 10.1152/ajplung.00103.2019] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
This study aimed to explore the value of synchrotron-based phase-contrast microcomputed tomography (micro-CT) in pulmonary vascular pathobiology. The microanatomy of the lung is complex with intricate branching patterns. Tissue sections are therefore difficult to interpret. Recruited intrapulmonary bronchopulmonary anastomoses (IBAs) have been described in several forms of pulmonary hypertension, including alveolar capillary dysplasia with misaligned pulmonary veins (ACD/MPV). Here, we examine paraffin-embedded tissue using this nondestructive method for high-resolution three-dimensional imaging. Blocks of healthy and ACD/MPV lung tissue were used. Pulmonary and bronchial arteries in the ACD/MPV block had been preinjected with dye. One section per block was stained, and areas of interest were marked to allow precise beam-alignment during image acquisition at the X02DA TOMCAT beamline (Swiss Light Source). A ×4 magnifying objective coupled to a 20-µm thick scintillating material and a sCMOS detector yielded the best trade-off between spatial resolution and field-of-view. A phase retrieval algorithm was applied and virtual tomographic slices and video clips of the imaged volumes were produced. Dye injections generated a distinct attenuation difference between vessels and surrounding tissue, facilitating segmentation and three-dimensional rendering. Histology and immunohistochemistry post-imaging offered complementary information. IBAs were confirmed in ACD/MPV, and the MPVs were positioned like bronchial veins/venules. We demonstrate the advantages of using synchrotron-based phase-contrast micro-CT for three-dimensional characterization of pulmonary microvascular anatomy in paraffin-embedded tissue. Vascular dye injections add additional value. We confirm intrapulmonary shunting in ACD/MPV and provide support for the hypothesis that MPVs are dilated bronchial veins/venules.
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Affiliation(s)
- Christian Norvik
- Department of Experimental Medical Science, Lund University, Lund, Sweden
| | | | - Niccolò Peruzzi
- Medical Radiation Physics, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Goran Lovric
- Centre d'Imagerie BioMédicale, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland.,Swiss Light Source, Paul Scherrer Institute, Villigen, Switzerland
| | - Oscar van der Have
- Department of Experimental Medical Science, Lund University, Lund, Sweden
| | | | - Ida Jeremiasen
- Department of Experimental Medical Science, Lund University, Lund, Sweden
| | - Hans Brunnström
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Csaba Galambos
- Children's Hospital Colorado, Department of Pathology and Laboratory Medicine, Aurora, Colorado
| | - Martin Bech
- Medical Radiation Physics, Department of Clinical Sciences, Lund University, Lund, Sweden
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Jeremiasen I, Hanséus K, Naumann P, Nilsson C, Tedgård U, Svensson PJ, Andersson NG. Establishing a regional paediatric registry improved the overview and detection of side effects in children on anticoagulants. Acta Paediatr 2018; 107:166-167. [PMID: 28898469 DOI: 10.1111/apa.14069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ida Jeremiasen
- Centre for Paediatric Cardiology, Skåne University Hospital, Lund, Sweden
| | - Katarina Hanséus
- Centre for Paediatric Cardiology, Skåne University Hospital, Lund, Sweden
| | - Pernilla Naumann
- Centre for Thrombosis and Haemostasis, Skåne University Hospital, Malmö, Sweden
| | - Camilla Nilsson
- Centre for Thrombosis and Haemostasis, Skåne University Hospital, Malmö, Sweden
| | - Ulf Tedgård
- Department for Paediatric Haematology and Oncology, Skåne University Hospital, Lund, Sweden
| | - Peter J Svensson
- Centre for Thrombosis and Haemostasis, Skåne University Hospital, Malmö, Sweden
| | - Nadine G Andersson
- Centre for Thrombosis and Haemostasis, Skåne University Hospital, Malmö, Sweden
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Cunningham T, Uzun O, Morris R, Franciosi S, Wong A, Jeremiasen I, Sherwin E, Sanatani S. The Safety and Effectiveness of Flecainide in Children in the Current Era. Pediatr Cardiol 2017; 38:1633-1638. [PMID: 28840327 DOI: 10.1007/s00246-017-1707-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 08/09/2017] [Indexed: 01/24/2023]
Abstract
This retrospective study sought to determine the safety and effectiveness of flecainide in children with normal hearts and those with congenital heart disease (CHD) or cardiomyopathy (CMO). Baseline and follow-up data at two pediatric cardiology sites were queried (2000-2015); a total of 175 patients (20 with CHD and two with CMO) receiving flecainide were assessed. When comparing patients with CHD to those with normal hearts, patients with CHD were younger at diagnosis (median age 19 days; IQR 3-157.5 days vs normal heart patients median age 21 days; IQR 7-172 days, p = 0.4) and severe cardiac dysfunction was more prevalent (30% in CHD patients vs 8% in normal heart patients, p = 0.009). Treatment duration did not differ between the two groups (CHD patients median duration 52 weeks; IQR 27-91.5 weeks vs normal heart patients median duration 55 weeks; IQR 32-156 weeks, p = 0.5). Cardiac dysfunction resulting in flecainide discontinuation occurred in two patients (1%), one with CHD and one without. Three patients experienced proarrhythmia (2%) and there were no cardiac arrests during follow-up. There was one death in this cohort in a patient with severe CHD and an RSV infection (<1%). Arrhythmia control did not differ between the groups (90% in CHD patients vs 77% in normal heart patients, p = 0.2). Flecainide was well tolerated in this cohort, with fewer than 3% discontinuing medication due to flecainide-associated adverse events. Contrary to adult studies, there was no difference in the incidence of adverse events between patients with normal hearts and patients with CHD. Flecainide is a safe and effective antiarrhythmic medication, even for children with underlying CHD.
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Affiliation(s)
- Taylor Cunningham
- Children's Heart Centre, British Columbia's Children's Hospital, 1F9, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada
| | - Orhan Uzun
- Children's Heart Centre, British Columbia's Children's Hospital, 1F9, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada.,Department of Pediatric Cardiology, Noah's Ark Children's Hospital for Wales, University Hospital of Wales, Cardiff, Wales, UK
| | - Rachel Morris
- Department of Pediatric Cardiology, Noah's Ark Children's Hospital for Wales, University Hospital of Wales, Cardiff, Wales, UK
| | - Sonia Franciosi
- Children's Heart Centre, British Columbia's Children's Hospital, 1F9, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada
| | - Amos Wong
- Department of Pediatric Cardiology, Noah's Ark Children's Hospital for Wales, University Hospital of Wales, Cardiff, Wales, UK
| | - Ida Jeremiasen
- Department of Pediatric Cardiology, Noah's Ark Children's Hospital for Wales, University Hospital of Wales, Cardiff, Wales, UK
| | - Elizabeth Sherwin
- Children's Heart Centre, British Columbia's Children's Hospital, 1F9, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada.,Division of Cardiology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.,Division of Cardiology, Department of Pediatrics, Children's National Health System, George Washington School of Medicine, Washington, DC, USA
| | - Shubhayan Sanatani
- Children's Heart Centre, British Columbia's Children's Hospital, 1F9, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada. .,Division of Cardiology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.
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