Catheter ablation of orthodromic reciprocating tachycardia and atrioventricular nodal reentrant tachycardia in children with hypoplastic left heart syndrome

INTRODUCTION

Experience with catheter ablation of orthodromic reciprocating tachycardia (ORT) and atrioventricular nodal reentrant tachycardia (AVNRT) in young children with hypoplastic left heart syndrome (HLHS) is limited. We report the feasibility, safety, and outcomes of catheter ablation of ORT and AVNRT in children with HLHS.

METHODS AND RESULTS

This was a retrospective review of patients with HLHS who underwent catheter ablation for reentrant supraventricular tachycardias (excluding atrial tachycardias) between 2005 and 2017 at a single center. Descriptive data including demographics, clinical history, procedural data, and outcomes were recorded. Ten children with HLHS underwent eleven catheter ablation procedures. Median age and weight at ablation were 2.7 years (range: 0.1-10.5) and 11.4 kg (range: 3.6-30.4), respectively. Tachycardia mechanism was AVNRT in four, ORT in five (two with preexcitation), and both in one. Acute procedural success was 100% and there was no spontaneous recurrence of tachycardia orpreexcitationin median 92 months (range: 21-175 months) follow-up. Five patients underwent subsequent EP studies at catheterization (intracardiac) or after surgery (via epicardial wires): three were noninducible, one after AVNRT ablation had inducible atrial tachycardia, and one after initial ORT ablation had inducible ORT at fenestration closure and underwent successful repeat ablation. Thus, long-term freedom from clinical tachycardia was 100% and from inducible AVNRT or ORT was 80%.

CONCLUSION

Transcatheter ablation for ORT and AVNRT in children with HLHS can be performed with excellent acute and long-term success without major complications.

Feeding Methods at Discharge Predict Long-Term Feeding and Neurodevelopmental Outcomes in Preterm Infants Referred for Gastrostomy Evaluation

OBJECTIVE

To test the hypothesis that oral feeding at first neonatal intensive care unit discharge is associated with less neurodevelopmental impairment and better feeding milestones compared with discharge with a gastrostomy tube (G-tube).

STUDY DESIGN

We studied outcomes for a retrospective cohort of 194 neonates <37 weeks' gestation referred for evaluation and management of feeding difficulties between July 2006 and July 2012. Discharge milestones, length of hospitalization, and Bayley Scales of Infant Development-Third Edition scores at 18-24 months were examined. χ², Mann-Whitney U, or t tests and multivariable logistic regression models were used.

RESULTS

A total of 60% (n = 117) of infants were discharged on oral feedings; of these, 96% remained oral-fed at 1 year. The remaining 40% (n = 77) were discharged on G-tube feedings; of these, 31 (40%) remained G-tube dependent, 17 (22%) became oral-fed, and 29 (38%) were on oral and G-tube feedings at 1 year. Infants discharged on a G-tube had lower cognitive (P <.01), communication (P = .03), and motor (P <.01) composite scores. The presence of a G-tube, younger gestation, bronchopulmonary dysplasia, or intraventricular hemorrhage was associated significantly with neurodevelopmental delay.

CONCLUSIONS

For infants referred for feeding concerns, G-tube evaluations, and feeding management, the majority did not require a G-tube. Full oral feeding at first neonatal intensive care unit discharge was associated with superior feeding milestones and less long-term neurodevelopmental impairment, relative to full or partial G-tube feeding. Evaluation and feeding management before and after G-tube placement may improve long-term feeding and neurodevelopmental outcomes.

Tracheostomy placement in infants with bronchopulmonary dysplasia: safety and outcomes

Optimizing the timing and safety for the placement of a tracheostomy in infants with bronchopulmonary dysplasia (BPD) has not been determined. The purpose of the present study was to describe the data from a single institution about the efficacy and safety of tracheostomy placement in infants with BPD needing long-term respiratory support. We established a service line for the comprehensive care of infants with BPD and we collected retrospective clinical data from this service line. We identified patients that had a trachostomy placed using the local Vermont-Oxford database, and obtained clinical data from chart reviews. We identified infants who had a tracheostomy placed for the indication of severe BPD only. Safety and respiratory efficacy was assessed by overall survival to discharge and the change in respiratory supportive care from just before placement to 1-month post-placement. Twenty-two patients (750 ± 236 g, 25.4 ± 2.1 weeks gestation) had a tracheostomy placed on day of life 177 ± 74 which coincided with a post-conceptual age of 51 ± 10 weeks. At placement these infants were on high settings to support their lung disease. The mean airway pressure (MAP) was 14.3 ± 3.3 cmH(2) O, the peak inspiratory pressure was 43.7 ± 8.0 cmH(2) O, and the FiO(2) was 0.51 ± 0.13. The mean respiratory severity score (MAP × FiO(2) ) 1 month after tracheostomy was significantly (P = 0.03) lower than prior to tracheostomy. Survival to hospital discharge was 77%. All patients with tracheostomies that survived were discharged home on mist collar supplemental oxygen. In conclusion, the high survival rate in these patients with severe BPD and the decreased respiratory support after placement of a tracheostomy suggests that high ventilatory pressures should not be a deterrent for placement of a tracheostomy. Future research should be aimed at determining optimal patient selection and timing for tracheostomy placement in infants with severe BPD.

Impact of feeding strategies on the frequency and clearance of acid and nonacid gastroesophageal reflux events in dysphagic neonates

BACKGROUND

Feeding difficulties and gastroesophageal reflux (GER) are common problems in neonates. The authors hypothesize that GER could be influenced by feeding mechanics by evaluating the effects of feeding volumes, feeding durations, feeding flow rates, and caloric density on the chemical composition and clearance of GER in dysphagic neonates.

METHODS

Symptomatic dysphagic neonates (n = 35) underwent evaluation for suspected GER using pH-impedance methods.

RESULTS

The proportions of acid and nonacid GER were different during the first, second, and third postprandial hours (P < .0001). Prolonged feeding duration was significantly associated with decreased total, nonacid GER and BCT (P < .03). Significant positive correlations (P < .05) were detected between feeding flow rate vs frequency of total, nonacid GER and BCT. Significant positive correlation (P = .002) was noted between feeding volume and BCT. BCT decreased with each hourly interval (analysis of variance [ANOVA] P < .05); however, ACT increased with each hourly interval (ANOVA P = .05). Comparison between BCT and ACT at each postprandial hour is remarkable for longer ACT during the second and third hours after the initiation of feed (P ≤ .001). No significant correlation was noted between the milk types (breast milk or formula) or caloric density with regard to the GER characteristics. Oral-fed infants had more GER events than gavage-fed infants.

CONCLUSIONS

Prolonged feeding durations and slower flow rates are associated with decreased frequency of GER. Modification of feeding duration and flow rate can be a useful adjunct to ameliorate GER in dysphagic neonates.