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The objective of this study was to evaluate the impact of the regular introduction of new technologies into interventional cardiac catheterization procedures, in this case new atrial septal defect (ASD) closure devices, while conducting a multi-center collaborative initiative to reduce radiation usage during all procedures. Data were collected prospectively by 8 C3PO institutions between January 1, 2014 and December 31, 2017 for ASD device closure procedures in the cardiac catheterization lab during a quality improvement (QI) initiative aimed at reducing patient radiation exposure. Radiation exposure was measured in dose area product per body weight (µGy*m

Background: The C3PO-QI (Congenital Cardiac Catheterization Project on Outcomes – Quality Improvement), a multicenter registry launched in 2015, instituted quality improvement (QI) initiatives to reduce patient radiation exposure. Through regular collaboration, this initiative would allow for harmony among active participants, maximizing efforts and efficiency at achieving radiation best practices. This study sought to report these efforts with a detailed methodology for which institutions can target initiatives, reducing radiation exposure, and increasing patient safety. Methods: Data were collected prospectively by 8 C3PO-QI institutions between January 1, 2015 and December 31, 2017. Radiation exposure was measured in dose area product per body weight (dose area product/kg; µGy*m 2 /kg) and reported by expected radiation exposure categories (REC) and institution for 40 published unique procedure types. Targeted interventions addressing selected strategic domains for radiation reduction were implemented in the pediatric catheterization labs of the C3PO-QI institutions. Results: The study consisted of 15 257 unique cases. Median exposure (dose area product/kg) was decreased by 30% for all procedures. Dose area product/kg was reduced in all 3 REC, with the greatest improvement observed in REC I (REC I, −37%; REC II, −23%; REC III, −27%). Although the baseline radiation exposures and exact percent decrease varied across all C3PO-QI sites, each institution demonstrated improvements in radiation dose over time. These improvements occurred with the implementation of institution-specific QI interventions accelerated by participation in the C3PO-QI multicenter collaborative. Conclusions: Substantial radiation dose reductions can be achieved using targeted QI methodology and interventions. Participation in a multicenter QI collaborative may accelerate improvement across all centers due to enhanced engagement and shared learning between sites.

ObjectiveWe aimed to investigate the incidence and causes of readmission of infants with single-ventricle and shunt-dependent biventricular CHD following routine, outpatient cardiac catheterisation.BackgroundCardiac catheterisation is commonly performed in patients with single-ventricle and shunt-dependent biventricular CHD for haemodynamic assessment and surgical planning. Best practices for post-procedural care in this population are unknown, and substantial variation exists between centres. Outpatient catheterisation reduces parental anxiety and decreases cost. Our institutional strategy is to discharge patients following a 4- to 6-hour post-procedure observation period.MethodsRetrospective cohort study using the Society of Thoracic Surgeons Database identified patients ResultsA total of 92 patients were included in the analysis. Among them, 62 patients (67%) were discharged after a 4- to 6-hour observation period with only 3% readmission, 18 patients (20%) stayed for a 23-hour observation period, and 12 patients (13%) were admitted for >23 hours. There were no differences in baseline characteristics between discharged and admitted patients. Patients who underwent intervention were more likely to be admitted. Patients with hypoplastic left heart syndrome did not have major adverse events or readmissions. No intra- or peri-procedural deaths occurred.ConclusionsOutpatient cardiac catheterisation may be a safe option for infants with single-ventricle and shunt-dependent biventricular CHD, with low readmission rates and minimal morbidity.

Background: Pediatric echocardiographic studies attempting to predict gold standard cardiac catheterization measures of left ventricular diastolic function (LVDFx) (pulmonary capillary wedge pressure (PCWP) or left ventricular end diastolic pressure (LVEDP)) are often retrospective, evaluated under variable hemodynamic and hydration conditions, and have demonstrated inconsistent results. We are unaware of any pediatric studies comparing echocardiographic measures of LVDFx with PCWP or LVEDP under the same loading conditions. We hypothesize, standard echocardiographic measurements of LVDFx can predict abnormal cardiac catheterization derived LVEDP or PCWP, when obtained under similar loading conditions and following …

Background Transcatheter pulmonary valve replacement (TPVR) is associated with a risk of procedural serious adverse events (SAE) and exposure to ionizing radiation. Objectives The purpose of this study was to define the risk of, and associations with, SAE and high-dose radiation exposure using large-scale registry data. Methods The analysis of the multicenter C3PO-QI registry was limited to patients who underwent TPVR from January 1, 2014, to December 31, 2016. SAE were defined as the occurrence of ≥1 moderate, major, or catastrophic events. Radiation dose was reported as dose area product adjusted for weight. Associations with outcome measures were explored in univariate and multivariable analyses. Results A total of 530 patients (59% male) underwent TPVR at a median age of 18.3 years (interquartile range [IQR]: 12.9 to 27.3 years) and weight of 58 kg (IQR: 43 to 77 kg) at 14 centers. Implant substrate included homograft (41%), bioprosthesis (30%), native right ventricular outflow tract (RVOT) (27%) and other (2%). TPVR indications were pulmonary insufficiency (28%), stenosis (23%), and mixed (49%). AE and SAE occurred in 26% and 13% of cases, respectively, including 1 mortality. SAE were more frequent in homograft conduit than other RVOT substrates, although SAE type and severity differed between implant substrates. Median radiation dose was 198 μGy·m2/kg (IQR: 94 to 350 μGy·m2/kg). Higher radiation dose was associated with older age, greater RVOT obstruction, and concomitant interventions (p Conclusions The incidence of SAE during TPVR in the C3PO-QI registry is high, but mortality is uncommon. Radiation dose is greater than for other congenital interventions and is associated with patient and procedural factors. Reintervention is common during early follow-up.

Background:Resource utilisation for infants with single ventricle CHD remains high without well-studied ways to decrease economic burden. Same-day discharge following cardiac catheterisation has been shown to be safe and effective in children with CHD, but those with single ventricle physiology are commonly excluded. The purpose of this study was to investigate the economic implications of planned same-day discharge following cardiac catheterisation versus universal overnight hospital admission in infants with single ventricle CHD.Methods and Results:A probabilistic decision-tree analysis with sensitivity analyses was performed. All included patients were categorised into four possible outcomes; discharge, readmission following discharge (within 48 hours), observation and prolonged hospitalisation. Baseline probabilities of each node of the tree were then combined with the cost data to evaluate the comparative dominance of one decision (immediately discharge) versus the other decision (routinely admit). Patients discharged on the same day as the procedure accrued the lowest attributed hospital cost ($5469), while patients readmitted to the hospital had the highest attributed cost ($11,851). Currently, no other studies have assessed the cost of hospitalisation following cardiac catheterisation in this population. Thus, we allowed for a wide range of cost variation, but same-day discharge dominated the decision outcome with a lower economic burden.Conclusion:Same-day discharge following routine cardiac catheterisation in patients with single ventricle physiology is less costly compared to universal overnight admission. This demonstrates an important cost-limiting step in a complex population of patients who have high resource utilisation.

Background: Controversy exists regarding the safety of cardiac catheterizations, particularly interventions, in the early post-operative period following congenital heart surgery. We sought to determine if adverse events are more frequent in patients undergoing early post-operative catheterizations

Background— Off-label use of transcatheter aortic and pulmonary valve prostheses for tricuspid valve-in-valve implantation (TVIV) within dysfunctional surgical tricuspid valve (TV) bioprostheses has been described in small reports. Methods and Results— An international, multicenter registry was developed to collect data on TVIV cases. Patient-related factors, procedural details and outcomes, and follow-up data were analyzed. Valve-in-ring or heterotopic TV implantation procedures were not included. Data were collected on 156 patients with bioprosthetic TV dysfunction who underwent catheterization with planned TVIV. The median age was 40 years, and 71% of patients were in New York Heart Association class III or IV. Among 152 patients in whom TVIV was attempted with a Melody (n=94) or Sapien (n=58) valve, implantation was successful in 150, with few serious complications. After TVIV, both the TV inflow gradient and tricuspid regurgitation grade improved significantly. During follow-up (median, 13.3 months), 22 patients died, 5 within 30 days; all 22 patients were in New York Heart Association class III or IV, and 9 were hospitalized before TVIV. There were 10 TV reinterventions, and 3 other patients had significant recurrent TV dysfunction. At follow-up, 77% of patients were in New York Heart Association class I or II ( P Conclusions— TVIV with commercially available transcatheter prostheses is technically and clinically successful in patients of various ages across a wide range of valve size. Although preimplantation clinical status was associated with outcome, many patients in New York Heart Association class III or IV at baseline improved. TVIV should be considered a viable option for treatment of failing TV bioprostheses.

Background: Cardiac catheterization (CC) is performed in patients with single ventricle congenital heart disease (SVCHD) to aid in hemodynamic assessment, intervention and surgical planning. Outpatient CC reduces anxiety to patients and families and decreases cost. Given the morbidity and mortality