'Interesting Research' in Pediatric Cardiology: AHA 2018

Focus on CPR, Prenatal Diagnosis of Congenital Heart Disease

Andrew C. Glatz, MD


December 21, 2018

Editorial Collaboration

Medscape &

Hi. My name is Andy Glatz. I am an interventional cardiologist in the Cardiac Center of the Children's Hospital of Philadelphia (CHOP). I also direct the Cardiac Center Clinical Research Core. Last week I attended the American Heart Association (AHA) Scientific Sessions in Chicago, and I want to give you an update on some of the highlights for me from the conference. Researchers from our cardiac center were well represented and presented lots of interesting research. I am going to focus on a couple of those studies today.

CARES Registry

The CARES registry, which is the Cardiac Arrest Registry to Enhance Survival, is a nationwide registry capturing about a third of the entire US population and looks at both the nature and outcomes of cardiac arrests that happen primarily outside of the hospital. Two presentations used this registry to answer some very interesting questions.

Mandatory CPR Training and Cardiac Arrest Outcomes

The first was by Dr Victoria Vetter.[1] She was interested in understanding whether there were differences in outcomes after out-of-hospital cardiac arrests, based on what state the arrest happened in. In the United States, 38 states have mandatory cardiopulmonary resuscitation (CPR) education for high school students. She wondered whether outcomes in states that had mandatory education were different from outcomes in states that did not have mandatory education.

What she found is very interesting. Looking at all out-of-hospital cardiac arrests, and not just ones that included children, the outcomes were better in states with mandatory CPR education. This means that CPR was more commonly performed [during arrests] as opposed to arrests where no CPR was performed. You are more likely to have a bystander perform CPR if you arrest in one of these states. The rate of surviving to discharge with a good neurologic outcome was better if you had a cardiac arrest in a state with mandatory CPR education.

Looking at specific age groups, she found that differences in outcomes are even more accentuated in the adolescent population, which is a suggestion that the education to high school students particularly affects other high school students because high school students are usually around other peers. In the rare event where a cardiac arrest happens in a high school or in an event involving adolescents, having other high school students around who have had CPR training, at least in this analysis, seems to be associated with better outcomes.

Pediatric CPR

The other presentation that was done using this very same registry was by Dr Maryam Naim,[2] one of the cardiac intensivists here in the Cardiac Center. She looked at differences in the method of CPR and outcomes in this new era where, for adult CPR, the AHA guidelines recommend compressions-only CPR for nonexperienced bystanders.

Historically, the AHA recommendation had always been to perform CPR with a combination of chest compressions and rescue breaths. In 2010, the recommendation was changed so that bystanders who were not medically trained can do compression-only CPR for adults who have a cardiac arrest (ie, they do not need to provide rescue breaths).[3] Because the majority of adults arrest because of a cardiac cause, the intention of this was to encourage more bystanders who might otherwise have been deterred from the rescue breathing to perform CPR. Maintaining a circulation with compressions is that important.

The concern with that recommendation is that some of that practice may have drifted down and affected how people respond to pediatric cardiac arrests. The recommendation [for pediatrics] remains to provide a combination of both compressions and rescue breaths, the so-called conventional CPR. Maryam looked at all arrests in children less than 18 years that happened out of the hospital.[2] She found a couple of very interesting things.

Over time, the use of compressions-only CPR has increased even though that is not the recommendation. Children who arrest out of the hospital and get conventional CPR (ie, compressions and rescue breaths) tend to do much better than those who get compressions only or those who get no bystander CPR.

In fact, the difference between no bystander CPR and compressions-only CPR was very minimal. The conclusion is that even though there is really no evidence that compressions-only CPR provides any benefit in children, people are doing it more and more. The best method by far for trying to resuscitate a child who has a cardiac arrest is conventional CPR with both compressions and rescue breaths. This supports the ongoing recommendations that for adults, compressions-only CPR may be okay, but for adolescent, child, or infant arrest, conventional CPR is still very important.

Prenatal Diagnosis of Congenital Heart Disease

The other topic I wanted to talk about is a little different from the CPR world but interesting nonetheless. Dr Michael Quartermain, who is the director of our echocardiography lab, participated in a debate on whether the prenatal diagnosis of congenital heart disease will result in better outcomes. It may seem like this question has an intuitively obvious answer that yes, of course, if you diagnose something as early as possible, it will be associated with better outcomes. It is actually a difficult thing to prove. One of the arguments is that all you are doing is diagnosing the more severe complex lesions. The outcomes may not look that much better because you are selecting a higher-risk group of patients.

Mike looked at our own experience here at CHOP as well as some research he participated in. I think what we have seen, both anecdotally and through a research study that Dr Quartermain has done, is that by diagnosing complex congenital heart disease in the prenatal period, you have a unique opportunity to do and plan for a lot of important things in advance that you might not otherwise have been able to do.

One is to prepare the family and give them a chance to adapt to this new reality. It is important to provide them with psychosocial support, because learning of a diagnosis is a huge stressor on the family. It's probably better to have time to prepare as opposed to learning of that very consequential diagnosis after birth.

You can prepare the care team. Many of these patients need complex multidisciplinary care very soon after birth, and all of those arrangements can be made. You can arrange for mothers with fetuses with complex heart disease to be born in specialty centers. We try to avoid the situation where a mother delivers at a small community hospital, a diagnosis of critical heart disease is made, and then a very risky transport has to happen. They can deliver in a hospital such as ours, which has an obstetric unit and special delivery unit for delivering these higher-risk infants who can be supported right away with our cardiac intensive care unit, literally right down the hall, so that there is not a separation of mother and baby.

We think that ability to prepare and make plans is really important. The other hope is that the child can be stabilized very early on. If an early operation is needed, we are delivering to the surgeon a more stable and healthier patient, and one who has not decompensated.

Dr Quartermain was able to prove this using a registry from the Society for Thoracic Surgeons, a heart disease registry, where he looked at a very large population of patients who had neonatal heart surgery, and then looked to compare differences both in the type of patient risk factors as well as outcomes based on whether they have been prenatally diagnosed.[4]

He was able to demonstrate that the patients who have had a prenatal diagnosis when they got to the operating room had much less risk of having some of the risk factors that we know are associated with poor surgical outcomes. For example, they seemed to be more stable and with lower rates of mechanical ventilation and inotropic support. They had better kidney function and better other end-organ function. We seem to be delivering to the surgeon a more stable patient.

This continues to highlight the importance of prenatal diagnosis. This is an area that is going to continue to expand and will continue to be a key element in the care we deliver to our patients.

Those were three of the many highlights of the meeting that I wanted to focus on today. I also want to make everyone aware that the next American Heart Association meeting, which will be in November 2019, will be right here in Philadelphia. We welcome all of you and hope to see many of you then. Thank you.