Background-Optical coherence tomography (OCT) is a high-resolution intravascular imaging technique used in adults.We tested the hypothesis that OCT could identify coronary abnormalities not seen by angiography in children with a history of Kawasaki disease (KD) and pediatric heart transplant (TX) recipients. Methods and Results-Patients with KD and TX recipients were evaluated between December 2012 and October 2013 with angiography and OCT (Ilumien System, LightLabs, St Jude Medical, Westford, MA). Modifications were made to the adult OCT protocol to adapt this technique for children. Serial cross-sectional area measurements of the lumen, intima, and media were made. Entire imaging data were analyzed for the presence of qualitative changes. Seventeen children were evaluated (5 patients with KD; 12 TX recipients). In patients with KD, angiography was normal. However, OCT imaging revealed that significant vessel wall abnormalities were present in all children including intimal thickening (intima/lumen cross-sectional area ratio>0.4), loss of the normal layered structure of the vessel wall, white thrombus, calcification, and neovascularization. There was extensive destruction of the internal elastic lamina. In TX recipients, angiography was normal; however, intimal thickening (intima/media cross-sectional area ratio>1) was seen in 9 of 12 patients. The median intima/media cross-sectional area ratio was 1.18. Conclusions-In this initial experience with OCT in children, we have identified significant coronary abnormalities withOCT that are angiographically silent in children with a history of coronary aneurysms because of KD and in pediatric TX recipients. (Circ Cardiovasc Imaging. 2014;7:671-678.)Key Words: coronary disease ◼ heart transplantation ◼ Kawasaki disease ◼ pediatrics © 2014 American Heart Association, Inc. We performed selective coronary angiography. We then performed OCT (Ilumien System, LightLabs, St Jude Medical, Westford, MA) on one or more coronary arteries based on patient size and technical factors. Two important modifications were made to the traditional OCT protocol used in adults to adapt this technique for children. First, we used a 5F coronary guide catheter with a 0.056″ lumen and standard adult curves (Vista brite tip, Cordis, Bridgewater, NJ) for children <40 kg and a 6F coronary guide catheter with a 0.070″ lumen (Vista brite tip, Cordis, Bridgewater, NJ) for children >40 kg. At present, there are no 5F coronary guide catheters with pediatricspecific curves that will permit OCT imaging. We often were more successful in engaging the right coronary artery with a Judkins right 3.5 or 4 than the left with a Judkins left 3.5 or 4. We typically used a 0.014″ Asahi Grand Slam wire (Abbott Laboratories, Abbott Park, IL) that was advanced via the coronary guide catheter. A Dragonfly Duo OCT imaging catheter (St Jude Medical, Westford, MA) was then positioned in routine fashion over the guidewire and 2 to 5 cm of imaging was obtained depending on patient size. The second modification we made to acc...

Objectives: We intended to assess emergency department physician's practice pattern and their motivations for obtaining electrocardiograms (ECGs) in pediatric vasovagal syncope presentations. We also explored if borderline ECG findings alters emergency department physicians' management in this population.Methods: We conducted a cross-sectional survey of emergency physicians enrolled in the Pediatric Emergency Research Canada network. The survey questionnaire introduced 2 clinical vignettes presenting a typical vasovagal syncope and a presentation suggestive of a cardiac etiology. Outcome measures included frequency investigations, specialist consultation, and disposition stratified by type of syncope presentation. We also evaluated which specific ECG findings were likely to change physicians' management and explored factors influencing the decision to perform or not perform the ECG. Results:The analyzable response rate was 47% (105/225). In the low-risk scenario, 51% of respondents requested an ECG, and none consulted the cardiology service, given that all requested investigations are normal. Forty-five percent of physicians modified their management if an ECG was reported as anything but totally normal. In the high-risk scenario, all respondents requested either a 12-lead ECG or a high-lead ECG, and 94% consulted the cardiology service. Physicians also identified clear differences in the motivations behind their decision to perform an ECG in typical vasovagal syncope.Conclusions: This study highlights the significant practice variation in the evaluation and management of typical vasovagal syncope among physicians, which is informed by complex interactions of patient, provider, and institutional factors and the perceived clinical significance of borderline ECG findings.

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Background Syncope affects up to 50% of individuals by age 21 years and accounts for 1% of presentations to the emergency department (ED). Cardiac causes of syncope, including structural heart defects and rhythm disorders, cannot always be ruled out by an electrocardiogram (ECG) as this test lacks sensitivity and specificity. Conflicting recommendations for the role of ECG in evaluation of pediatric syncope underscore the clinical equipoise of how ECG findings influence physicians’ clinical decisions. Objectives The primary objective of this study is to determine how ECG findings affect ED physicians’ management of children presenting with vasovagal syncope. Our secondary objective is to document the practice pattern variation among ED physicians regarding their decision to obtain an ECG for the evaluation of vasovagal syncope in children. Design/Methods We conducted a prospective cross-sectional survey study using the REDCap platform. Our sample frame consisted of practicing emergency physicians enrolled in the Pediatric Emergency Research Canada (PERC) network. Outcome measures included frequency investigations, specialist consultation, and disposition stratified by type of syncope presentation (low/high risk). We also evaluated which specific ECG findings were likely to change physicians’ management and explored factors influencing the decision to perform or not perform the ECG. Results We obtained data from 105/225 (47%) potential respondents. In a clinical scenario presenting a vasovagal syncope, 52% of respondents would order an ECG. Forty-five percent changed their management if the ECG interpretation was anything other than “Normal ECG”. In a high-risk syncope scenario, an ECG was performed by 96% of respondents. Cardiology referral was requested by 93% of respondents, despite normal ECG findings. Borderline ECG findings led to significant practice variation in management, for both low and high-risk presentations scenarios. Overall, 66% of respondents stated that performing an ECG is not important to rule out a cardiac etiology in a typical vasovagal syncope presentation, but 64% stated that performing an ECG is important to reassure the patient. Conclusion There is substantial practice pattern variation among emergency physicians with regards to the frequency and motivations to order ECGs, and how ECG findings impact the management of pediatric syncope in the ED. Information provided by an ECG can lead to unnecessary change to clinical management, additional testing, and referrals to specialists for typical vasovagal syncope. This reinforces the importance of better knowledge translation surrounding evidence-based management of vasovagal syncope among ED physicians.