title: A Pilot Study Assessing ECG versus ECHO Ventriculoventricular Optimization in Pediatric Resynchronization Patients.
abstract: BACKGROUND
  Cardiac resynchronization therapy indications and management are well described in adults. Echocardiography (ECHO) has been used to optimize mechanical synchrony in these patients; however, there are issues with reproducibility and time intensity. Pediatric patients add challenges, with diverse substrates and limited capacity for cooperation. Electrocardiographic (ECG) methods to assess electrical synchrony are expeditious but have not been extensively studied in children. We sought to compare ECHO and ECG CRT optimization in children.
  
  
  METHODS
  Prospective, pediatric, single-center cross-over trial comparing ECHO and ECG optimization with CRT. Patients were assigned to undergo either ECHO or ECG optimization, followed for 6 months, and crossed-over to the other assignment for another 6 months. ECHO pulsed-wave tissue Doppler and 12-lead ECG were obtained for 5 VV delays. ECG optimization was defined as the shortest QRSD and ECHO optimization as the lowest dyssynchrony index. ECHOs/ECGs were interpreted by readers blinded to optimization technique. After each 6 month period, these data were collected: ejection fraction, velocimetry-derived cardiac index, quality of life, ECHO-derived stroke distance, M-mode dyssynchrony, study cost, and time. Outcomes for each optimization method were compared.
  
  
  RESULTS
  From June 2012 to December 2013, 19 patients enrolled. Mean age was 9.1 ± 4.3 years; 14 (74%) had structural heart disease. The mean time for optimization was shorter using ECG than ECHO (9 ± 1 min vs. 68 ± 13 min, P < 0.01). Mean cost for charges was $4,400 ± 700 less for ECG. No other outcome differed between groups.
  
  
  CONCLUSIONS
  ECHO optimization of synchrony was not superior to ECG optimization in this pilot study. ECG optimization required less time and cost than ECHO optimization.
authors.affiliation: Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Punn
authors.affiliation: Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA.
authors.forename: Debra
authors.initials: D
authors.lastname: Hanisch
authors.affiliation: Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA.
authors.forename: Kara S
authors.initials: KS
authors.lastname: Motonaga
authors.affiliation: Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA.
authors.forename: David N
authors.initials: DN
authors.lastname: Rosenthal
authors.affiliation: Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA.
authors.forename: Scott R
authors.initials: SR
authors.lastname: Ceresnak
authors.affiliation: Division of Pediatric Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA.
authors.forename: Anne M
authors.initials: AM
authors.lastname: Dubin
mesh_terms: D000200:Action Potentials; D000293:Adolescent; D000367:Age Factors; D058406:Cardiac Resynchronization Therapy; D058409:Cardiac Resynchronization Therapy Devices; D002648:Child; D002675:Child, Preschool; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D018592:Cross-Over Studies; D018619:Echocardiography, Doppler, Pulsed / Q000191:economics; D004562:Electrocardiography / Q000191:economics; D004867:Equipment Design; D005260:Female; D006327:Heart Block / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D006330:Heart Defects, Congenital / Q000150:complications / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D006339:Heart Rate; D017722:Hospital Charges; D017721:Hospital Costs; D006801:Humans; D008297:Male; D010865:Pilot Projects; D011237:Predictive Value of Tests; D011446:Prospective Studies; D015203:Reproducibility of Results; D013997:Time Factors; D016896:Treatment Outcome
keywords: cardiac resynchronization therapy; optimization; pediatric