Clinical Focus

  • Pediatric Cardiology

Professional Education

  • Fellowship: UCLA Mattel Children's Hospital Pediatric Cardiology Fellowship (2007) CA
  • Board Certification: American Board of Pediatrics, Pediatric Cardiology (2008)
  • Residency: Children's Hospital Los Angeles (2004) CA
  • Medical Education: Stanford University School of Medicine (2001) CA

All Publications

  • Quality Improvement in a Pediatric Echocardiography Laboratory: A Collaborative Process. Children (Basel, Switzerland) Sganga, D., Behera, S., Beattie, M. J., Stauffer, K. J., Burlinson, A., Lopez, L., Tierney, E. S. 2022; 9 (12)


    Transthoracic echocardiography (TTE) is an essential tool for diagnosis and management of congenital heart disease. Pediatric echocardiography presents unique challenges including complex anatomy, variable patient cooperation and provider expertise. Diagnostic errors inevitably occur. We designed a collaborative and stepwise quality improvement (QI) process to address diagnostic errors within our laboratory. We retrospectively reviewed medical records to identify diagnostic TTE errors in 100 consecutive cardiac surgery patients ≤ 5 years old (July 2020-January 2021). We identified 18 diagnostic errors. Most errors had minor impact (14/18), and 13 were preventable or possibly preventable. We presented these results to our sonographers and faculty and requested input on preventing and managing diagnostic errors. Our root cause analysis based on their responses yielded 7 areas for improvement (imaging, reporting, systems, time, environment, people, QI processes). Our faculty and sonographers chose QI processes and imaging as initial areas for intervention. We defined our SMART goal as a 10% reduction in diagnostic errors. We implemented interventions focused on QI processes. On initial follow up in May 2022, we identified 7 errors in 70 patients (44% reduction in error rate). Utilizing a stepwise and team-based approach, we successfully developed QI initiatives in our echocardiography laboratory. This approach can serve as a model for a collaborative QI process in other institutions.

    View details for DOI 10.3390/children9121845

    View details for PubMedID 36553289

    View details for PubMedCentralID PMC9776848

  • Impact of Fetal Echocardiogram Comprehensiveness on Diagnostic Accuracy. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography Behera, S. K., Ding, V. Y., Chung, S., Tacy, T. A. 2022


    BACKGROUND: Fetal echocardiography is a major diagnostic imaging modality for prenatal detection of critical congenital heart disease (CHD). Diagnostic accuracy is essential for appropriate planning of delivery and neonatal care. The relationship between study comprehensiveness and diagnostic error is not well understood.OBJECTIVES: We hypothesized that high fetal echocardiogram study comprehensiveness would be associated with low diagnostic error. Diagnostic errors were defined as discordant fetal and postnatal diagnoses, and were further characterized by potential causes, contributors, and clinical significance.METHODS: Fetal echocardiograms performed at Lucile Packard Children's Hospital (LPCH) in which fetuses with critical CHD were anticipated to require postnatal surgical or catheter intervention in the first year of life were identified using the fetal cardiology program database. For this cohort, initial fetal echocardiogram images were reviewed and given a fetal echocardiogram comprehensiveness score (FECS). Fetal diagnoses obtained from initial fetal echocardiogram images and reports were compared with postnatal diagnoses confirmed by transthoracic echocardiogram and other imaging studies, and/or surgery to determine diagnostic error. The relationship between FECS and diagnostic error was evaluated using multivariable logistic regression.RESULTS: Of the 304 initial fetal echocardiograms, diagnostic error (discrepant diagnosis, false negative, or false positive) occurred in 92 cases (30.3%). FECS was not associated with diagnostic error, but low FECS (< 80% complete) was associated with false negatives and procedural/conditional (p<0.001) and technical contributors (p=0.005) compared with high FECS (>80% complete). Cognitive factors made up the largest proportion of contributors to error.CONCLUSIONS: Study comprehensiveness of fetal echocardiograms was not related to diagnostic error. The most common contributor to error were cognitive factors. Echocardiogram laboratories can work to mitigate preventable cognitive error through quality improvement initiatives.

    View details for DOI 10.1016/j.echo.2022.02.014

    View details for PubMedID 35257895

  • Comparison of Initial Pediatric Outpatient Echocardiogram Indications between Community and Academic Practice. The Journal of pediatrics Balasubramanian, S., Ramirez, F. D., Bui, Y., Selamet Tierney, E. S., Behera, S. K. 2019


    OBJECTIVE: To compare the appropriateness and diagnostic yield of initial outpatient transthoracic echocardiography (TTE) between a community pediatric cardiology practice and an academic children's hospital.STUDY DESIGN: Initial outpatient pediatric TTE ordered by pediatric cardiologists between January and March 2014 at a community practice (Packard Children's Health Alliance [PCHA]; n=238) and an academic tertiary center (Lucile Packard Children's Hospital [LPCH]; n=76) were evaluated based on appropriate use criteria (AUC) released in December 2014. Multivariate logistic regression was used to identify predictors of "rarely appropriate" indications and abnormal TTE findings.RESULTS: Of 314 TTEs, 165 (52.5%) were classified as "appropriate," 40 (12.7%) were classified as "may be appropriate," 100 (31.9%) were classified as "rarely appropriate," and 9 (2.9%) were unclassifiable. The proportion of abnormal findings did not differ between the 2 practice settings (5.3% for LPCH vs 7.6% for PCHA; P=.61). TTEs performed at PCHA were significantly more likely to be "rarely appropriate" (OR, 2.57; 95% CI, 1.28-5.15; P=.008). Children aged <1 year (OR, 1.90; 95% CI, 1.03-3.50; P=.04) and ordering providers with<10 years since the completion of their fellowship (OR, 2.15; 95% CI, 1.20-3.87; P=.01) were associated with "rarely appropriate" indications. "Appropriate" TTEs were associated with abnormal findings (OR, 8.69; 95% CI, 1.77-42.68; P=.008).CONCLUSION: The community practice was independently associated with greater inappropriate ordering of initial outpatient pediatric TTEs compared with the academic practice. The assessment of practice patterns following AUC release should account for physician and practice-related factors that could influence differences in TTE ordering patterns.

    View details for DOI 10.1016/j.jpeds.2018.11.057

    View details for PubMedID 30661793

  • Development of quality metrics for ambulatory pediatric cardiology: Chest pain CONGENITAL HEART DISEASE Lu, J. C., Bansal, M., Behera, S. K., Boris, J. R., Cardis, B., Hokanson, J. S., Kakavand, B., Jedeikin, R. 2017; 12 (6): 751–55


    As part of the American College of Cardiology Adult Congenital and Pediatric Cardiology Section effort to develop quality metrics (QMs) for ambulatory pediatric practice, the chest pain subcommittee aimed to develop QMs for evaluation of chest pain.A group of 8 pediatric cardiologists formulated candidate QMs in the areas of history, physical examination, and testing. Consensus candidate QMs were submitted to an expert panel for scoring by the RAND-UCLA modified Delphi process. Recommended QMs were then available for open comments from all members.These QMs are intended for use in patients 5-18 years old, referred for initial evaluation of chest pain in an ambulatory pediatric cardiology clinic, with no known history of pediatric or congenital heart disease.A total of 10 candidate QMs were submitted; 2 were rejected by the expert panel, and 5 were removed after the open comment period. The 3 approved QMs included: (1) documentation of family history of cardiomyopathy, early coronary artery disease or sudden death, (2) performance of electrocardiogram in all patients, and (3) performance of an echocardiogram to evaluate coronary arteries in patients with exertional chest pain.Despite practice variation and limited prospective data, 3 QMs were approved, with measurable data points which may be extracted from the medical record. However, further prospective studies are necessary to define practice guidelines and to develop appropriate use criteria in this population.

    View details for PubMedID 28653469

  • Impact of Accreditation on Quality in Echocardiograms: A Quantitative Approach JOURNAL OF THE AMERICAN SOCIETY OF ECHOCARDIOGRAPHY Behera, S. K., Smith, S. N., Tacy, T. A. 2017; 30 (9): 913–22


    Accreditation through the Intersocietal Accreditation Commission (IAC) is believed but not proven to increase quality in imaging. The goal of this study was to use quality metrics to evaluate the impact of accreditation on quality in pediatric echocardiography.This is a retrospective study comparing quality metrics in 236 pediatric transthoracic echocardiograms in patients with congenital heart disease from (1) California Pacific Medical Center (CPMC), a community hospital, before and after IAC accreditation, and (2) the IAC-accredited Lucile Packard Children's Hospital (LPCH), an academic children's referral center, during equivalent eras. Consecutive patients who required cardiac intervention were matched between sites based on age, complexity, and time period. Two raters independently evaluated echocardiograms for image quality and study comprehensiveness. A third rater reviewed echocardiogram reports and medical charts for report completeness and diagnostic accuracy. Diagnostic error characterization was performed by consensus among the three raters. Report completeness was an IAC tool approved for maintenance of certification. The remaining quality metrics were developed by the American College of Cardiology Adult Congenital Pediatric Cardiology Quality Metrics Working Group initiative.At each site, 74 echocardiograms in the era before CPMC accreditation and 44 echocardiograms in the era after CPMC accreditation were included. There was no significant difference in image quality and diagnostic accuracy at CPMC before and after accreditation. Study comprehensiveness and report completeness improved at CPMC after accreditation (P < .001).Accreditation through the IAC leads to increased study comprehensiveness and report completeness. Image quality and diagnostic accuracy did not differ significantly before and after IAC accreditation. We recommend further studies to assess the effects of accreditation on quality in echocardiography and patient outcomes.

    View details for PubMedID 28865558

  • Decompressing vein and bilateral superior venae cavae in a patient with hypoplastic left heart syndrome. Echocardiography (Mount Kisco, N.Y.) Stauffer, K. J., Arunamata, A., Vasanawala, S. S., Behera, S. K., Kipps, A. K., Silverman, N. H. 2016; 33 (9): 1428-1431


    The levoatrial cardinal vein (LACV), first described in 1926, acts as a decompressing vessel for pulmonary venous return in cases of severe left-sided obstruction with an intact or significantly restrictive atrial septum. The LACV and the persistent left superior vena cava (LSVC) are thought to share similar embryologic origins. To challenge this notion, we present a unique case of a neonate with hypoplastic left heart syndrome, cor triatriatum, and a decompressing LACV in the presence of bilateral superior venae cavae.

    View details for DOI 10.1111/echo.13292

    View details for PubMedID 27641733

  • Nesiritide improves hemodynamics in children with dilated cardiomyopathy: a pilot study. Pediatric cardiology Behera, S. K., Zuccaro, J. C., Wetzel, G. T., Alejos, J. C. 2009; 30 (1): 26-34


    This study aimed to obtain hemodynamic measurements of nesiritide in children with dilated cardiomyopathy.A prospective, randomized, double-blinded, placebo-controlled pilot study was conducted in the pediatric intensive care unit at the University of California, Los Angeles. All subjects younger than 21 years admitted to the pediatric intensive care unit with a diagnosis of dilated cardiomyopathy and submitted to cardiac catheterization were randomized to receive either nesiritide or placebo. Right heart catheterization with Swan-Ganz catheter placement was performed. Nesiritide was infused over 24 h. Hemodynamic data were obtained before, during, and after the 24-h nesiritide infusion. The measures obtained included pulmonary capillary wedge pressure (PCWP), central venous pressure, mean pulmonary arterial pressure (MPAP), systolic arterial blood pressure (SBP), cardiac index, and systemic vascular resistance.The study included 20 children: 9 randomized to nesiritide and 11 to placebo. At 24 h, the mean decreases in PCWP, MPAP, and SBP were significantly greater for nesiritide than for placebo: PCWP (-5.3 vs. 1.2 mmHg; p = 0.02), MPAP (-8.0 vs. 0.4 mmHg; p = 0.006), SBP (-7.9 vs. 2.6 mmHg; p = 0.04).Nesiritide significantly decreases PCWP, MPAP, and SBP in children with dilated cardiomyopathy.

    View details for DOI 10.1007/s00246-008-9272-6

    View details for PubMedID 18704555

  • The use of Doppler tissue imaging to predict cellular and antibody-mediated rejection in pediatric heart transplant recipients. Pediatric transplantation Behera, S. K., Trang, J., Feeley, B. T., Levi, D. S., Alejos, J. C., Drant, S. 2008; 12 (2): 207-14


    DTI indices have been associated with cellular rejection in adult heart transplant recipients, but their predictive value in pediatric recipients is unknown. The purpose of this study was to evaluate DTI measures in the detection of cellular and AMR in pediatric heart transplant recipients. One hundred and forty-eight pediatric heart transplant recipients who had 267 cardiac catheterization procedures with EMB, echocardiogram with DTI, and BNP level performed on the same day were included in the study. For the mitral and tricuspid valves, the ratios (E/E') between the early diastolic inflow velocity by pulsed Doppler (E, m/s) and the early diastolic annular velocity by DTI (E', m/s) were obtained and compared between subjects with and without rejection. Of the 148 recipients, 30 subjects had a total of 37 episodes of rejection: 10 cellular (>or=1B), 17 AMR, and 10 biopsy-negative clinical rejection. Mitral and tricuspid valve E/E' ratios were significantly higher in rejectors than in non-rejectors (5.5 +/- 1.3 vs. 4.4 +/- 1.4, p < 0.001 and 4.9 +/- 2.1 vs. 4.1 +/- 1.5, p < 0.01, respectively). By multivariate linear regression, mitral valve E/E' was an independent predictor of rejection. Mitral and tricuspid valve E/E' <5.0 had 93% and 89% NPV, respectively, for rejection. Mitral and tricuspid valve E/E' ratios <5.0 may be useful non-invasive screening measures to exclude rejection in pediatric heart transplant recipients.

    View details for DOI 10.1111/j.1399-3046.2007.00812.x

    View details for PubMedID 18307670

  • Transcatheter closure of coronary artery fistulae using the Amplatzer Duct Occluder. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions Behera, S. K., Danon, S., Levi, D. S., Moore, J. W. 2006; 68 (2): 242-8


    The aim of this study is to report our experience using the Amplatzer Duct Occluder (ADO) for occlusion of significant coronary artery fistulae (CAF).Transcatheter closure of CAF with coils is well described. Use of newer devices may offer advantages such as improved control of device placement, use of a single instead of multiple devices, and high rates of occlusion.A retrospective review of all patients catheterized for CAF from July 2002 through August 2005 was performed.Thirteen patients with CAF underwent cardiac catheterization, of which a total of 6 patients had ADO placement in CAF (age, 21 days to 56 years; median age, 4.3 years and weight, 3.8 kg to 74.6 kg; median weight, 13.3 kg). An arteriovenous wire loop was used to advance a long sheath antegrade to deploy the ADO in the CAF. Immediate and short-term outcomes (follow-up, 3 months to 14 months; median follow-up, 8.5 months) demonstrated complete CAF occlusion in 5 patients and minimal residual shunt in 1 patient (who had resolution of right atrial and right ventricular enlargement). On follow-up clinical evaluation, all 6 patients had absence of fistula-related murmurs, and 2 previously symptomatic patients had resolution of congestive heart failure symptoms. Early complications included transient palpitations and atrial arrhythmia in the 2 oldest patients (52 and 56 years old).Use of the ADO is applicable for transcatheter closure of significant CAF. Advantages of using the ADO include the antegrade approach, use of a single device, and effective CAF occlusion.

    View details for DOI 10.1002/ccd.20811

    View details for PubMedID 16819766

  • Risk factors for persistent pleural effusions after the extracardiac Fontan procedure. The Journal of thoracic and cardiovascular surgery Gupta, A., Daggett, C., Behera, S., Ferraro, M., Wells, W., Starnes, V. 2004; 127 (6): 1664-9


    Pleural effusions after the Fontan operation contribute significantly to morbidity and prolonged hospitalization. This study investigates the association between selected preoperative, operative, and postoperative variables and persistent pleural effusions after the extracardiac Fontan procedure.We conducted a retrospective study of extracardiac Fontan procedures. The variables analyzed as potential risk factors included age and weight at the time of the operation, anatomic diagnosis, preoperative oxygen saturation, mean pulmonary artery pressure, ventricular end-diastolic pressure, presence of an accessory source of pulmonary blood flow, presence of significant aortopulmonary collateral vessels, presence of fenestration, cardiopulmonary bypass time, conduit size, postoperative pulmonary artery pressure, use of angiotensin-converting enzyme inhibitors, and presence of postoperative infection. The outcome measures evaluated were duration and volume of chest tube drainage after surgical intervention.From June 1997 to August 2002, 100 consecutive patients underwent the extracardiac Fontan procedure. The median age at operation was 3.1 years. The median duration of chest tube drainage was 10 days, and the median volume of drainage was 14.7 As determined by means of multivariate analysis, significant risk factors for pleural effusions lasting more than 2 weeks were lower preoperative oxygen saturation (P =.011) and the presence of postoperative infections (P =.003). Significant risk factors for pleural effusions draining at more than 20 were lower preoperative oxygen saturation (P =.005), smaller conduit size (P =.04), and longer duration of cardiopulmonary bypass (P =.004).Lower preoperative oxygen saturation, presence of postoperative infection, smaller conduit size, and longer duration of cardiopulmonary bypass were associated with persistent pleural effusions after the extracardiac Fontan procedure. Modifications of some of these risk factors might influence the duration and volume of pleural drainage after surgical intervention.

    View details for DOI 10.1016/j.jtcvs.2003.09.011

    View details for PubMedID 15173721

  • Meningitis in a newborn infant with urosepsis, negative blood cultures and initially normal cerebrospinal fluid findings. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians Behera, S., Seri, I. 2004; 15 (2): 129-31


    This case presentation supports the observation that initial cerebrospinal fluid findings can be normal in newborn infants with sepsis syndrome who then develop evidence for meningeal involvement. Therefore, if initial lumbar puncture results are negative, a repeat lumbar puncture is recommended to look for meningitis in newborns that are critically ill with sepsis syndrome.

    View details for DOI 10.1080/14767050410001659860

    View details for PubMedID 15209122

  • Clinical and molecular features of congenital disorder of glycosylation in patients with type 1 sialotransferrin pattern and diverse ethnic origins JOURNAL OF PEDIATRICS Enns, G. M., Steiner, R. D., Buist, N., Cowan, C., Leppig, K. A., McCracken, M. F., Westphal, V., Freeze, H. H., O'Brien, J. F., Jaeken, J., Matthijs, G., Behera, S., Hudgins, L. 2002; 141 (5): 695-700


    To increase awareness of congenital disorders of glycosylation (CDG), we report the features of patients with a variety of clinical presentations ranging from mild hypotonia and strabismus to severe neurologic impairment.Nine North American patients with CDG type I and different ethnic origins were studied.All patients had transferrin isoelectric focusing studies with a type 1 sialotransferrin pattern. Molecular analysis showed the previously described R141H, V231M, and T237M PMM2 mutations in four patients as well as 3 rare mutations (DeltaC389, L104V, and IVS1 -1 G-->A) in the PMM2 gene in two Asian patients.The clinical features of these patients with diverse ethnic backgrounds confirm the variable course of CDG type I. Screening for CDG should be considered in children with relatively mild neurologic impairment, especially if they have suggestive findings such as cerebellar hypoplasia and abnormal fat distribution.

    View details for DOI 10.1067/mpd.2002.128658

    View details for PubMedID 12410200

  • Low awareness of cardiovascular disease risk among low-income African-American women AMERICAN JOURNAL OF HEALTH PROMOTION Behera, S. K., Winkleby, M. A., Collins, R. 2000; 14 (5): 301-305


    Focus groups were conducted with low-income African-American women in six different community settings in Northern California to assess their awareness of and concern for cardiovascular disease (CVD). These women had low awareness of the prevalence of CVD, attributed CVD to stress and low socioeconomic status, saw the media as an important source of health-related knowledge, and saw a need for more community awareness on CVD among African-American people.

    View details for Web of Science ID 000088212000005

    View details for PubMedID 11009856