Impact of delayed systemic heparinization on postoperative bleeding and thromboembolism during post-cardiotomy extracorporeal membrane oxygenation in neonates

INTRODUCTION

Veno-arterial extracorporeal membrane oxygenation is well-established for pediatric patients with post-cardiotomy heart failure. However, extracorporeal membrane oxygenation support is associated with major complications, that is, hemorrhage and thromboembolism. We seek to report our experience with delayed systemic heparinization during neonatal cardiac extracorporeal membrane oxygenation and its impact on bleeding and thromboembolism.

METHODS

We retrospectively identified 15 consecutive neonates who were placed on extracorporeal membrane oxygenation after congenital heart surgery during a period of 3 years (2015-2017). Our anticoagulation protocol consisted of full heparin reversal by protamine after switching from cardiopulmonary bypass to extracorporeal membrane oxygenation (target activated clotting time: 120 ± 20 seconds). Administration of systemic heparinization was delayed until postoperative drainage volume declined to <1 mL/kg/h. Primary study endpoints were thromboembolism, bleeding, and requirement of blood products on extracorporeal membrane oxygenation.

RESULTS

Our cohort (mean age: 13 ± 2.6 days; mean weight: 3.1 ± 0.3 kg; 66.7% male) required post-cardiotomy extracorporeal membrane oxygenation with a mean support time of 4.5 ± 2.2 days. Systemic heparinization was delayed averagely for 18.1 ± 9.3 hours. No thromboembolic events were observed on extracorporeal membrane oxygenation or after weaning. Relevant surgical site bleeding occurred in two patients (13.3%) requiring re-thoracotomy on the first postoperative day. Analysis of transfusion volumes revealed 24.5 ± 21.9 mL/kg/d mean packed red blood cells, 9.6 ± 7.1 mL/kg/d mean fresh frozen plasma, and 7.5 ± 5.7 mL/kg/d mean platelets. In-hospital survival was 86.6% (n = 13).

CONCLUSION

In this retrospective analysis, the results of delayed systemic heparinization in neonatal post-cardiotomy extracorporeal membrane oxygenation could lead one to conclude that this routine is safe and favorable with low risk for thromboembolic events, reduced postoperative hemorrhage, and reduced blood product utilization.

Noninvasive Neurally Adjusted Ventilatory Assist Versus High Flow Cannula Support After Congenital Heart Surgery

BACKGROUND

Extubation failure rates for critical patients in pediatric intensive care units (ICUs) range from 5% to 29%. Noninvasive (NIV) ventilation has been shown to decrease extubation failure. We compared reintubation rates and outcomes of patients supported with NIV neurally adjusted ventilation assist (NAVA) versus historical controls supported with high-flow nasal cannula (HFNC).

METHODS

Case-control study of infants less than three months of age who underwent cardiac surgery and received NIV support after extubation from January 2011 to May 2017. All patients supported with NIV NAVA after it became available in September 2013 were compared to matched patients extubated to HFNC from prior to September 2013.

RESULTS

Forty-two patients identified for the NIV NAVA group were matched with 42 historical controls supported with HFNC. Groups had similar baseline characteristics based on rate of acute kidney injury, number of single ventricle patients, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category, age, weight, bypass time, and duration of intubation. There was no significant difference in reintubation rates within 72 hours (14.3% in the HFNC group and 16.7% in the NIV NAVA group, P = 1.0). Median duration from extubation to coming off NIV support was longer in the NIV NAVA group (3.6 days vs 0.6 days, P < .001). Median time from extubation to ICU discharge was longer in the NIV NAVA group (10.5 vs 6.8 days, P = .02), as was total postoperative ICU length of stay (LOS; 17.6 vs 12.2, P = .01).

CONCLUSIONS

Introduction of NIV NAVA for postextubation support did not reduce reintubation rates compared to HFNC. Further study is needed as adoption of NIV NAVA may prolong LOS.

Congenital Heart Disease and Thyroid Dysfunction: Combination, Association, and Implication

BACKGROUND

Patients with congenital heart disease have higher prevalence of thyroid dysfunction due to embryonic and genetic coexistence. Marked changes in cardiac function occur secondary to alternations in thyroid hormone levels. Cardiac catheterizations or cardiac surgeries with cardiopulmonary bypass can cause abnormalities in the circulating hormones, in the absence of primary thyroid disease. Therefore, monitoring of thyroid function should be routinely performed in children with congenital heart disease. Thyroid hormone supplementation has been postulated as a possible therapeutic option; however, the therapeutic decisions should be made based on individual circumstances, symptoms, and the severity of the thyroid dysfunction.

OBJECTIVES

To describe the correlation between congenital heart disease in children and thyroid dysfunction and the debate on monitoring, intervention, and treatment.

METHODS

PubMed, Clinical Key, and the Cochrane Library were searched using keywords relevant to congenital heart disease/surgery, cardiopulmonary bypass, thyroid hormones, sick euthyroid syndrome, and cardiac catheterization. Studies were limited to the English language and to children 0 to 18 years old. Studies in adults with important findings were reviewed as well. All clinical studies believed to have relevance were considered. All relevant studies were reviewed, and the most pertinent data were incorporated in this review.

CONCLUSION

There is lack of significant evidence concerning treatment for thyroid dysfunction in children with a congenital cardiac diagnosis. Adequately powered studies are needed before a uniform recommendation about treatment can be made.

Transition from Hemochron Response to Hemochron Signature Elite Activated Clotting Time Devices in a Congenital Cardiac Surgery Practice

Heparin is the primary anticoagulant used during cardiac surgery to prevent thrombosis due to cardiopulmonary bypass (CPB)-related activation of the hemostatic system. The efficacy of heparin in the operating room is generally determined by activated clotting time (ACT) point-of-care tests performed throughout the procedure. In an effort to transition to the Hemochron Elite which requires approximately 1/10th the sampling volume of blood, we conducted a prospective study in 260 pediatric patients undergoing CPB. ACT tests were performed during CPB with a total of 260 pre-bypass and 1,117 on-bypass ACT values recorded. All samples were run simultaneously on both ACT devices. Several therapeutic cut-off possibilities ranging from >380 to >480 seconds were evaluated to ascertain the ACT level on the Elite device which best correlated with results from the Response device. Linear regression was used to determine correlation. The correlation between the two methods was moderate with a Pearson r of .6 and .4 for pre-bypass bolus ACT values and on-bypass ACT values, respectively. As the therapeutic ACT cut-off values were lowered from 480 to 380 seconds on the Elite device relative to the Response device (>480 seconds) for the on-bypass heparin samples, more patients would be under-dosed (incidence rising from 1 to 2%) and fewer patients would be overdosed (incidence decreasing from 32 to 5%) and the percent correlation between devices increased from 67 to 93%. A similar trend was observed with the pre-bypass heparin bolus samples. There was no significant effect of temperature on the ACT values comparing both devices. A therapeutic ACT value of >400 seconds for CPB with the Hemochron Elite device reasonably approximates a therapeutic ACT value of >480 seconds on the Hemochron Response device in our congenital cardiac surgery practice. Transitioning to the Elite device significantly reduces the overall sampling volume required for ACT monitoring during cardiac surgery.

Development and validation of a procedure-specific assessment tool for hands-on surgical training in congenital heart surgery

BACKGROUND

Hands-on surgical simulation has been sought to address training limitations within congenital heart surgery (CHS). However, there is a need for objective assessment methods to measure surgeons' performance to justify its global adoption. This study aimed to validate a procedure-specific assessment tool for the simulation of the arterial switch operation on 3D-printed models and to evaluate the consistency of scoring among evaluators with different levels of experience in CHS.

METHODS

Five "expert" and 5 "junior" surgeons performed the arterial switch procedure on 3D-printed models with transposition of the great arteries during 2 hands-on surgical training courses. Their performance was retrospectively assessed by 9 evaluators with varying experience in CHS (staff surgeons, resident surgeons, and non-MD raters). Assessments were done using 2 assessment tools: the Hands-On Surgical Training-Congenital Heart Surgery (HOST-CHS) assessment tool and the global rating scale (GRS).

RESULTS

The HOST-CHS tool showed a higher interrater and intrarater reliability compared with the GRS. Total scores for expert surgeons were highly consistent across all evaluators. Non-MD raters' total scores for junior surgeons were slightly higher than those of residents and staff evaluators. All grades of evaluator were able to discriminate between junior and expert surgeons.

CONCLUSIONS

This study demonstrates the development and validation of an objective, procedure-specific assessment tool for the arterial switch operation with consistency among evaluators with different experience. There is now a platform for quantifying and accurately evaluating performance, which will be highly beneficial in training and developing the next generation of congenital heart surgeons.

Quantitative assessment of technical performance during hands-on surgical training of the arterial switch operation using 3-dimensional printed heart models

OBJECTIVE

Data supporting the use of hands-on simulation in congenital heart surgery are promising but primarily qualitative. This study aimed to demonstrate if there was an objective improvement in time and technical performance of the arterial switch procedure on 3-dimensional printed heart models by surgeons using a validated assessment method.

METHODS

A total of 30 surgeons of varying experience performed the arterial switch procedure twice on 3-dimensional printed models with transposition of the great arteries during the Hands-on Surgical Training courses. Surgeons' performances were recorded and retrospectively assessed for both time and performance using the Hands-on Surgical Training-Congenital Heart Surgery tool, a validated procedure-specific assessment tool for the arterial switch.

RESULTS

A total of 60 videos were scored. Eighty percent of surgeons (24/30) had improved from their first attempt. The mean total score of the first attempt performance compared with the second was 103 and 120, respectively, with a mean difference in score of 17 (95% confidence interval, 10-24). All surgeons were statistically significantly quicker in their second attempt. The mean time for the first attempt compared with the second was 1 hour, 28 minutes, 4 seconds and 1 hour, 5 minutes, and 45 seconds, respectively, with a mean difference of 0 hours, 22 minutes, 19 seconds (95% confidence interval, 0 hours, 15 minutes, 22 seconds to 0 hours, 25 minutes, 34 seconds).

CONCLUSIONS

This is the first study to demonstrate an objective improvement in time and technical performance of the arterial switch procedure on 3-dimensional printed heart models. This supports the evidence that simulation in the form of deliberate practice with constructive, objective feedback is fundamental in the training of future congenital heart surgeons. These simulations and assessments should be incorporated to create structured, standardized training curricula within congenital heart surgery.

Selective Antegrade Cerebral Perfusion With or Without Additional Lower Body Perfusion During Aortic Arch Reconstruction in Infants

BACKGROUND

Aortic arch reconstruction is often challenging, especially in infants, owing to its high postoperative complication risks. This study aimed to compare the effectiveness between selective antegrade cerebral perfusion (SACP) alone and SACP in combination with continuous lower body perfusion with descending aortic cannulation (DAC) in preserving renal function, and to determine the influence of perfusion strategy on the postoperative course of infants who underwent aortic arch reconstruction.

MATERIAL AND METHODS

A total of 121 infants who underwent aortic arch reconstruction between January 2008 and December 2018 were included in the analysis. Patients (median age: 29 days, range: 3-270 days) were divided into the following groups: those who underwent repair with SACP (SACP group, 79 patients) and those who underwent additional lower body perfusion (DAC group, 42 patients).

RESULTS

Three (7.1%) and nine (11.4%) patients died in the DAC and SACP groups, respectively (P = .54). The SACP group had more patients requiring renal replacement therapy (P = .002) and higher incidence of second stage acute kidney injury (AKI) development (Kidney disease improving global outcomes (KDIGO) criteria; P = .032). The SACP group had higher frequency of open chest postoperatively than the DAC group (P = .011). The DAC group had lower vasoactive inotropic score (VIS) at the first postoperative day (P < .001) and shorter intensive care unit length of stay (P = .050). There was no difference in neurological complications between the groups (P = .061). High VIS was associated with early mortality (odds ratio [OR]: 1.79 [1.33-2.41], P < .001) and AKI (OR: 1.60 [1.35-1.91], P < .001). The DAC perfusion strategy with minimal hypothermia was associated with lower risk of AKI (OR: 0.91 [0.84-0.98], P = .016).

CONCLUSION

Antegrade cerebral perfusion with continuous lower body perfusion via DAC could effectively be used for improving early postoperative results among infants undergoing procedures that include aortic arch reconstruction.

Diepoxy- Versus Glutaraldehyde-Treated Xenografts: Outcomes of Right Ventricular Outflow Tract Reconstruction in Children

BACKGROUND

Xenografts used for right ventricular outflow tract (RVOT) reconstruction are typically treated with glutaraldehyde. However, potential benefit of epoxy treatment was demonstrated in experimental studies. We aimed to compare diepoxy-treated bovine pericardial valved conduits (DE-PVCs) and glutaraldehyde-treated bovine pericardial valved conduits (GA-PVCs) for RVOT reconstruction in pediatric patients.

METHODS

Between 2002 and 2017, 117 patients underwent RVOT reconstruction with PVC in single center: DE-PVC group, n = 39; and GA-PVC group, n = 78. After performing propensity score analysis (1:1) for the entire sample, 29 patients from the DE-PVC group were matched with 29 patients from the GA-PVC group.

RESULTS

There were no conduit-related deaths. In the DE-PVC group, the freedom from conduit failure was 90.9% at four years and 54.3% at eight years postoperatively. In the GA-PVC group, it was 46.3% and 33.1%, respectively. The difference was significant (P = .037). Conduit failure was typically caused by stenosis in both groups. In the DE-PVC group, the main cause of stenosis was xenograft calcification (27.6%); while in the GA-PVC group, it was mostly due to neointimal proliferation (25.0%) and, less often, calcification (14.3%). Conduit thrombosis was the cause of replacement in 6.9% of patients from the GA-PVC group.

CONCLUSIONS

Diepoxy-treated bovine pericardial valved conduit is a suitable alternative to GA-PVC for RVOT reconstruction in pediatric patients. Diepoxy-treated bovine pericardial valved conduits may be less prone to conduit failure and more resistant to neointimal proliferation and conduit thrombosis than GA-PVCs.

Results of a phase 1 multicentre investigation of dexmedetomidine bolus and infusion in corrective infant cardiac surgery

BACKGROUND

Dexmedetomidine (DEX) is increasingly used intraoperatively in infants undergoing cardiac surgery. This phase 1 multicentre study sought to: (i) determine the safety of DEX for cardiac surgery with cardiopulmonary bypass; (ii) determine the pharmacokinetics (PK) of DEX; (iii) create a PK model and dosing for steady-state DEX plasma levels; and (iv) validate the PK model and dosing.

METHODS

We included 122 neonates and infants (0-180 days) with D-transposition of the great arteries, ventricular septal defect, or tetralogy of Fallot. Dose escalation was used to generate NONMEM® PK modelling, and then validation was performed to achieve low (200-300 pg ml-1), medium (400-500 pg ml-1), and high (600-700 pg ml-1) DEX plasma concentrations.

RESULTS

Five of 122 subjects had adverse safety outcomes (4.1%; 95% confidence interval [CI], 1.8-9.2%). Two had junctional rhythm, two had second-/third-degree atrioventricular block, and one had hypotension. Clearance (CL) immediately postoperative and CL on CPB were reduced by approximately 50% and 95%, respectively, compared with pre-CPB CL. DEX clearance after CPB was 1240 ml min-1 70 kg-1. Age at 50% maximum clearance was approximately 2 days, and that at 90% maximum clearance was 18 days. Overall, 96.1% of measured DEX concentrations fell within the 5th-95th percentile prediction intervals in the PK model validation. Dosing strategies are recommended for steady-state DEX plasma levels ranging from 200 to 1000 pg ml-1.

CONCLUSIONS

When used with a careful dosing strategy, DEX results in low incidence and severity of adverse safety events in infants undergoing cardiac surgery with cardiopulmonary bypass. This validated PK model should assist clinicians in selecting appropriate dosing. The results of this phase 1 trial provide preliminary data for a phase 3 trial of DEX neuroprotection.

CLINICAL TRIALS REGISTRATION

NCT01915277.

Intermediate Outcomes of Staged Tetralogy of Fallot Repair

BACKGROUND

The optimal surgical strategy for tetralogy of Fallot (TOF) repair in neonates and young infants requiring early surgical intervention remains controversial. Our surgical center follows the uniform strategy of a staged approach with initial systemic-to-pulmonary artery shunt the majority of time when early surgical intervention is required. We characterized a contemporary cohort of patients with TOF with pulmonary stenosis (PS) undergoing staged repair in order to determine the rate of pulmonary valve-sparing repair (PVSR), growth of the pulmonary valve annulus and pulmonary arteries, postoperative morbidity and mortality, and need for reintervention.

METHODS

We retrospectively studied patients with TOF/PS who underwent staged repair from 2000 to 2017. Surgical details, postoperative course, and reinterventions were noted. Echocardiographic measurements and Z-score values of pulmonary valve annulus, main pulmonary artery (MPA), right pulmonary artery (RPA), and left pulmonary artery (LPA) diameters were evaluated.

RESULTS

Of the 59 patients with staged TOF/PS, PVSR was performed in 25 (42%). There was a 5% incidence of postoperative arrhythmia. The Z-scores of MPA, RPA, and LPA were significantly higher before complete repair when compared to before palliative shunt. The 5 and 10-year survival rates were both 93%, and the probability of freedom from reoperation at 5 and 10 years was 87% and 82%, respectively.

CONCLUSIONS

Staged repair of TOF in young symptomatic infants results in 42% receiving PVSR, pulmonary artery growth, low incidence of postoperative arrhythmia, and relatively low rate of reoperations.

Neurodevelopmental Outcomes Among Children With Congenital Heart Disease: At-Risk Populations and Modifiable Risk Factors

As survivable outcomes among patients with complex congenital heart disease (cCHD) have continued to improve over the last several decades, more attention is being dedicated to interventions that impact not just survival but quality of life among patients with cCHD. In particular, patients with cCHD are at risk for impaired neurodevelopmental outcomes. In this review summarizing select presentations given at the 14th Annual Pediatric Cardiac Intensive Care Society's Annual Meeting in 2019, we discuss the neurodevelopmental phenotype of patients with cCHD, patients at greatest risk of impaired development, and three specific modifiable risk factors impacting development.

Prevalence of Culture-Negative Fever in Infants With Down Syndrome Undergoing Cardiac Surgery

BACKGROUND

Children with Down syndrome (DS) often have congenital heart disease that requires surgical repair in the first year. Anecdotally, we have noted that patients with DS seem to have a higher rate of culture-negative postoperative fever. The objective was to evaluate the prevalence of postoperative fever and recovery among patients with DS undergoing cardiac surgery.

METHODS

We conducted a retrospective, case-control study of all patients at our institution less than one year of age with DS undergoing surgical repair of an atrioventricular septal defect or ventricular septal defect between 2010 and 2016. The control group was patients with no chromosomal anomalies who were age and surgery matched to the DS group. Temperatures were recorded for the first 72 hours postoperatively, with duration and degree of fever being assessed using the area under the curve.

RESULTS

Patients with DS (n = 34) had a significantly higher prevalence of fever than the control group (59% vs 24%, P = .003), longer ventilator time, and longer length of stay. Among the DS group, those who developed fever tended to be older at the time of surgery (146 ± 63 vs 103 ± 45 days, P = .04). The DS group with fever had similar cardiopulmonary bypass times, intensive care unit and total lengths of stay, ventilator days, and hospital costs compared to patients with DS without fever.

CONCLUSIONS

Patients with DS have a higher incidence of culture-negative fever within the first 72 hours. The presence of fever in these patients, however, does not affect their overall postoperative course.

Impact of 3D Printouts in Optimizing Surgical Results for Complex Congenital Heart Disease

Planning corrective and palliative surgery for patients who have complex congenital heart disease often relies on the assessment of cardiac anatomy using two-dimensional noninvasive cardiac imaging modalities (echocardiography, cardiac magnetic resonance imaging, and computed tomography scan). Advances in cardiac noninvasive imaging now include the use of three-dimensional (3D) reconstruction tools that produce 3D images and 3D printouts. There is scant evidence available in the literature as to what effect the availability of 3D printouts of complex congenital heart defects has on surgical outcomes. Surgical outcomes of study subjects with a 3D cardiac printout available and their paired control subject without a 3D cardiac printout available were compared. We found a trend toward shorter surgical times in the study group who had the benefit of 3D models, but no statistical significance was found for bypass time, cross-clamp time, total time, length of stay, or respiratory support. These preliminary results support the proposal that 3D modeling be made readily available to congenital cardiac surgery teams, for use in patients with the most complex congenital heart disease.

Autologous Patch Angioplasty of a Giant Right Coronary Artery Aneurysm and Coronary Stenosis in Kawasaki Disease

We describe our management of a 2-year-old patient with Kawasaki disease with a giant proximal right coronary artery (RCA) aneurysm and a >99% RCA ostial stenosis. After median sternotomy and cardioplegic arrest of the heart, we opened the aorta and cut into the RCA ostium past the stenosis and giant aneurysm. The RCA was reconstructed with an autologous pericardial patch. Cross-clamp and cardiopulmonary bypass times of 84 minutes and 114 minutes, respectively, were required. Our approach avoids mammary harvesting and grafting in such small patients while successfully treating ischemia and hopefully prevents further aneurysmal dilation over time.

Epicardial Echocardiography in Pediatric and Congenital Heart Surgery

Epicardial echocardiography (e-echo) is a useful approach to intraoperative imaging for the smallest patients and in those with contraindications to transesophageal echocardiography (TEE). The e-echo has additional advantages that include improved visualization of anterior and vascular structures and three-dimensional capabilities. In this review, we describe the advantages and disadvantages of e-echo versus TEE for pediatric and congenital heart surgery with the goal of enhancing the utility and feasibility of the former among congenital heart surgeons. We also review the technique for performance of an e-echo and provide demonstrations of the images obtained for select lesions.

149 Fontan Conversions

Patients with a functionally univentricular heart who have had an atriopulmonary Fontan are at risk for atrial dilatation, atrial arrhythmias, and progressive circulatory failure. Between 1994 and 2018, we performed 149 Fontan conversions with arrhythmia surgery and epicardial pacemaker placement at Ann & Robert H. Lurie Children's Hospital of Chicago. This operation converts the atriopulmonary Fontan to an extracardiac Fontan that improves hemodynamics and controls the atrial arrhythmias. Operative mortality during that time was 2%, and freedom from death or heart transplant at 10 years is 84%. For properly selected patients, Fontan conversion improves both survival and quality of life. Patients with an atriopulmonary Fontan constitute an eroding population, as they face many comorbidities and have a decreased life expectancy without treatment; therefore, all patients with an atriopulmonary Fontan should be evaluated for this procedure.

Surgical treatment of anomalous left main coronary artery with an intraconal course

OBJECTIVE

Anomalous left main coronary artery (LMCA) with an intraconal course is a relatively rare form of anomalous aortic origin of a coronary artery (AAOCA) from the wrong sinus of Valsalva. There is currently a paucity of information regarding this entity. The purpose of this article is to review our surgical experience with repair of anomalous LMCA with an intraconal course.

METHODS

This was a retrospective review of 12 patients with an anomalous LMCA and an intraconal course who underwent surgical repair. The median age at surgery was 15 years (range 2-47). The seven oldest patients all had preoperative symptoms of exertional chest pain and one also had exertional syncope. The five youngest patients had no preoperative symptoms. One of these patients had a hemodynamically significant ventricular septal defect and one patient was the sibling of a patient who had undergone repair of AAOCA.

RESULTS

The 12 patients underwent surgical repair including unroofing of the myocardial bridge overlying the intraconal LMCA and a LeCompte procedure. There was no early or late mortality and there were no significant complications. All 12 patients have resumed normal, unrestricted activities.

CONCLUSIONS

Twelve patients with an anomalous LMCA and intraconal course presented to our institution for treatment. Surgical repair was performed successfully in all 12, with resolution of symptoms in the 7 patients who were symptomatic preoperatively. These results suggest that the surgical treatment is safe and efficacious in patients with an anomalous LMCA and intraconal course.

Reversible right heart failure after redo operation of a post-traumatic Gerbode defect

INTRODUCTION

Gerbode defect is a rare entity and represents a small percent of all congenital defects. If left untreated, right heart failure may occur.

CASE REPORT

We describe a redo case of a 47-year-old patient complaining about the signs and symptoms of decompensating right heart failure after a surgically treated post-traumatic Gerbode defect 8 years prior.

DISCUSSION

Although it is described as a congenital defect, in clinical practice, results mostly as an iatrogenic complication after heart valve surgery, endocarditis, nodal ablation, or post-traumatic defect. Surgical correction is the treatment of choice independently of the provided cause. Dimensions, the position of the defect, are very important factors for the interventional approach. At 12 months post-operatively, the patient remained completely asymptomatic. He has an active life and presents all the echocardiographic metrics within normal values.

CONCLUSION

We strongly recommend that in cardiac areas where high wall tension is applied, durable materials such as Dacron should be used. We also believe that a well-documented discussion with the patient, about his medical condition and his therapeutic alternatives, is imperative.

Proceedings From the 3rd Symposium of the World Database for Pediatric and Congenital Heart Surgery

The World Database for Pediatric and Congenital Heart Surgery was created to provide a resource for centers to be able to perform complex outcomes analyses of children undergoing repair of a congenital heart defect. In just under two years, the World Society for Pediatric and Congenital Heart Surgery (WSPCHS) has amassed over 13,000 procedures from 55 centers into the database. This Proceedings of the 3rd World Database Symposium held at the 6th Scientific Meeting of the WSPCHS summarizes the presentations of international experts in the fields of outcomes analysis and care of children with congenital heart surgery.