Early Impact of the COVID-19 Pandemic on Congenital Heart Surgery Programs Across the World: Assessment by a Global Multi-Societal Consortium

The coronavirus disease 2019 (COVID-19) pandemic currently gripping the globe is impacting the entire health care system with rapidly escalating morbidities and mortality. Although the infectious risk to the pediatric population appears low, the effects on children with congenital heart disease (CHD) remain poorly understood. The closure of congenital heart surgery programs worldwide to address the growing number of infected individuals could have an unintended impact on future health for COVID-19-negative patients with CHD. Pediatric and congenital heart surgeons, given their small numbers and close relationships, are uniquely positioned to collectively assess the impact of the pandemic on surgical practice and care of children with CHD. We present the results of an international survey sent to pediatric and congenital heart surgeons characterizing the early impact of COVID-19 on the care of patients with CHD.

Coil occlusion of a congenital left ventricular aneurysm in a newborn

We report interventional treatment of a congenital left ventricular aneurysm in a neonate. The aneurysm was detected prenatally at 20 weeks of gestation. Postnatally, the aneurysm increased in size during the first few days of life and therefore we opted for interventional closure to abolish the potential risk of rupture. The aneurysm was entered with a 2.7 French microcatheter, and complete occlusion was achieved by successive placement of three detachable large volume coils (Ruby Coil Penumbra^R , Alameda, California). To the best of our knowledge, this is the first report describing interventional occlusion of a congenital ventricular aneurysm in early infancy. Interventional occlusion with detachable large volume coils appears to be an attractive alternative to surgical resection in patients presenting with ventricular outpouchings and narrow base connection to the ventricle.

The total artificial heart in patients with congenital heart disease

Background

While ventricular assist devices (VADs) remain the cornerstone of mechanical circulatory support (MCS), the total artificial heart (TAH-t) has gained popularity for certain patients in whom VAD support is not ideal. Congenital heart disease (CHD) patients often have barriers to VAD placement due to anatomic and physiological variation and thus can benefit from the TAH-t. The purpose of this study is to analyze the differences in TAH application and outcomes in patients with and without CHD.

Methods

The SynCardia Department of Clinical Research provided data upon request for all TAH-t implantations worldwide from December 1985 to October 2019. These patients were divided into two groups by pre-implantation diagnosis of CHD and non-CHD.

Results

A total of 1,876 patients were identified. Eighty (4%) of these patients also carried a diagnosis of CHD. There was a higher proportion of children in the CHD cohort (16.3% vs. 2.1%, P<0.001) and this translated into a lower average age amongst the two groups (34±13 vs. 49±13 years, P<0.001). There were also significantly more females in the CHD group (22.8% vs. 12.8%, P=0.010). CHD patients were more likely to be supported with a 50 cc TAH-t (11.3% vs. 4.5%, P=0.005) while all other support characteristics, including duration of support, were similar between the groups. All measured outcomes were similar between CHD and non-CHD patients including positive outcome (alive on device or transplanted), 1-month conditional survival, and rate of Freedom Driver use.

Conclusions

TAH-t is an effective means to support patients with CHD. Patients with CHD had similar survival, support characteristics, and frequency of discharge compared to patients without CHD. As MCS continues to grow, its indications broadened, and its contraindications narrowed, more patient populations will see the benefit of the TAH's continuously developing technology.

Double-Outlet Right Atrium: Review of a Rare Anomaly With an Exemplary Case

BACKGROUND

Double-outlet right atrium (DORA) is a rare congenital cardiac defect, where the right atrium (RA) is connected to both the right ventricle (RV) and the left ventricle (LV). Double-outlet right atrium is classified into two types, each containing two subtypes: malaligned atrial septum with common or single atrioventricular (AV) valve and malaligned ventricular septum (VS) with adequate or inadequate RV. The VS type is characterized by straddling right AV valve (RAVV) with intact VS, resulting in two RAVV orifices.

METHODS

We report a case of "acquired DORA" in a 17-year-old male patient previously treated with subaortic VSD closure. At admission, we diagnosed DORA with VS malalignment and adequate RV. The patient had 2 orifices within the RAVV, connecting the RA to both the RV (via RAVV orifice 1) and the LV (via RAVV orifice 2). The latter was insufficient, with severe LV to RA shunt. A review of the literature indexed in PubMed and Scopus databases was undertaken.

RESULTS

The patient underwent biventricular repair through closure of the RAVV orifice 2 with a pericardial patch. Pacemaker implantation for complete AV block was necessary. Postoperative course and follow-up were regular. The literature review showed 39 cases of DORA, of which 8 had a malaligned VS and an adequate RV, as in our case.

CONCLUSION

Acquired DORA is an interesting post-surgical variant of a rare congenital heart defect. Biventricular repair is a feasible and viable option, which involves closing the third AV orifice. Careful attention is required in order to avoid injury to the conduction system.

Utility of three-dimensional printing in preoperative planning for children with anomalous pulmonary venous connection: a single center experience

Background

This study sought to assess the application of three-dimensional (3D) printing in preoperative planning for anomalous pulmonary venous connection (APVC).

Methods

From November 2017 to January 2019, 17 children diagnosed with APVC were enrolled in this study (total APVC supracardiac type in 10 children, intracardiac type in 2 children, infracardiac type in 1 child, mixed type in 1 child, partial APVC in 3 children). The age was ranged 2 days to 20 months old (median age 1 m 5 d). Before operation, 3D-printed patient-specific heart models were created based on a cardiac computed tomography (CCT) data set with photosensitive resin materials in stereolithography (SLA) technology. These 3D models were used for presurgical decision making and navigation in the operation room. After surgery, the roles of the 3D models were evaluated with questionnaires.

Results

All 17 children successfully underwent surgeries. 3D heart models accurately demonstrated the malformations, which were all confirmed consistent with surgery findings. The final surgery programs were in accord with presurgical planning. Modeling took 0.5-2 h, with an average of 0.9±0.4 h. Printing took 2-5 h, with an average of 3.4±1.2 h. All these children were discharged without adverse events. During follow-up, 2 children suspect of anastomotic stenosis were performed cardiac CT, and 3D printed heart models were created. Results confirmed there was no obvious anastomotic stenosis. Questionnaire results indicate that 3D printing is a promising technique in clinical practice.

Conclusions

3D printing is beneficial for preoperative planning and post-surgery follow-up in APVC.

Quality Improvement Basics: A Crash Course for Pediatric Cardiac Care

BACKGROUND

Lack of knowledge of quality improvement (QI) methodology and change management principles can explain many of the difficulties encountered when trying to develop effective QI initiatives in health care.

METHODS

An interactive QI workshop at the 14th Annual Meeting of the Pediatric Cardiac Intensive Care Society provided an overview of the role of QI in health care, basic QI frameworks and tools, and leadership and organizational culture pitfalls. The top five QI projects submitted to the meeting were later presented to an expert QI panel in a separate session to illustrate examples of QI principles.

RESULTS

Workshop presenters introduced two major QI methodologies used to design QI projects. Important first steps include identifying a problem, forming a multidisciplinary team, and developing an aim statement. Key driver diagrams were highlighted as an important tool to develop a project's framework. Several diagnostic tools used to understand the problem were discussed, including the "5 Why's," cause-and-effect charts, and process flowcharts. The importance of outcome, process, and balancing measures was emphasized. Identification of interventions, the value of plan-do-study-act cycles to fuel continuous QI, and use of statistical process control, including run charts or control charts, were reviewed. The importance of stakeholder engagement, transparency, and sustainability was discussed. Later, the top five QI projects presented highlighted multiple "QI done well" practices discussed during the preconference QI workshop.

CONCLUSIONS

Understanding QI methodology and appropriately applying basic QI tools are pivotal steps to realizing meaningful and sustained improvement.

Artificial intelligence in pediatric and adult congenital cardiac MRI: an unmet clinical need

Cardiac MRI (CMR) allows non-invasive, non-ionizing assessment of cardiac function and anatomy in patients with congenital heart disease (CHD). The utility of CMR as a non-invasive imaging tool for evaluation of CHD have been growing exponentially over the past decade. The algorithms based on artificial intelligence (AI), and in particular, deep learning, have rapidly become a methodology of choice for analyzing CMR. A wide range of applications for AI have been developed to tackle challenges in various aspects of CMR, and significant advances have also been made from image acquisition to image analysis and diagnosis. We include an overview of AI definitions, different architectures, and details on well-known methods. This paper reviews the major deep learning concepts used for analyses of patients with CHD. In the end, we have summarized a list of open challenges and concerns to be considered for future studies.

Awareness of oral health in adults with congenital heart disease

Background

Poor oral health is known to be a risk factor for infective endocarditis (IE) and acquired cardiovascular disease. Many patients with congenital heart disease (CHD) are at risk for developing IE. Excellent oral health is deemed essential to prevent IE, a potentially life-threatening condition, and therefore is important in adults with congenital heart defects (ACHD). As data on oral heath in ACHD are scarce, the current study aims to assess the prevalence of caries among ACHD and the knowledge of patients about oral health as a risk factor for IE and cardiovascular disease.

Methods

A cross-sectional study included ACHD who subsequently presented at the German Heart Center Munich. The participants completed a questionnaire assessing oral health and risk awareness. Additionally, as an indicator of caries prevalence, a dentist documented the DMFT index (sum of decayed, missing and filled teeth).

Results

The median age of the 112 participants was 31.5 (range, 18-77) years. Forty-three patients (38%) were unaware of a correlation between oral health and heart disease. Twelve participants (11%) did not know about poor oral health being a risk factor for cardiovascular diseases. Less than half of the surveyed patients knew the term endocarditis. An additional twelve patients (11%) reported caveats against dental treatment because of their CHD. In twenty-three patients (21%), caries was found at the dentine level. The mean DMFT index, representing caries prevalence, was 7.91 (±6.54). There was no correlation between the Bethesda criteria of CHD and the DMFT index (P=0.69). The DMFT index was higher in patients at high risk for IE (P<0.01). However, this difference in the caries score was mainly due to more extracted and filled teeth in the high-risk patients for IE, whereas the number of decayed teeth did not differ significantly (P=0.09).

Conclusions

The awareness of the importance of optimized oral health in ACHD needs to be improved.

The value of hand grip strength (HGS) as a diagnostic and prognostic biomarker in congenital heart disease

Background

In patients with congenital heart disease (CHD), there is little data on the diagnostic and prognostic relevance of hand grip strength (HGS) for clinical assignment, while in the general population the loss of muscle strength and mass is an important risk factor in cardiovascular disease which is conversely associated with morbidity and all-cause mortality. This study aimed to assess the degree of muscle dysfunction using HGS as a biomarker in a large group of patients with CHD who often develop muscle dysfunction.

Methods

In total, 385 patients (27.6±13.1 years, 43% female) were included and assigned to 5 diagnostic groups: complex anomalies (n=131), left heart anomalies/aortopathies (n=107), right heart/pulmonary artery anomalies (n=92), primary left to-right-shunts (n=42) and miscellaneous CHD (n=13). Patients with Fontan circulation, chronic cyanosis, morphologic right systemic ventricle, arterial switch operation, or Ebstein's anomaly were analyzed separately. A control group (CG) consisted of 124 healthy individuals (30.1±12.1 years, 42% female). HGS was measured with a Jamar Hydraulic Hand Dynamometer.

Results

HGS was reduced in CHD patients compared to controls (35.2±14.6 versus 43.7±14.4 kg). Most impairments were present in females (26.1±7.6 kg). Patients with cyanosis had lower HGS values compared to acyanotic CHD patients (P=0.03). Patients with left heart lesions had the highest HSG values (40.7±14.7 kg), while patients with primary left-to-right shunt lesions had the lowest HSG values (30.9±11.3 kg). Within specific groups of cardiac anomalies, patients with Fontan circulation showed the lowest (P=0.033) and patients with a morphologic right system ventricle showed higher results (P=0.004). The late mid-term survival was favorable, and 7 patients (1.8%) died in a median interval of 422 days (range, 206-1,824 days) after HGS-testing.

Conclusions

This study provides the most comprehensive data on the use of HGS in CHD to date. Grip strength is an easily applicable, repeatedly usable and a cost-effective diagnostic tool to gain a quick, quantifiable assessment of the patient's current muscle function as an expression of cardiac fitness. Considering the low number of patients who died in the observation period, HGS may not be a suitable tool for survival assessment or identification of patients at risk. However, HGS is well suited to determine muscle function and strength and thereby to identify and to follow-up patients who have an increased cardiovascular risk.

Lecompte Procedure for Relief of Severe Airway Compression in Children With Congenital Heart Disease

PURPOSE

Children with congenital heart disease may present with severe airway compression prior to any surgical procedure or may develop airway compression following their surgical procedure. This combination of congenital heart defect and airway compression poses a significant management challenge. The purpose of this study was to review our experience with the Lecompte procedure for relief of severe airway compression.

METHODS

This was a retrospective review of ten patients who underwent a Lecompte procedure for relief of severe airway compression over the past nine years (2010-2018). Three patients with absent pulmonary valve syndrome presented with severe symptoms prior to any surgical procedure. Seven patients presented with symptoms of airway compression following repair of their congenital heart defects (one with absent pulmonary valve syndrome, three patients had repair of pulmonary atresia with ventricular septal defect, and three patients had undergone aortic arch surgery). The median age at presentation was two years (range: one day to seven years).

RESULTS

The ten patients underwent a Lecompte procedure without any significant complications or operative mortality. The median interval between the surgical procedure and extubation was 9.5 days. No patients have required any further interventions for relief of airway obstruction.

CONCLUSIONS

The Lecompte procedure is a surgical option for young children who present with severe airway compression. The patients in this series responded well to the Lecompte procedure as evidenced by clinical relief of airway compression.

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.

Challenges of Caring for Functionally Single Ventricle Patients in Africa

Surgical palliation has remarkably improved survival of functionally single ventricle (FSV) patients born in developed nations but such outcomes have not occurred in Africa. The poor care coverage for FSV patients in Africa exists within the larger sphere of deficient health care for children born with congenital heart defects (CHDs) in Africa generally. This review takes the position that to improve health-care coverage for CHD patients on the continent, political priority is paramount. This can be attained with cohesive leadership for the CHD agenda, a guiding institution, and the mobilization of civil society to drive advocacy at national and international levels.

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.

Potential Impact of MicroRNA-423 Gene Variability in Coronary Artery Disease

AIM

Studies have evaluated the association of miRNA-423 C>A genotyping with the susceptibility to various diseases such cancers, atherosclerosis and inflammatory bowel disease but the results were contradictory. However, no studies have reported the association between miRNA-423 rs6505162 C>A polymorphism and susceptibility of coronary artery disease. MicroRNAs regulate expression of multiple genes involved in atherogenesis. Therefore, we investigated the association of microRNA-423C>T gene variations with susceptibility to coronary artery disease.

METHODOLOGY

This study was conducted on 100 coronary artery disease patients and 117 matched healthy controls. The genotyping of the microRNA-423 rs6505162C>A was performed by using Amplification refractory mutation system PCR method (ARMS-PCR).

RESULTS

A significant difference was observed in the genotype distribution among the coronary artery disease cases and sex-matched healthy controls (P=0.048). The frequencies of all three genotypes CC, CA, AA reported in the patient's samples were 55%, 41% and 4% and in the healthy controls samples were 55%, 41% and 4% respectively. Our findings showed that the microRNA-423 C>A variant was associated with an increased risk of coronary artery disease in codominant model (OR = 1.96, 95 % CI, 1.12-3.42; RR 1.35(1.05-1.75, p=0.017) of microRNA-423CA genotype and significant association in dominant model (OR 1.97, 95% CI (1.14-3.39), (CA+AA vs CC) and non-significant association for recessive model (OR=1.42, 95%CI=0.42-4.83, P=0.56, AA vs CC+CA).While, the A allele significantly increased the risk of coronary artery disease (OR =1.56, 95 % CI, 1.03-2.37; p=0.035) compared to C allele. Therefore, it was observed that more than 1.96, 1.97 and 1.56 fold increased risk of developing coronary artery disease.

CONCLUSION

Our findings indicated that microRNA-423 CA genotype and A allele are associated with an increased susceptibility to Coronary artery disease.

Total Anomalous Pulmonary Venous Connection Beyond the First Decade of Life

OBJECTIVE

We report our experience with surgery for total anomalous pulmonary venous connection (TAPVC) beyond first decade of life.

METHODS

Between January 1987 and July 2017, 98 patients ≥ten years underwent TAPVC repair. Their detailed case-records were analyzed.

RESULTS

Mean age was 19.05 (± 12.8; median 18) years. Anatomic subtypes were supracardiac (n = 62), cardiac (n = 20), and mixed (n = 16). An atrial septal defect (ASD) was present in all. Severe tricuspid valve regurgitation was present in four patients and severe rheumatic mitral regurgitation was present in one. On preoperative cardiac catheterization, mean pulmonary artery pressure was 67 ± 15.6 mm Hg (median 58; range 37-96). Mean pulmonary vascular resistance was 5.6 ± 3.9 Woods units·m² (median 4.7, range 2.9-11.8). Twenty-five patients had moderate and eight had severe pulmonary arterial hypertension. Right ventricular dysfunction was present in eight patients. At repair, a small ASD was left open in 87 patients while in 11 patients, the ASD was closed using a unidirectional valved patch. Follow-up was available for 90 (92%) patients. There were no late deaths over a mean follow-up of 163 ± 103.98 months (median 163, range 1-362). Eighty-two patients were in NYHA class I and eight were in class II. Right ventricular function normalized in 82 patients while 80 patients had reduction in pulmonary artery pressure. Event-free survival was 94.2% at 5 years, 92.3% at 10 years, and 90% at 20 and 30 years.

CONCLUSIONS

Outcomes of surgical repair for TAPVC beyond first decade of life are satisfactory. Close follow-up, however, is necessary for possible persistence of pulmonary arterial hypertension.

Palliation of Functionally Single Ventricle Patients in Sub-Saharan Africa-Is It Justifiable?

Resource constraints in many sub-Saharan African countries undermine efforts to provide the full spectrum of pediatric cardiology and cardiac surgery. Palliation of the child born with functionally single ventricle is the lowest priority for policymakers when viewed from the perspective of cost-effectiveness. This commentary focuses on the relative importance of different criteria that policymakers and the general public consider important in setting health-care priorities as it relates to palliation of the patient with functionally single ventricle in sub-Saharan Africa. It argues the position that cost-effectiveness analysis tends to exclude those with high cost-to-treat illness, and decisions made on that basis alone are not acceptable to the general population on whose behalf those decisions are made.

Cardiopulmonary Exercise Testing-A Valuable Tool, Not Gatekeeper When Referring Patients With Adult Congenital Heart Disease for Transplant Evaluation

INTRODUCTION

Treatment of patients with adult congenital heart disease (ACHD) with advanced therapies including heart transplant (HT) is often delayed due to paucity of objective prognostic markers for the severity of heart failure (HF). While the utility of Cardiopulmonary Exercise Testing (CPET) in non-ACHD patients has been well-defined as it relates to prognosis, CPET for this purpose in ACHD is still under investigation.

METHODS

We performed a retrospective cohort study of 20 consecutive patients with ACHD who underwent HT between March 2010 and February 2016. Only 12 of 20 patients underwent CPET prior to transplantation. Demographics, standard measures of CPET interpretation, and 30-day and 1-year post transplantation outcomes were collected.

RESULTS

Patient Characteristics. Twenty patients with ACHD were transplanted at a median of 40 years of age (range: 23-57 years). Of the 12 patients who underwent CPET, 4 had undergone Fontan procedures, 4 had tetralogy of Fallot, 3 had d-transposition of the great arteries, and 1 had Ebstein anomaly. Thirty-day and one-year survival was 100%. All tests included in the analysis had a peak respiratory quotient _1.0. The median peak oxygen consumption per unit time (_VO2) for all diagnoses was 18.2 mL/kg/min (46% predicted), ranging from 12.2 to 22.6.

CONCLUSION

There is a paucity of data to support best practices for patients with ACHD requiring transplantation. While it cannot be proven based on available data, it could be inferred that outcomes would have been worse or perhaps life sustaining options unavailable if providers delayed referral because of the lack of attainment of CPET-specific thresholds.

The Arterial Switch Operation in 2019: How to Do It and How to Teach It

This article presents technical aspects of the arterial switch procedure. The arterial switch procedure is a technically reproducible operation that involves less three-dimensional judgment and fewer difficult sequencing decisions than many other complex cardiac procedures. Hemostasis is the most important principal that must be adhered to mainly through meticulous surgical technique. Meticulous technique will also lead to successful transfer of the coronary arteries. Teaching a surgical trainee how to manage a child who requires an arterial switch procedure requires instruction in the technical aspects of the procedure. However, this is just one component of the overall management of babies requiring this procedure. Attention and training should be directed at all areas of competence that have been emphasized by bodies such as the American College of Surgeons. Simulation is playing an increasingly important role in the instruction of surgical trainees within the domain of congenital heart disease.

Delaying Decannulation After Extracorporeal Membrane Oxygenation Is Safe and Advantageous

Removal of extracorporeal membrane oxygenation (ECMO) cannulae and discontinuing systemic anticoagulation typically occurs soon after separation from ECMO. We have found, however, that delaying decannulation after terminating ECMO therapy does not predispose to adverse outcomes and may be advantageous. Between January 2014 and June 2016, 36 postcardiotomy patients at the Children's Hospital of Oklahoma required ECMO. In this cohort of 36 patients, there was a need for 42 ECMO runs. Of the 42 ECMO runs, 29 (69%) survived to decannulation. Of those ECMO runs that survived to decannulation, 18 (62%) were cannulated centrally and 11 (38%) were cannulated via the neck. For the runs where the patient survived to decannulation, the mean number of days on ECMO support was 4 ± 2 days. There was an average time interval of 21 ± 14 hours from ECMO termination to decannulation. A single patient failed being separated from ECMO support and required reinstitution of ECMO 18 hours after separation (but did not require recannulation).

Wide Dissection and Intercostal Vessel Division Allows for Repair of Hypoplastic Aortic Arch Through Thoracotomy

BACKGROUND

The approach to coarctation of the aorta with hypoplastic aortic arch is controversial. We evaluated the outcomes in patients with coarctation of the aorta with or without hypoplastic aortic arch operated through a posterior left lateral thoracotomy.

METHODS

A retrospective cohort of patients with aortic coarctation, who underwent repair between January 2009 and October 2017, was analyzed. Preoperative, postoperative, and echocardiographic characteristics were reviewed. Statistical analysis examined survival, freedom from reintervention, and freedom from recoarctation.

RESULTS

In nine years, 389 patients who underwent surgical treatment for coarctation of the aorta were identified; after exclusion criteria and complete echocardiographic reports, 143 patients were analyzed, of which 29 patients had hypoplastic aortic arch. The modification in the extended end-to-end anastomosis technique was a wide dissection and mobilization of the descending aorta that was achieved due to the ligation and division of 3 to 5 intercostal vessels. In both groups, patients were close to one month of age and had a median weight of 3.6 and 3.4 kg for hypoplastic and nonhypoplastic arch, respectively. In postoperative events, there was no statistically significant difference between the groups ( P = .57 for renal failure, P = .057 for transient, nonpermanent neurologic events, P = .496 for sepsis), as for intensive care unit ( P = .502) and total in-hospital stay ( P = .929). There was one case of postoperative mortality in each group and both were associated with noncardiac comorbidities. Regarding survival (log-rank = 0.060), freedom from reintervention (log-rank = 0.073), and freedom from recoarctation (log-rank = 0.568), there was no statistically significant difference between the groups.

CONCLUSION

We believe that it is the modified technique that allowed greater mobilization of the aorta and successful repair of hypoplastic arch through thoracotomy, without an increase in paraplegia or other adverse outcomes.

Extracardiac Fontan With Direct Inferior Vena Cava to Main Pulmonary Artery Connection Without Cardiopulmonary Bypass

We report the case of a six-year-old patient who underwent an extracardiac Fontan operation including bilateral bidirectional superior cavopulmonary anastomosis and direct inferior vena cava to main pulmonary artery connection that was performed without cardiopulmonary bypass.

Current Topics and Controversies in Pediatric Heart Transplantation: Proceedings of the Pediatric Heart Transplantation Summit 2017

In October 2017, a pediatric heart transplant summit was held in Seattle-the first of its kind internationally-which focused solely upon controversies in pediatric end-stage heart failure management and pediatric heart transplantation. We selected five of the most popular and contentious topics and asked the speakers to provide a position paper. Worldwide, the vast majority of programs perform only a handful of pediatric heart transplants a year. Because of this, these "orphan" areas of investigation provide an opportunity for us as a community to aggregate our collective knowledge, which may represent the only viable way that we might sort through these complex and controversial issues in the field. We hope this represents the first of many such conferences and that this initial selection of papers encourages us to begin this collaborative process.

Cryopreserved Saphenous Vein Compared With PTFE Graft for Use as Modified Blalock-Taussig or Central Shunt in Cyanotic Congenital Heart Disease

Many infants with congenital heart disease undergo palliative shunt procedures. In our center, cryopreserved saphenous vein and polytetrafluoroethylene (PTFE) are used as grafts to construct these shunts. In this retrospective review, we compare morbidity, mortality, and freedom from reoperation associated with the use of these graft materials. We conducted a retrospective study of 136 consecutive patients who were palliated with shunts between 2006 and 2015. A total of 136 patients were identified, 9 had incomplete data; thus, 127 patients were included: 69 saphenous and 58 PTFE. The cohorts were matched with respect to birth weight, gestational age, age and weight at time of surgery, and underlying cardiac condition. There were 15 (12%) deaths in the study cohort with no intraoperative mortality. Thrombosis was seen in 5.2% (2/38) of the saphenous modified Blalock-Taussig shunt (mBTS) group and 20.6% (14/68) of those with PTFE mBTS. There was no thrombosis in the central shunt group. Freedom from reoperation was 83% in the saphenous vein group and 81% in the PTFE group. There was no difference in overall morbidity or mortality, although thrombosis was significantly less in the saphenous vein group. Cryopreserved saphenous vein is a safe alternative, either as a mBTS or as a central shunt.

Morphological Substrates for Atrial Arrhythmogenesis in a Heart With Atrioventricular Septal Defect

Due to advances in corrective surgery, congenital heart disease has an ever growing patient population. Atrial arrhythmias are frequently observed pre- and post-surgical correction. Pharmaceutical antiarrhythmic therapy is not always effective, therefore many symptomatic patients undergo catheter ablation therapy. In patients with atrioventricular septal defects (AVSD), ablation therapy itself has mixed success; arrhythmogenic recurrences are common, and because of the anatomical displacement of the atrioventricular node, 3-degree heart block post-ablation is a real concern. In order to develop optimal and safe ablation strategies, the field of congenital cardiac electrophysiology must combine knowledge from clinical electrophysiology with a thorough understanding of the anatomical substrates for arrhythmias. Using image-based analysis and multi-cellular mathematical modeling of electrical activation, we show how the anatomical alterations characteristic of an AVSD serve as arrhythmogenic substrates. Using ex-vivo contrast enhanced micro-computed tomography we imaged post-mortem the heart of a 5 month old male with AVSD at an isometric spatial resolution of 38 μm. Morphological analysis revealed the 3D disposition of the cardiac conduction system for the first time in an intact heart with this human congenital malformation. We observed displacement of the compact atrioventricular node inferiorly to the ostium of the coronary sinus. Myocyte orientation analysis revealed that the normal arrangement of the major atrial muscle bundles was preserved but was modified in the septal region. Models of electrical activation suggest the disposition of the myocytes within the atrial muscle bundles associated with the "fast pathway," together with the displaced atrioventricular node, serve as potential substrates for re-entry and possibly atrial fibrillation. This study used archived human hearts, showing them to be a valuable resource for the mathematical modeling community, and opening new possibilities for the investigations of arrhythmogenesis and ablation strategies in the congenitally malformed heart.

Pulmonary hypertension in patients with 9q34.3 microdeletion-associated Kleefstra syndrome

Kleefstra Syndrome is a rare genetic disorder caused by mutations in EHMT1, Euchromatin Histone Methyl Transferase 1, or deletions encompassing EHMT1 on 9q34.3. Congenital heart defects are among the major findings in patients with 9q34.3 microdeletion/Kleefstra Syndrome along with recognizable facial appearance, developmental delay/intellectual disability including severely delayed or absent speech, hypotonia, seizures, behavioral and sleep abnormalities. Pulmonary hypertension (PH) is a rare condition associated with increased pulmonary artery and right heart pressures that can lead to right heart failure and death if untreated. PH can be idiopathic, heritable, or associated with co-morbid conditions including congenital heart disease (CHD), lung diseases and other metabolic disorders. Genetic factors play important roles in heritable and idiopathic PH development and are particularly relevant but more diverse in etiology in children. PH is also reported in some chromosomal disorders such as Down syndrome in which congenital heart defects are common; however, PH has rarely been reported in patients with 9q34.3 microdeletion/Kleefstra Syndrome. Here, we present three patients with 9q34.3 microdeletions with CHD and PH along with review of five similar cases reported in the literature and discuss the potential association of PH with Kleefstra syndrome.

Successful Late Recruitment of the Occluded Left Main Coronary Artery After Initial Arterial Switch Operation

We describe a surgical technique for late recruitment of the proximally occluded left main coronary artery (LMCA) after initial arterial switch operation, which had been complicated by severe left ventricular dysfunction. This technique allowed for LMCA recanalization, using the patent conal artery branching off the LMCA close to the ostium. It is particularly useful in small children, where surgical options for coronary arteries are limited and associated with a high risk of restenosis. It was successfully used in a two-month-old boy with successful revascularization confirmed by angiography.

The World Database for Pediatric and Congenital Heart Surgery: Update

Following several years of planning and design, the World Database for Pediatric and Congenital Heart Surgery (WDPCHS) went live on January 1, 2017. The first operational year of this valuable database has proven very successful. As of February 28, 2018, more than 4,500 patients have been submitted from 39 centers; participation currently spans 19 countries over 6 continents, with 120 more centers in the enrollment pipeline. This update, the first in a series, is intended to provide World Society for Pediatric and Congenital Heart Surgery members and others who care for children with congenital heart disease with a broad overview of current progress and ongoing activities surrounding the WDPCHS.

Cardiopulmonary Bypass for a Patient With Congenital Hyperinsulinemia

Congenital hyperinsulinism is a clinical syndrome of pancreatic β-cell dysfunction characterized by failure to suppress insulin secretion in the presence of hypoglycemia. Here, we describe the concerns, the techniques used to ameliorate these potential problems, and the outcomes for a child with this condition undergoing cardiopulmonary bypass for correction of an atrial septal defect.

Parental perceptions of disease-severity and health-related quality of life in school-age children with congenital heart disease

PURPOSE

Understanding parents' perceptions of their child's health status is important as parents are drivers of healthcare utilization in the pediatric setting. Understanding parent-perceived disease-severity and its effects on a child's health-related quality of life (HRQOL) in children with congenital heart disease (CHD) is necessary to evaluate outcomes of care, improve care coordination, and inform policies focused on advancing family-centered care for pediatric cardiac patients. The impact of CHDs and disease-severity on the child's HRQOL has been investigated with inconsistent results. The overall aim of this study was to examine parents' perceptions of HRQOL in their school-age child with CHD, and to compare HRQOL among patients with CHD across severity categories.

DESIGN

This was a descriptive correlational study design.

METHODS

A total of 71 parents of school-age children aged 5-12 years completed the Pediatric Quality of Life Inventory 4.0 Generic Core Scale (PedsQL) (including total, physical health, and psychosocial health summary scores) and cardiac-specific HRQOL Scale (PedsQL 3.0). PedsQL scores among CHD severity categories were compared by analysis of variance.

RESULTS

School-age children with CHDs had an overall good HRQOL with significant differences among disease severity categories for all scores. Parents reported lower scores on their HRQOL of older children compared to younger children across severity groups (p < .01) and for those children with more severe disease (p < .01).

PRACTICE IMPLICATIONS

Based on the results of this study, interventions should focus on targeting psychosocial health in older children with CHD and physical health in younger children with CHD. This information is useful in providing practical recommendations in caring for children with CHDs while informing relevant policies.

Externally applied compression therapy for Fontan patients

BACKGROUND

Limited therapeutic options are available for Fontan patients with dysfunctional or failing single ventricle physiology. This study describes the evaluation of an alternative, non-invasive, at-home therapeutic compression treatment for Fontan patients. Our hypothesis is that routinely administered, externally applied compression treatments to the lower extremities will augment systemic venous return, improve ventricular preload, and thus enhance cardiac output in Fontan patients.

METHODS

To initially evaluate this hypothesis, we employed the NormaTec pneumatic compression device (PCD) in a pilot clinical study (n=2). This device is composed of inflatable trouser compartments that facilitate circumferentially and uniformly applied pressure to a patient's lower extremities. Following an initial health screening, test subjects were pre-evaluated with a modified-Bruce treadmill exercise stress test, and baseline data on cardiorespiratory health was collected. After training, test subjects conducted 6 days of external compression therapy at-home. Subjects were then re-evaluated with a final treadmill stress test and data acquisition of new cardiorespiratory parameters.

RESULTS

Both subjects demonstrated improvement in exercise duration time, peak oxygen volume, and ventilator threshold, as compared to the baseline evaluation.

CONCLUSIONS

These findings are promising and provide the foundation for future studies that will focus on increasing study participation (sample size) to better assess the clinical benefit of compression therapy for Fontan patients.

Risk factors and methylenetetrahydrofolate reductase gene in congenital heart disease

Background

Congenital heart disease (CHD), which involve congenital cardiovascular malformations that occur during an embryo stage, may be the result of a complex interaction between genetic factors and environmental factors. The homozygous 677 T/T MTHFR gene and potential factors have been associated with CHD. Our objective was to study associations between potential environmental risk factors and methylenetetrahydrofolate reductase (MTHFR) gene polymorphisms in CHD.

Methods

A total of 346 children with CHD and 237 healthy children were recruited. Their parents were also enlisted in the study and interviewed face-to-face to identify potential environmental risk factors. The MTHFR genotype was analyzed by restriction fragment length polymorphism (RFLP). Interactions between environmental risk factors and MTHFR gene polymorphisms were evaluated by the relative excess risk due to interaction (RERI), the attributable proportion due to interaction (AP), and the synergy index (S).

Results

There were significant differences in the occupational statuses of the mothers and their levels of drug exposure during gestation between the controls and the cases (P<0.05). These differences significantly increased offspring CHD risk (occupation: OR =5.45, 95% CI: 3.46-8.58; drug exposure: OR =4.91, 95% CI: 2.18-11.09). The frequency of the MTHFR gene 677 TT polymorphism in the mothers who had offspring with CHD was significantly different from that in the non-CHD controls (P<0.05). The frequency of this polymorphism also significantly differed between the children with CHD and the control group (P<0.05). An interaction was identified between the presence of the homozygous 677 TT genotype in the children and the mothers' occupational statuses (RERI =9.43, CI: 0.06-18.91).

Conclusions

A significant interaction was found between the homozygous 677 T/T MTHFR gene in children and the maternal occupational status and level of drug exposure during gestation. Avoiding or reducing the exposure of the risk factors mentioned above, strengthening pre-pregnancy checkups and guidance might help to reduce the risk of CHD.

Transplantation in the single ventricle population

The single ventricle patient population comprises the most complex cohort presenting to the cardiac transplant team, in terms of demographics, anatomic substrate, and unique physiology. It is also the most rapidly growing diagnostic group presenting for heart transplantation. In this manuscript, we aim to describe the changing landscape of transplantation in single ventricle conditions through reflection on our own institution's practice and experience, alongside contemporary literature review. Single ventricle patients are heterogeneous in terms of age, anatomic diagnosis and physiology according to surgical stage of repair. Progress in surgical palliative strategies has impacted upon the present composition of the population, with growing numbers of hypoplastic left heart syndrome patients and those with late physiology failure following Fontan completion. Multiple prior surgeries, immunological sensitivity and multi-organ involvement impart high peri-operative risk but can be mitigated in part by careful pre-operative planning by a dedicated multi-disciplinary team addressing issues such as planning of concurrent reconstructive surgery, minimizing the post-operative effect of collaterals, timely harvesting, oversizing of donor organs to minimize graft failure, and strategies to address anticipated post-operative elevation in pulmonary vascular resistance. Determining optimal timing for transplant in these patients remains unclear, but understanding the risk of alternative surgical options can help guide decision making with regards to listing.

Outcomes of Patients Undergoing Primary Fontan Operation Beyond First Decade of Life

OBJECTIVES

Studies on older patients undergoing primary Fontan operation (FO) are limited, with conflicting results. We review our experience with these patients beyond the first decade of life.

PATIENTS AND METHODS

Between January 2000 and December 2014, a total of 105 patients ≥10 years of age (mean 15.6 ± 4.9, range 10-31, median 15 years) underwent primary FO without a prior bidirectional superior cavopulmonary anastomosis (Bidirectional Glenn [BDG]). Mean preoperative New York Heart Association (NYHA) class was 2.2 ± 0.57.

RESULTS

Operative procedure was extra-cardiac FO in 62 patients (8 were fenestrated). Forty-three had a lateral tunnel FO (26 were fenestrated). There were 11 (10.5%) early deaths. Fourteen of the 94 early survivors experienced prolonged pleural effusions, 7 had arrhythmias, and 2 had thromboembolic events. Two patients underwent Fontan takedown. On univariate analysis, NYHA functional class III, mean pulmonary artery (PA) pressure ≥15 mm Hg, hematocrit ≥60%, preoperative ventricular dysfunction, and atrioventricular valve regurgitation (AVVR) were associated with early mortality. Median follow-up was 78 (mean 88.9 ± 6.3) months. In 94 survivors, 6 (6.4%) late deaths were encountered. At last follow-up, 81 (86.2%) survivors were in NYHA class I. Actuarial survival was 84.7% ± 3.7% at 5, 10, and 15 years.

CONCLUSION

Carefully selected adolescents and young adults can safely undergo the primary FO. However, persistent pleural effusions, arrhythmias, thromboembolic events, and the need for reoperation mandate regular follow-up in such patients. Preoperative NYHA functional class III, mean PA pressure ≧ 15 mm Hg, hematocrit ≥ 60%, ventricular dysfunction, and AVVR were associated with early mortality, suggesting that primary FO should be avoided in such patients.

A Quarter-Century After Primary Direct Arterial Switch Operation: Four-D-Flow MRI Video Imaging of Blood Flow Dynamics Outcomes

Four-dimensional (4-D) flow magnetic resonance imaging (MRI) examination was performed 25 years after a neonatal direct arterial switch operation for simple transposition of the great arteries. The 4-D flow MRI video shows physiological spiral anatomical configuration and laminar streamlines in the great arteries.

Acquired von Willebrand Syndrome: An Under-Recognized Cause of Major Bleeding in the Cardiac Intensive Care Unit

BACKGROUND

Acquired von Willebrand syndrome (AvWS) in the setting of congenital heart disease is an under-recognized cause of bleeding in the pediatric cardiac critical care unit.

METHODS

Fourteen patients diagnosed with AvWS admitted to the cardiac intensive care unit at the Children's National Health System between December 2009 and September 2015 were identified with subsequent chart review and case analysis.

RESULTS

Of the 14 patients included in this study, 4 patients were on ventricular-assist devices, 6 patients were on extracorporeal membrane oxygenation, and 4 were patients with congenital heart disease not receiving any mechanical circulatory support. All patients identified manifested persistent severe bleeding, despite appropriate management of anticoagulation and blood product administration based on the established protocols. Detailed hemostatic testing including quantitative von Willebrand factor (vWF) multimer analysis revealed decreased high-molecular-weight multimers (HMWMs) and absent ultra-HMWM, consistent with AvWS in all patients. Eight patients received treatment with vWF concentrate, one patient with desmopressin, and five recovered without specific treatment. Bleeding ceased in all but one patient.

CONCLUSIONS

Acquired von Willebrand syndrome is an uncommon but important cause of bleeding in pediatric patients with cardiac disease. A high index of clinical suspicion with knowledge of the characteristic clinical scenario in addition to low levels of vWF multimers is required to manage and diagnose AvWS. Although the optimal management of AvWS in this patient population is unclear, vWF concentrates are available and appear to be efficacious for controlling life-threatening bleeding.

Three Dimensional Visualization of Human Cardiac Conduction Tissue in Whole Heart Specimens by High-Resolution Phase-Contrast CT Imaging Using Synchrotron Radiation

BACKGROUND

The feasibility of synchrotron radiation-based phase-contrast computed tomography (PCCT) for visualization of the atrioventricular (AV) conduction axis in human whole heart specimens was tested using four postmortem structurally normal newborn hearts obtained at autopsy.

METHODS

A PCCT imaging system at the beamline BL20B2 in a SPring-8 synchrotron radiation facility was used. The PCCT imaging of the conduction system was performed with "virtual" slicing of the three-dimensional reconstructed images. For histological verification, specimens were cut into planes similar to the PCCT images, then cut into 5-μm serial sections and stained with Masson's trichrome.

RESULTS

In PCCT images of all four of the whole hearts of newborns, the AV conduction axis was distinguished as a low-density structure, which was serially traceable from the compact node to the penetrating bundle within the central fibrous body, and to the branching bundle into the left and right bundle branches. This was verified by histological serial sectioning.

CONCLUSION

This is the first demonstration that visualization of the AV conduction axis within human whole heart specimens is feasible with PCCT.

Anomalous Origin of Pulmonary Artery From Aorta: Neonatal Autologous Aortopulmonary Reconstruction

Anomalous origin of a branch pulmonary artery (PA) from the ascending aorta is rather rare within the spectrum of congenital cardiovascular anomalies. In the scarce subset of patients with anomalous origin of right PA (RPA) from the ascending aorta originating from the lateral aspect of the distal ascending aorta, early neonatal repair by employing native aortic tissue for RPA reconstruction combined with translocation of the aorta posteriorly to the RPA can be an alternative option in the surgical armamentarium.

Experience Using Kaolin-Impregnated Sponge to Minimize Perioperative Bleeding in Norwood Operation

PURPOSE

A kaolin-impregnated hemostatic sponge (QuikClot) is reported to reduce intraoperative blood loss in trauma and noncardiac surgery. The purpose of this study was to assess if this sponge was effective for hemostasis during Norwood operation.

DESCRIPTION

We conducted a retrospective review of patients undergoing Norwood operation in infancy between 2011 and 2016 at our institution.

EVALUATION

Of 31 identified Norwood operations, a kaolin-impregnated sponge was used intraoperatively in 15 (48%) patients. The preoperative profiles and cardiopulmonary bypass status were similar between the operations with or without kaolin-impregnated sponge. The comparison on each operative outcome between operations with or without kaolin-impregnated sponge showed that the intraoperative platelets, cryoprecipitate, and factor VII dosage were significantly less in the operations with kaolin-impregnated sponge (55 mL, 10 mL, 0 µg/kg vs 72 mL, 15 mL, 45 µg/kg; P = .03, .021, .019), as well as the incidence of perioperative bleeding complications (second cardiopulmonary bypass for hemostasis or postoperative mediastinal exploration, 0% vs 31%, P = .043). A logistic regression model showed that the nonuse of kaolin-impregnated sponge and longer aortic cross clamp time were associated with perioperative bleeding complication in univariable model ( P = .02 and .005).

CONCLUSIONS

Use of kaolin-impregnated hemostatic sponge was associated with reduced blood product use and perioperative bleeding complications in Norwood operation at a single institution.

Hypomethylation and decreased expression of BRG1 in the myocardium of patients with congenital heart disease

BACKGROUND

BRG1, an ATPase subunit of the SWItch/Sucrose Non-Fermentable complex, is tightly associated with cardiac development. However, little is known about the association between the pathogenesis of CHD and BRG1.

METHODS

The methylation of a BRG1 promoter and a novel CpG island in the second intron was analyzed in the myocardium of congenital heart disease (CHD) patients (n = 24) and normal controls (n = 11) using pyrosequencing and the MassARRAY platform. BRG1 expression was sketched in the normal fetal and postnatal heart using real-time PCR. BRG1 mRNA and protein expression was detected by means of real-time PCR and immunohistochemistry. The expression of GATA4 was analyzed with real-time PCR.

RESULTS

The CpG shore in the second intron of BRG1 was hypomethylated in the myocardium of patients (p < 0.05). BRG1 showed a high level of expression in the normal fetal heart in the second trimester (p < 0.01). Compared with that of the normal subjects, BRG1 expression was decreased by 70% in the myocardium of patients (n = 92; p < 0.05). Of note, the expression of GATA4 was significantly correlated with BRG1 expression (r = 0.7475; p = 0.0082) in the myocardium, and it was also decreased by 70% in these patients (n = 92; p < 0.05).

CONCLUSION

These results suggested that the early high expression of BRG1 in fetal hearts maintained normal cardiac development and that the abnormal hypomethylation and decreased expression of BRG1 in human hearts probably affect the expression of GATA4, which affects the pathogenesis of CHD. Birth Defects Research 109:1183-1195, 2017. © 2017 Wiley Periodicals, Inc.

Xq26.1-26.3 duplication including MOSPD1 and GPC3 identified in boy with short stature and double outlet right ventricle

Xq25q26 duplication syndrome has been reported in individuals with clinical features such as short stature, intellectual disability, syndromic facial appearance, small hands and feet, and genital abnormalities. The symptoms are related to critical chromosome regions including Xq26.1-26.3. In this particular syndrome, no patient with congenital heart disease was previously reported. Here, we report a 6-year-old boy with typical symptoms of Xq25q26 duplication syndrome and double outlet right ventricle (DORV) with pulmonary atresia (PA). He had the common duplicated region of Xq25q26 duplication syndrome extending to the distal region including the MOSPD1 locus. MOSPD1 regulates transforming growth factor beta (TGFβ) 2,3 and may be responsible for cardiac development including DORV. In the patient's lymphocytes, mRNA expression of TGFβ2 was lower than control, and might cause DORV as it does in TGFβ2-deficient mice. Therefore, MOSPD1 is a possible candidate gene for DORV, probably in combination with GPC3. Further studies of the combined functions of MOSPD1 and GPC3 are needed, and identification of additional patients with MOSPD1 and GPC3 duplication should be pursued.

MicroRNAs: pleiotropic players in congenital heart disease and regeneration

Congenital heart disease (CHD) is the leading cause of infant death, affecting approximately 4-14 live births per 1,000. Although surgical techniques and interventions have improved significantly, a large number of infants still face poor clinical outcomes. MicroRNAs (miRs) are known to coordinately regulate cardiac development and stimulate pathological processes in the heart, including fibrosis or hypertrophy and impair angiogenesis. Dysregulation of these regulators could therefore contribute (I) to the initial development of CHD and (II) at least partially to the observed clinical outcomes of many CHD patients by stimulating the aforementioned pathways. Thus, miRs may exhibit great potential as therapeutic targets in regenerative medicine. In this review we provide an overview of miR function and elucidate their role in selected CHDs, including hypoplastic left heart syndrome (HLHS), tetralogy of Fallot (TOF), ventricular septal defects (VSDs) and Holt-Oram syndrome (HOS). We then bridge this knowledge to the potential usefulness of miRs and/or their targets in therapeutic strategies for regenerative purposes in CHDs.

Tracheostomy Following Surgery for Congenital Heart Disease: A 14-year Institutional Experience

BACKGROUND

Tracheostomy following congenital heart disease (CHD) surgery is a rare event and associated with significant mortality. Hospital survival has been reported from 20% to 40%. Late mortality for these patients is not well characterized.

METHODS

We performed a retrospective observational study of patients who had a tracheostomy following CHD surgery (excluding isolated patent ductus arteriosus ligation) between January 2000 and December 2013. Patients were categorized into single-ventricle or biventricular physiology groups. Demographics, genetic syndromes, pulmonary disease, and comorbidities were collected. Outcomes including hospital survival, long-term survival, and weaning from positive pressure ventilation are reported. Bivariate and time-to-event models were used.

RESULTS

Over a 14-year period, 61 children (0.9% incidence) had a tracheostomy placed following CHD surgery. There were 12 single-ventricle patients and 49 biventricular patients. Prematurity, genetic syndromes, lung/airway disease, and other comorbidities were common in both CHD groups. Gastrostomy tubes were used more frequently in biventricular physiology patients (91.8%) versus single-ventricle patients (66.7%, P = .04). Survival to hospital discharge was 50% in the single-ventricle group compared to 86% in biventricular patients (P = .01). Long-term survival continued to be poor in the single-ventricle group comparatively (three years, 27.8% vs 64.8%, P = .01). Gastrostomy tube placement was independently associated with survival in both groups (P = .002).

CONCLUSION

Tracheostomy is performed following many types of surgery for CHD and is commonly associated with other comorbidities. Both hospital and long-term survival are substantially lower in children with single-ventricle physiology as compared to patients with biventricular physiology.

Critical cardiac care in children: looking backward and looking forward

The growth of Pediatric Cardiovascular Intensive Care as a subspecialty has been incredible. Outcomes have improved, care delivery has matured, and research has made advances. Within this review, we take the opportunity to examine the subspecialty's past accomplishments with pride, take stock in its current state, and look forward with excitement to its future. While outcomes in general have improved dramatically, we must always be aware of the outcomes that matter to families and patients. Additionally, we must constantly ask ourselves to improve. Research into neuroprotection and individual therapeutic strategies based in genomic medicine provide the next opportunity for the subspecialty to improve.

Innovation in Pediatric Cardiac Intensive Care: An Exponential Convergence Toward Transformation of Care

The word innovation is derived from the Latin noun innovatus, meaning renewal or change. Although companies such as Google and Apple are nearly synonymous with innovation, virtually all sectors in our current lives are imbued with yearn for innovation. This has led to organizational focus on innovative strategies as well as recruitment of chief innovation officers and teams in a myriad of organizations. At times, however, the word innovation seems like an overused cliché, as there are now more than 5,000 books in print with the word "innovation" in the title. More recently, innovation has garnered significant attention in health care. The future of health care is expected to innovate on a large scale in order to deliver sustained value for an overall transformative care. To date, there are no published reports on the state of the art in innovation in pediatric health care and in particular, pediatric cardiac intensive care. This report will address the issue of innovation in pediatric medicine with relevance to cardiac intensive care and delineate possible future directions and strategies in pediatric cardiac intensive care.

Streptobacillus moniliformis Endocarditis: An Unusual Case of Pulmonary Valve Erosion Resulting in Free Pulmonary Regurgitation and Aneurysm

Endocarditis is a consideration in the differential diagnosis when masses are seen on echocardiography in a patient with congenital heart disease. We present a case of insidious development of endocarditis caused by Streptobacillus moniliformis in a seven-month-old baby after a rat bite, when the baby was three months of age.