Mortality Associated With Congenital Heart Defects in the United States

Devising, implementing, and evaluating interventions to eliminate health care disparities in minority children

Despite an accumulating body of literature addressing racial/ethnic disparities in children's health and health care, there have been few published studies of interventions that have been successful in eliminating these disparities. The objectives of this article, therefore, are to (1) describe 3 interventions that have been successful in eliminating racial/ethnic disparities in children's health and health care, (2) highlight tips and pitfalls regarding devising, implementing, and evaluating pediatric disparities interventions, and (3) propose a research agenda for pediatric disparities interventions. Key characteristics of the 3 successful interventions include rigorous study designs; large sample sizes; appropriate comparison groups; community-based interventions that are culturally and linguistically sensitive and involve collaboration with participants; research staff from the same community as the participants; appropriate blinding of outcomes assessors; and statistical adjustment of outcomes for relevant covariates. On the basis of these characteristics, I propose tips, pitfalls, an approach, and a research agenda for devising, implementing, and evaluating successful pediatric disparities interventions. Examination of 3 successful interventions indicates that pediatric health care disparities can be eliminated. Achievement of this goal requires an intervention that is rigorous, evidence-based, and culturally and linguistically appropriate. The intervention must also include community collaboration, minimize attrition, adjust for potential confounders, and incorporate mechanisms for sustainability.

Trends in hospitalizations for adults with congenital heart disease in the U.S

OBJECTIVES

The purpose of this study was to better define the epidemiology of hospitalizations for adults with congenital heart disease (ACHD) in the U.S.

BACKGROUND

There is a growing population of ACHD as the result of advances in pediatric care and diagnostic testing.

METHODS

We used nationally representative data from the 1998 to 2005 Nationwide Inpatient Sample to identify patients > or =18 years of age admitted to an acute care hospital with an International Classification of Diseases-9th Revision code designating a CHD diagnosis. National estimates of hospitalizations and total hospital charges by year were calculated.

RESULTS

The number of ACHD hospitalizations increased 101.9% from 35,992 +/- 2,645 in 1998 to 72,656 +/- 5,258 in 2005. During this period, the annual number of admissions grew for both simple (19,448 +/- 1,614 to 44,707 +/- 3,644) and complex (12,507 +/- 1,172 to 19,973 +/- 1,624) diagnoses. The percentage of admissions originating in the emergency department (41.7 +/- 0.8%) or involving cardiac surgery (17.7 +/- 0.7%) remained stable during the study period. The average patient age (52.3 +/- 0.8 years to 53.8 +/- 0.6 years, p < 0.0001) and proportion of patients with > or =2 medical comorbidities (23.3 +/- 0.9% to 33.0 +/- 0.7%, p < 0.0001) increased. Mean hospital charges per hospitalization increased 127% from 19,186 +/- 803 to 43,496 +/- 2,166 US dollars, and the estimated total national charges for these hospitalizations increased 357% from 691 million US dollars in 1998 to 3.16 billion US dollars in 2005 (in inflation-adjusted 2005 dollars).

CONCLUSIONS

The number of hospital admissions for ACHD in the U.S. more than doubled between 1998 and 2005. Hospital charges attributable to these admissions have grown even more dramatically.

Role of pulse oximetry in examining newborns for congenital heart disease: a scientific statement from the AHA and AAP

BACKGROUND

The purpose of this statement is to address the state of evidence on the routine use of pulse oximetry in newborns to detect critical congenital heart disease (CCHD).

METHODS AND RESULTS

A writing group appointed by the American Heart Association and the American Academy of Pediatrics reviewed the available literature addressing current detection methods for CCHD, burden of missed and/or delayed diagnosis of CCHD, rationale of oximetry screening, and clinical studies of oximetry in otherwise asymptomatic newborns. MEDLINE database searches from 1966 to 2008 were done for English-language papers using the following search terms: congenital heart disease, pulse oximetry, physical examination, murmur, echocardiography, fetal echocardiography, and newborn screening. The reference lists of identified papers were also searched. Published abstracts from major pediatric scientific meetings in 2006 to 2008 were also reviewed. The American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. In an analysis of pooled studies of oximetry assessment performed after 24 hours of life, the estimated sensitivity for detecting CCHD was 69.6%, and the positive predictive value was 47.0%; however, sensitivity varied dramatically among studies from 0% to 100%. False-positive screens that required further evaluation occurred in only 0.035% of infants screened after 24 hours.

CONCLUSIONS

Currently, CCHD is not detected in some newborns until after their hospital discharge, which results in significant morbidity and occasional mortality. Furthermore, routine pulse oximetry performed on asymptomatic newborns after 24 hours of life, but before hospital discharge, may detect CCHD. Routine pulse oximetry performed after 24 hours in hospitals that have on-site pediatric cardiovascular services incurs very low cost and risk of harm. Future studies in larger populations and across a broad range of newborn delivery systems are needed to determine whether this practice should become standard of care in the routine assessment of the neonate.

Four-dimensional fetal echocardiography with spatiotemporal image correlation (STIC): A systematic study of standard cardiac views assessed by different observers

OBJECTIVE

To test the agreement between observers and reproducibility of a technique to display standard cardiac views of the left and right ventricular outflow tracts from four-dimensional volume datasets acquired with Spatiotemporal Image Correlation (STIC).

METHODS

A technique was developed to obtain dynamic multiplanar images of the left ventricular outflow tract (LVOT) and right ventricular outflow tract (RVOT) from volume datasets acquired with STIC. Volume datasets were acquired from fetuses with normal cardiac anatomy. Twenty volume datasets of satisfactory quality were pre-selected by one investigator. The data was randomly assigned for a blinded review by two independent observers with previous experience in fetal echocardiography. Only one volume dataset was used for each fetus. After a training session, the observers obtained standardized cardiac views of the LVOT and RVOT, which were scored on a scale of 1 to 5, based on diagnostic value and image quality (1=unacceptable, 2=marginal, 3=acceptable, 4=good, and 5=excellent). Median scores and interquartile range, as well as inter- and intraobserver agreement were calculated for each view.

RESULTS

The mean menstrual age at the time of volume acquisition was 25.5+/-4.5 weeks. Median scores (interquartile range) for LVOT images, obtained by the first and second observers, were 3.5 (2.25-5.00) and 4 (3.00-5.00), respectively. The median scores (interquartile range) for RVOT images obtained by the first and second observers were 3 (3.00-5.00) and 3 (2.00-4.00), respectively. The interobserver intraclass correlation coefficient for the LVOT was 0.693 (95% CI 0.380-0.822), and 0.696 (95% CI 0.382-0.866) for the RVOT. For the intraobserver agreement analysis, observer 1 gave higher scores to the LVOT the second time the volumes were analyzed [LVOT: 3.50 (2.25-5.00) vs. 5.00 (4.00-5.00, p=0.008)].

CONCLUSION

STIC can be reproducibly used to evaluate fetal cardiac outflow tracts by independent examiners. Slightly better image quality rating scores during the intraobserver variability trial suggests the presence of a learning curve for the manipulation and analysis of volume data obtained by STIC.

Prevalence of severe congenital heart disease after folic acid fortification of grain products: time trend analysis in Quebec, Canada

OBJECTIVE

To investigate whether the 1998 government policy for mandatory fortification of flour and pasta products with folate was followed by a reduction in the prevalence of severe congenital heart defects.

DESIGN

Time trend analysis.

SETTING

Province of Quebec, Canada.

PARTICIPANTS

Infants born in 1990-2005 identified with severe congenital heart defects (tetralogy of Fallot, endocardial cushion defects, univentricular hearts, truncus arteriosus, or transposition complexes) in Quebec administrative databases.

METHODS

Data analysed in two time periods (before and after fortification). Birth prevalence measured annually as infants (live and stillbirths) with severe congenital heart defects per 1000 births in Quebec. Changes in the birth prevalence from the period before to the period after fortification were estimated with Poisson regression.

RESULTS

Among the 1, 324,440 births in Quebec in 1990-2005 there were 2083 infants born with severe congenital heart defects, corresponding to an average birth prevalence of 1.57/1000 births. Time trend analysis showed no change in the birth prevalence of severe birth defects in the nine years before fortification (rate ratio 1.01, 95% confidence interval 0.99 to 1.03), while in the seven years after fortification there was a significant 6% decrease per year (0.94, 0.90 to 0.97).

CONCLUSIONS

Public health measures to increase folic acid intake were followed by a decrease in the birth prevalence of severe congenital heart defects. These findings support the hypothesis that folic acid has a preventive effect on heart defects.

Increase of macrophage migration inhibitory factor (MIF) expression in cardiomyocytes during chronic hypoxia

BACKGROUND

Macrophage migration inhibitory factor (MIF) might play an important role in the myocardium during chronic hypoxia because MIF protects the heart during myocardial ischemia by activating 5'-adenosine monophosphate activated protein kinase (AMPK).

METHODS

We investigated 35 infants with cyanotic or acyanotic cardiac defects and H9c2 embryonic rat cardiomyocytes to examine the effect of chronic hypoxia on the expression of MIF in vivo and in vitro, respectively.

RESULTS

We found out an increase of endogenous cardiac MIF expression positively correlated with degree of hypoxia. Also, AMPK activation was elevated while MIF expression was increased in cells exposed to long periods of hypoxia in vitro. There was no significant difference in the growth ratio of cells cultivated in long periods of hypoxia and normoxia.

CONCLUSIONS

The expression of MIF is significantly increased in cardiomyocytes exposed to chronic hypoxia, and the activation of AMPK was increased accordingly.

Psychological adjustment and quality of life in children and adolescents following open-heart surgery for congenital heart disease: a systematic review

BACKGROUND

Children with congenital heart defects (CHD) requiring open-heart surgery are a group at high risk for health-related sequelae. Little consensus exists regarding their long-term psychological adjustment (PA) and health-related quality of life (QoL). Thus, we conducted a systematic review to determine the current knowledge on long-term outcome in this population.

METHODS

We included randomized controlled trials, case control, or cohort studies published between 1990-2008 evaluating self- and proxy-reported PA and QoL in patients aged between two and 17 years with a follow-up of at least two years after open heart surgery for CHD.

RESULTS

Twenty-three studies assessing psychological parameters and 12 studies assessing QoL were included. Methodological quality of the studies varied greatly with most studies showing a moderate quality. Results were as follows: (a) A considerable proportion of children experienced psychological maladjustment according to their parents; (b) studies on self-reported PA indicate a good outcome; (c) the studies on QoL suggest an impaired QoL for some children in particular for those with more severe cardiac disease; (d) parental reports of psychological maladjustment were related to severity of CHD and developmental delay.

CONCLUSION

A significant proportion of survivors of open-heart surgery for CHD are at risk for psychological maladjustment and impaired QoL. Future research needs to focus on self-reports, QoL data and adolescents.

Descriptive epidemiology of congenital heart disease in Northern England

Congenital heart disease (CHD) is the most prevalent group of congenital anomalies. There is considerable variation in the reported epidemiology of CHD, mainly attributable to methodological differences. Using register-based data, the current study describes the epidemiology of CHD in a geographically well-defined population of the North of England during 1985-2003. The total prevalence of CHD was 85.9 per 10 000 births and terminations of pregnancy for fetal anomaly. Livebirth prevalence was 79.7 per 10 000 livebirths. Both total and livebirth prevalence increased during the study period. Ninety-two per cent of affected pregnancies resulted in a livebirth, 5% were terminated, 2% resulted in a stillbirth, and 1% in a late miscarriage. Almost a quarter (23%) of cases had one or more coincident anomalies of other organs, with chromosomal abnormalities the most frequent group. A total of 89.2% of cases survived to 1 year and the survival improved during the study period. This population-based study has demonstrated an increasing trend in both prevalence and survival among children with CHD.

Factors associated with adverse neurodevelopmental outcomes in infants with congenital heart disease

OBJECTIVE

To review reported neurodevelopmental outcome data for patients with congenital heart disease, identify risk factors for adverse neurodevelopmental sequelae and summarize potential neuromonitoring strategies that have been described.

METHODS

A Medline search was performed utilizing combinations of the keywords congenital heart, cardiac, neurologic, neurodevelopment, neuromonitoring, quality of life, and outcome. All prospective and longitudinal follow-up studies of patients with congenital heart disease were included. Additionally, studies that examined neuroimaging, neuromonitoring, and clinical factors in relation to outcome were examined. Case reports and editorials were excluded. Additional references were retrieved from selected articles if the abstract described an evaluation of neurodevelopmental outcomes and/or predictors of outcome in patients with congenital heart disease.

RESULTS

Overall, patients with CHD have increased rates of neurodevelopmental impairments, although intelligence appears to be in the normal range. Preoperative risk stratification, intraoperative techniques, postoperative care, and neuromonitoring strategies may all contribute to ultimate long-term neurodevelopmental outcomes in patients with CHD postsurgical repair.

CONCLUSIONS

As advances in the medical and surgical management improves survival in patients with CHD, increasing knowledge about neurodevelopmental outcomes and the factors that affect them will provide for strategies to optimize long-term outcome in this high-risk population.

Morphological changes in hepatic vessels during modeling of pulmonary trunk stenosis and after its elimination

Experiments on dogs showed that pulmonary trunk stenosis increased the tone of arterial vessels in the liver and led to the development of veno-arterial and veno-venous reactions. The number of vessels with intimal musculature and myoelastic sphincters in the arterial bed increases, and muscle rolls in large hepatic veins are thickened. The walls are hypertrophic in all vessels. Elimination of the defect abolished the previously formed vascular adaptation reactions, the tone in afferent liver vessels decreased, which leads to regression of hypertrophic changes in their tunica media. The number of arteries with intimal musculature and sphincters decreases. Muscle rolls in the efferent hepatic veins are thinned.

Getting to the heart of the matter: epidemiology of cyanotic heart defects

Congenital heart defects (CHDs) are the most common type of birth defect, making significant contributions to infant morbidity and mortality, but not all CHDs contribute equally to such outcomes. Although cyanotic CHDs constitute some of the most serious CHDs, its epidemiology is poorly understood. We present a comprehensive systematic review of the literature on the epidemiology of cyanotic CHD, with emphasis on the most current knowledge on identified risk/etiologic factors. Literature for this review was identified by searching the PubMed database from the National Center for Biotechnology Information at the US National Library of Medicine as well as bibliographies of identified papers. The 100 reports that contributed to this review describe risk factors such as infant sex, race, and ethnicity, environmental exposures, and maternal and paternal age. Several studies reported differences in prevalence rates by race and ethnicity and elevated sex ratios, and they identified some risk factors, including advanced maternal age. Investigators have made significant progress in the effort to describe the etiology of cyanotic CHDs, but discrepancies, such as the variation in prevalence rates by race and ethnicity and the impact of environmental exposures, still need to be addressed.

Physiologic limitation of omega exists in patients after the Norwood palliation and is underestimated by the arterial venous oxygen saturation difference

BACKGROUND

Survival after the Norwood palliation (NW) is dependent on maximizing systemic oxygen delivery. Omega (Omega) is used to express the excess of oxygen delivery to oxygen consumption. We hypothesized that an intrinsic deficiency in the ability to maximize the relationship between oxygen delivery (DO(2)) and oxygen consumption (VO(2)) is present in infants after NW and is underestimated by arterial venous oxygen saturation difference (a-vO(2)).

METHODS

Simultaneous arterial and systemic venous blood gas data were prospectively collected for the first 24 hours after surgery in 10 neonates after NW and 32 infants after biventricular repair (BV). Blood gas data were compared between groups. These data were compared with a group of 11 infants with hypoplastic left heart syndrome (HLHS) status post NW who were undergoing routine hemodynamic evaluation in the cardiac catheterization lab prior to a bidirectional Glenn operation (pre-Glenn).

RESULTS

The mean systemic arterial oxygen saturation was 77% for NW, 83% for pre-Glenn, and 97% for biventricular repair. NW group had a mean systemic venous oxygenation saturation (SvO(2)) of 47% (range 12-67%) vs. 67% (range 29-84%) in the BV group (P = .001). Pre-Glenn patients had a SvO(2) of 46 (not significant [NS] vs. NW, P = .001 vs. BV). In NW, a-vO(2) mean was 32 (range 15-63) compared with mean 32 (range 16-71) in BV group (NS). Pre-Glenn a-vO(2) mean was 33.6 (NS vs. NW or BV). Omega for NW group was 2.6 (range 1.1-4.2) and 3.4 (1.4-6.25) in BV group (P = .001). Omega for pre-Glenn was 2.5 (range 1.7-3.8) (NS vs. NW, P = .001 vs. BV).

CONCLUSION

Omega is lower for patients in the immediate postoperative period after NW and prior to their bidirectional Glenn operation than in patients after biventricular repair. This places NW patients closer to the critical point of DO(2) and therefore at greater risk for hemodynamic compromise than BV patients. The a-vO(2) difference underestimates this risk.

Epidemiologic features of the presentation of critical congenital heart disease: implications for screening

OBJECTIVE

Critical congenital heart disease has been proposed as a target of newborn screening. This study aimed to define the incidence and timing of significant physiologic compromise attributable to critical congenital heart disease as well as the distribution of vulnerable lesions. These descriptive parameters must be defined to evaluate the impact and feasibility of any proposed screening strategy.

METHODS

A retrospective cohort study of neonates who had critical congenital heart disease and were admitted to a single institution was conducted. Critical congenital heart disease was defined as congenital heart disease that required invasive intervention or resulted in death in the first 30 days of life. Significant physiologic compromise was defined by severe metabolic acidosis, seizure, cardiac arrest, or laboratory evidence of renal or hepatic injury before invasive intervention. Significant physiologic compromise was classified as potentially preventable when it occurred as a result of undiagnosed congenital heart disease after 12 hours of life.

RESULTS

Significant physiologic compromise occurred in 76 (15.5%) of 490 patients, and potentially preventable significant physiologic compromise occurred in 33 (6.7%) of 490 patients. Most (83%) significant physiologic compromise as a result of unrecognized congenital heart disease occurred after 12 hours of age. A total of 90.9% of cases of potentially preventable significant physiologic compromise had aortic arch obstruction. The incidence of potentially preventable significant physiologic compromise as a result of congenital heart disease in the general population is estimated to be 1 per 15,000 to 1 per 26,000 live births.

CONCLUSIONS

The incidence and timing of significant physiologic compromise as a result of critical congenital heart disease seems amenable to postnatal screening. Any viable screening strategy must be sensitive for lesions with aortic arch obstruction.

Maternal smoking and congenital heart defects

OBJECTIVES

In a population-based case-control study, we investigated the association between congenital heart defects and maternal smoking.

METHODS

The National Birth Defects Prevention Study enrolled 3067 infants with nonsyndromic congenital heart defects and their parents and 3947 infants without birth defects and their parents. Affected infants had > or = 1 of the following defects: conotruncal, septal, anomalous pulmonary venous return, atrioventricular septal defects, and left-sided or right-sided obstructive heart defects. Mothers of case and control infants were asked if they smoked during the periconceptional period, defined as 1 month before pregnancy through the first trimester. Maternal home and workplace exposure to tobacco smoke during the same period was also determined. Logistic regression was used to compute odds ratios and 95% confidence intervals while controlling for potential confounders.

RESULTS

Case infants were more likely to be premature and have lower birth weight than control infants. Women who smoked anytime during the month before pregnancy to the end of the first trimester were more likely to have infants with septal heart defects than women who did not smoke during this time period. This association was stronger for mothers who reported heavier smoking during this period. This relation was independent of potential confounding factors, including prenatal vitamin use, alcohol intake, maternal age, and race or ethnicity. Women who smoked > or = 25 cigarettes per day were more likely than nonsmoking mothers to have infants with right-sided obstructive defects. There was no increased risk of congenital heart defects with maternal exposure to environmental tobacco smoke.

CONCLUSIONS

Maternal smoking during pregnancy was associated with septal and right-sided obstructive defects. Additional investigation into the timing of tobacco exposure and genetic susceptibilities that could modify this risk will provide a more precise evidence base on which to build clinical and public health primary prevention strategies.

Mechanisms and potential therapeutic targets for folic acid in cardiovascular disease

Folic acid (FA) is a member of the B-vitamin family with cardiovascular roles in homocysteine regulation and endothelial nitric oxide synthase (eNOS) activity. Its interaction with eNOS is thought to be due to the enhancement of tetrahydrobiopterin bioavailability, helping maintain eNOS in its coupled state to favor the generation of nitric oxide rather than oxygen free radicals. FA also plays a role in the prevention of several cardiac and noncardiac malformations, has potent direct antioxidant and antithrombotic effects, and can interfere with the production of the endothelial-derived hyperpolarizing factor. These multiple mechanisms of action have led to studies regarding the therapeutic potential of FA in cardiovascular disease. To date, studies have demonstrated that FA ameliorates endothelial dysfunction and nitrate tolerance and can improve pathological features of atherosclerosis. These effects appear to be homocysteine independent but rather related to their role in eNOS function. Given the growing evidence that nitric oxide synthase uncoupling plays a major role in many cardiovascular disorders, the potential of exogenous FA as an inexpensive and safe oral therapy is intriguing and is stimulating ongoing investigations.

Long-term behavioural and emotional problems in four cardiac diagnostic groups of children and adolescents after invasive treatment for congenital heart disease

AIMS

To assess the occurrence of a wide range of behavioural and emotional problems long-term after invasive treatment for congenital heart disease (ConHD) in infancy and childhood.

METHODS

Parents of 125 ConHD children, aged 7-17, completed the Child Behavior Checklist and 85, 11-17-year-old, ConHD children completed the Youth Self-Report.

RESULTS

According to parents' reports of problem behaviours a significant proportion of ConHD children scored in the deviant range (16.9%) compared to the reference group (10.2%). The proportion of ConHD boys scoring in the deviant range according to parents (21.4%) was significantly greater than that in the reference sample (10%). Parents reported significantly higher problems scores for the scales Somatic Complaints, Social Problems, Attention Problems, Internalising and Total Problems compared to the reference group. In contrast, reports of patients were comparable to those of reference peers. No differences were found on the self-reports between problem scores for different cardiac diagnostic groups. Discrepancies between self- and parent-reports were found, indicating that more problems were reported by ConHD patients themselves than by their parents.

CONCLUSION

Overall, parents of ConHD patients reported higher levels of behavioural and emotional problems compared to the reference group whereas patients themselves reported no long-term behavioural impairment compared to same-sex reference peers. Assessing behavioural and emotional problems in ConHD patients can be helpful to detect children at risk for developing psychopathology. Especially younger male ConHD patients deserve special attention.

Controversies of fetal cardiac intervention

Remarkable advances in ultrasound imaging technology have made it possible to diagnose fetal cardiovascular lesions as early as 12-14 weeks of gestation and to assess their physiological relevance by echocardiography. Moreover, invasive techniques have been developed and refined to relieve significant congenital heart disease (CHD), such as critical aortic and pulmonary stenoses in the pediatric population including neonates. Recognition of the fact that certain CHDs can evolve in utero, and early intervention may improve the outcome by altering the natural history of such conditions has led to the evolution of a new fetal therapy, i.e. fetal cardiac intervention. Two entities, pulmonary valvar atresia and intact ventricular septum (PA/IVS) and hypoplastic left heart syndrome (HLHS), are associated with significant morbidity and mortality even with postnatal surgical therapy. These cases are believed to occur due to restricted blood flow, leading to impaired growth and function of the right or left ventricle. Therefore, several centers started the approach of antenatal intervention with the primary goal of improving the blood flow through the stenotic/atretic valve orifices to allow growth of cardiac structures. Even though centers with a reasonable number of cases seem to have improved the technique and the immediate outcome of fetal interventions, the field is challenged by ethical issues as the intervention puts both the mother and the fetus at risk. Moreover, the perceived benefits of prenatal treatment have to be weighed against steadily improving postnatal surgical and hybrid procedures, which have been shown to reduce morbidity and mortality for these complex heart defects. This review is an attempt to provide a balanced opinion and an update on fetal cardiac intervention.

Hospital readmissions in children with congenital heart disease: a population-based study

BACKGROUND

Little is known about the factors that predispose children with congenital heart disease (CHD) to readmission soon after hospital discharge. We sought to determine rates and risk factors for hospital readmission within 1 month among children with CHD.

METHODS

Data were obtained from administrative databases that record all hospitalizations within the province of Quebec. We included children 0 to 17 years with CHD who were hospitalized with a cardiac diagnosis (an "index hospitalization") between 1990 and 2005. Cox proportional hazards analysis was used to identify predictors of readmission.

RESULTS

Among 3675 hospitalizations, there were 518 readmissions (15%) within 31 days. Median time to readmission was 12 days (interquartile range 5-19 days). Readmissions occurred in the same hospital as the index hospitalization 86% of the time. The most common diagnoses at readmission were cardiac (59%) and respiratory illnesses (12%). Independent predictors of readmission were severe CHD lesion, younger age, Friday or Saturday discharge, having an emergency department visit within the preceding 6 months, length of index hospitalization > 14 days, and multiple (> or = 4) diagnoses (either cardiac diagnoses or comorbid conditions). Having an invasive procedure during the index hospitalization reduced the likelihood of readmission.

CONCLUSIONS

Readmission occurred after 1 in 7 hospitalizations. Infants and patients with severe CHD lesions were among those more likely to be readmitted. The risk of readmission may be reduced by avoiding hospital discharge at the beginning of a weekend. Further studies are needed to determine if targeted interventions will reduce readmission rates in high-risk patients.

Management of the sick neonate with suspected heart disease

A proportion of symptomatic neonates with congenital heart disease have lesions requiring urgent stabilisation. Despite increasing antenatal diagnoses, the importance of early recognition of symptomatic neonates is highlighted by the fact that up to 10% of all deaths in congenital heart disease continue to occur in children undiagnosed at the time of death. Specific anatomical knowledge of the many complex lesions is not required for good early management. The focus of this article is the specific symptom complexes in critically ill neonates with congenital heart disease, initial management strategies for stabilization and transfer to specialist centres, and issues in the ongoing preoperative care.

ACR appropriateness criteria on suspected congenital heart disease in adults

The number of adults with congenital heart disease is increasing in North America. This is attributable to a variety of factors, including improvements in surgical techniques and increases in immigration. Cardiac imaging is critical for the initial assessment of adults with newly suspected congenital heart disease as well as for the serial assessment of adults with known congenital heart disease. Chest radiography and echocardiography continue to be the initial tools used to evaluate adult congenital heart disease. However, cardiac computed tomography and magnetic resonance imaging have significantly improved over the years and have become integral to the evaluation of adult congenital heart disease, often precluding the necessity for invasive cardiac catheterization. Noninvasive imaging is particularly useful for the surveillance of patients with surgically corrected congenital heart disease, who often require 2 or more additional operations.

Assessment of hydraulic performance and biocompatibility of a MagLev centrifugal pump system designed for pediatric cardiac or cardiopulmonary support

The treatment of children with life-threatening cardiac and cardiopulmonary failure is a large and underappreciated public health concern. We have previously shown that the CentriMag is a magnetically levitated centrifugal pump system, having the utility for treating adults and large children (1,500 utilized worldwide). We present here the PediVAS, a pump system whose design was modified from the CentriMag to meet the physiological requirements of young pediatric and neonatal patients. The PediVAS is comprised of a single-use centrifugal blood pump, reusable motor, and console, and is suitable for right ventricular assist device (RVAD), left ventricular assist device (LVAD), biventricular assist device (BVAD), or extracorporeal membrane oxygenator (ECMO) applications. It is designed to operate without bearings, seals and valves, and without regions of blood stasis, friction, or wear. The PediVAS pump is compatible with the CentriMag hardware, although the priming volume was reduced from 31 to 14 ml, and the port size reduced from 3/8 to (1/4) in. For the expected range of pediatric flow (0.3-3.0 L/min), the PediVAS exhibited superior hydraulic efficiency compared with the CentriMag. The PediVAS was evaluated in 14 pediatric animals for up to 30 days, demonstrating acceptable hydraulic function and hemocompatibility. The current results substantiate the performance and biocompatibility of the PediVAS cardiac assist system and are likely to support initiation of a US clinical trial in the future.

Obesity is a common comorbidity in children with congenital and acquired heart disease

OBJECTIVES

Obesity may pose additional cardiovascular risk to children with acquired and congenital heart disease. Many children with heart disease are sedentary as a result of physician-, parent-, and/or self-imposed restrictions. The aim of this study was to evaluate the impact of the epidemic of obesity on children with heart disease.

PATIENTS AND METHODS

A cross-sectional review was performed of children evaluated in 2004 at 2 cardiology outpatient clinics. Differences in the prevalence of obese (BMI > or = 95%) and overweight (BMI 85%-95%) children were compared with national data and healthy control subjects. Dictated letters were reviewed to determine whether obesity was discussed with referring practitioners.

RESULTS

Of 2921 patients assessed, 1523 had heart disease. Diagnostic subgroups included "mild" heart disease (n = 401), arrhythmia (n = 447), biventricular repair (n = 511), univentricular palliation (Fontan; n = 108), and heart transplantation (n = 56). More than 25% of the patients with heart disease were obese or overweight; the prevalence of obese and overweight children was significantly lower only in the Fontan group (15.9%). Pediatric cardiologists failed to document obesity or weight counseling in the majority of clinic letters.

CONCLUSIONS

Obesity is common in children with congenital and acquired heart disease. Pediatric cardiologists demonstrate inadequate communication regarding this problem to referring practitioners. Healthy-lifestyle counseling and routine exercise in children with heart disease may be underemphasized.

Multimodality optical imaging of embryonic heart microstructure

Study of developmental heart defects requires the visualization of the microstructure and function of the embryonic myocardium, ideally with minimal alterations to the specimen. We demonstrate multiple endogenous contrast optical techniques for imaging the Xenopus laevis tadpole heart. Each technique provides distinct and complementary imaging capabilities, including: 1. 3-D coherence microscopy with subcellular (1 to 2 microm) resolution in fixed embryos, 2. real-time reflectance confocal microscopy with large penetration depth in vivo, and 3. ultra-high speed (up to 900 frames per second) that enables real-time 4-D high resolution imaging in vivo. These imaging modalities can provide a comprehensive picture of the morphologic and dynamic phenotype of the embryonic heart. The potential of endogenous-contrast optical microscopy is demonstrated for investigation of the teratogenic effects of ethanol. Microstructural abnormalities associated with high levels of ethanol exposure are observed, including compromised heart looping and loss of ventricular trabecular mass.

The utility of the general practice research database to examine selected congenital heart defects: a validation study

OBJECTIVE

The purpose of this research was (1) to validate that ventricular septal defect (VSD), tetralogy of Fallot (TOF), and coarctation of the aorta (COA) can be studied in the UK General practice research database (GPRD) and (2) to understand which of the available GPRD components (computerized medical records, questionnaires, and maternal/infant free text) provide maximal information about these heart defects.

METHODS

Using a practitioner questionnaire, the positive predictive value (PPV) of the computerized medical record for VSD, TOF, and COA were determined. Both infant and maternal free text was examined. Concordance between the infant free text information and questionnaires was calculated. The proportion of infant information captured in the maternal free text was determined.

RESULTS

A 93% response rate was achieved. Based on questionnaire responses, an overall PPV of 93.5% was achieved (VSD = 95%, TOF = 90%, COA = 100%). Approximately half of the records contained infant free text information including information on the type and size of VSD, echocardiogram findings, and surgery. Concordance between the infant's free text and questionnaire information occurred in most of the cases (92-100%). The proportion of infant information in the maternal free text was low (4-19%).

CONCLUSION

The GPRD computerized medical records are sufficient to assess VSD, TOF, and COA. This study confirms that maternal free text provides a low yield of limited information pertaining to the infants' defect, while the infant free text may provide an additional information usually obtainable from practitioner questionnaires. The information provided by an infant free text may limit the need for practitioner questionnaire validation.

Seeking causes: Classifying and evaluating congenital heart defects in etiologic studies

BACKGROUND

Classification and analysis of congenital heart defects (CHD) in etiologic studies is particularly challenging because of diversity of cardiac phenotypes and underlying developmental mechanisms. We describe an approach to classification for risk assessment of CHD based on developmental and epidemiologic considerations, and apply it to data from the National Birth Defect Prevention Study (NBDPS).

METHODS

The classification system incorporated the three dimensions of cardiac phenotype, cardiac complexity, and extracardiac anomalies. The system was designed to facilitate the assessment of simple isolated defects and common associations. A team with cardiologic expertise applied the system to a large sample from the NBDPS.

RESULTS

Of the 4,703 cases of CHDs in the NBDPS with birth years 1997 through 2002, 63.6% were simple, isolated cases. Specific associations of CHDs represented the majority of the remainder. The mapping strategy generated relatively large samples for most cardiac phenotypes and provided enough detail to isolate important subgroups of CHDs that may differ by etiology or mechanism.

CONCLUSIONS

Classification of CHDs that considers cardiac and extracardiac phenotypes is practically feasible, and yields manageable groups of well-characterized phenotypes. Although best suited for large studies, this approach to classification and analysis can be a flexible and powerful tool in many types of etiologic studies of heart defects.

Strong and independent prognostic value of peak circulatory power in adults with congenital heart disease

BACKGROUND

The identification of patients with adult congenital heart disease (ACHD) who are at higher risk of death is challenging. Peak circulatory power (CircP; expressed as peak exercise oxygen uptake multiplied for peak mean arterial blood pressure) is a strong predictor of death in adults with acquired heart disease. We sought to establish the distribution and the prognostic value of peak CircP across a wide spectrum of patients with ACHD.

METHODS

Four hundred thirty-two consecutive patients with ACHD of varying diagnosis underwent cardiopulmonary exercise testing at a single laboratory between 1996 and 2005. Patient age was 32 +/- 10 years.

RESULTS

A gradual variation in peak CircP was found across the spectrum of congenital heart defects (P < .0001 at analysis of variance). Reduced peak CircP values were associated with the presence of heart failure symptoms (P < .0001), absence of sinus rhythm (P = .010), and use of antiarrhythmic medications (P = .0013). At a follow-up of 4.4 +/- 2.4 years, 23 patients (5.3%) had died. Peak CircP was a strong predictor of mortality when univariate analysis was used and the strongest independent predictor of mortality among exercise parameters. A peak CircP < or = 1476 mm Hg mlO2 min(-1) kg(-2) was associated with a 15.4-fold increase in the 4-year risk of death.

CONCLUSIONS

Peak CircP is abnormal across the spectrum of ACHD. Peak CircP appears as the strongest predictor of adverse outcome in ACHD.

Hypoplastic left heart syndrome

Hypoplastic left heart syndrome(HLHS) refers to the abnormal development of the left-sided cardiac structures, resulting in obstruction to blood flow from the left ventricular outflow tract. In addition, the syndrome includes underdevelopment of the left ventricle, aorta, and aortic arch, as well as mitral atresia or stenosis. HLHS has been reported to occur in approximately 0.016 to 0.036% of all live births. Newborn infants with the condition generally are born at full term and initially appear healthy. As the arterial duct closes, the systemic perfusion becomes decreased, resulting in hypoxemia, acidosis, and shock. Usually, no heart murmur, or a non-specific heart murmur, may be detected. The second heart sound is loud and single because of aortic atresia. Often the liver is enlarged secondary to congestive heart failure. The embryologic cause of the disease, as in the case of most congenital cardiac defects, is not fully known. The most useful diagnostic modality is the echocardiogram. The syndrome can be diagnosed by fetal echocardiography between 18 and 22 weeks of gestation. Differential diagnosis includes other left-sided obstructive lesions where the systemic circulation is dependent on ductal flow (critical aortic stenosis, coarctation of the aorta, interrupted aortic arch). Children with the syndrome require surgery as neonates, as they have duct-dependent systemic circulation. Currently, there are two major modalities, primary cardiac transplantation or a series of staged functionally univentricular palliations. The treatment chosen is dependent on the preference of the institution, its experience, and also preference. Although survival following initial surgical intervention has improved significantly over the last 20 years, significant mortality and morbidity are present for both surgical strategies. As a result pediatric cardiologists continue to be challenged by discussions with families regarding initial decision relative to treatment, and long-term prognosis as information on long-term survival and quality of life for those born with the syndrome is limited.

Pediatric Neuroanesthesia

Recent advances in pediatric neurosurgery have drastically improved the outcome in infants and children afflicted with surgical lesions of the central nervous system (CNS). Because most of these techniques were first applied to adults, the physiologic and developmental differences that are inherent in pediatric patients present challenges to neurosurgeons and anesthesiologists alike. The aim of this paper is to highlight these age-dependent approaches to the pediatric neurosurgical patient.

Early In Vivo Experience With the Pediatric Jarvik 2000 Heart

The need for smaller, more efficient ventricular assist devices that can be used in a more chronic setting have led to exploration of mechanical circulatory support in the pediatric population. The pediatric Jarvik 2000 heart (child size), under development, was implanted in six juvenile sheep and studied for both acute fit and chronic performance evaluation. Daily hemodynamic measurements of cardiac output and pump output at varying pump speeds were taken. In addition, plasma free hemoglobin, lactic acid dehydrogenase, and platelet activation from blood samples were determined at baseline, after implantation, and twice a week thereafter. The measured flow through the outflow graft at increasing speeds from 10,000 rpm to 14,000 rpm with an increment of 1,000 rpm were 1.47 +/- 0.43, 1.89 +/- 0.52, 2.36 +/- 0.61, 2.80 +/- 0.73, and 3.11 +/- 0.86 (L/min). The baseline plasma free hemoglobin was 11.95 +/- 4.76 (mg/dL), with subsequent mean values being <30 mg/dL at postimplantation and weekly postimplantation measurements. Both lactic acid dehydrogenase and platelet activation showed an acute increase within the first week after implantation with subsequent return to baseline by 2 weeks after surgery. Our initial animal in vivo experience with the pediatric Jarvik 2000 heart shows that a small axial flow pump can provide partial to nearly complete circulatory support with minimal adverse effects on blood components.

Association between congenital heart defects and small for gestational age

OBJECTIVES

Infants with congenital heart defects may experience inhibited growth during fetal life. In a large case-control study, we addressed the hypothesis that infants with congenital heart defects are more likely to be small for gestational age than infants without congenital heart defects after controlling for selected maternal and infant characteristics.

METHODS

Using data from population-based birth defect registries, the National Birth Defects Prevention Study enrolled infants with nonsyndromic congenital heart defects (case subjects) and infants without congenital heart defects or any other birth defect (control subjects). Small for gestational age was defined as birth weight below the 10th percentile for gestational age and gender. Association between congenital heart defects and small for gestational age was examined by conditional logistic regression adjusting for maternal covariates related to fetal growth.

RESULTS

Live-born singleton infants with congenital heart defects (case subjects, n = 3395) and live-born singleton infants with no birth defect (control subjects, n = 3924) were included in this study. Case subjects had lower birth weights compared with control subjects. Small for gestational age was observed among 15.2% of case subjects and among only 7.8% of control subjects. Congenital heart defect infants were significantly more likely to be small for gestational age than control infants.

CONCLUSIONS

Infants with congenital heart defects are approximately twice as likely to be small for gestational age as control subjects. Small for gestational age status may affect clinical management decisions, therapeutic response, and prognosis of neonates with congenital heart defects. Although the etiology of growth retardation among infants with congenital heart defects is uncertain, further exploration may uncover a common pathogenesis or causal relationship between congenital heart defects and small for gestational age.

Comparing the clinical and economic effects of clinical examination, pulse oximetry, and echocardiography in newborn screening for congenital heart defects: A probabilistic cost-effectiveness model and value of information analysis

Objectives: Congenital heart defects (CHD) are an important cause of death and morbidity in early childhood, but the effectiveness of alternative newborn screening strategies in preventing the collapse or death—before diagnosis—of infants with treatable but life-threatening defects is uncertain. We assessed their effectiveness and efficiency to inform policy and research priorities.

Methods: We compared the effectiveness of clinical examination alone and clinical examination with either pulse oximetry or screening echocardiography in making a timely diagnosis of life-threatening CHD or in diagnosing clinically significant CHD. We contrasted their cost-effectiveness, using a decision-analytic model based on 100,000 live births, and assessed future research priorities using value of information analysis.

Results: Clinical examination alone, pulse oximetry, and screening echocardiography achieved 34.0, 70.6, and 71.3 timely diagnoses per 100,000 live births, respectively. This finding represents an additional cost per additional timely diagnosis of £4,894 and £4,496,666 for pulse oximetry and for screening echocardiography. The equivalent costs for clinically significant CHD are £1,489 and £36,013, respectively. Key determinants of cost-effectiveness are detection rates and screening test costs. The false-positive rate is very high with screening echocardiography (5.4 percent), but lower with pulse oximetry (1.3 percent) or clinical examination alone (.5 percent).

Conclusions: Adding pulse oximetry to clinical examination is likely to be a cost-effective newborn screening strategy for CHD, but further research is required before this policy can be recommended. Screening echocardiography is unlikely to be cost-effective, unless the detection of all clinically significant CHD is considered beneficial and a 5 percent false-positive rate acceptable.

Causes of death after congenital heart surgery

BACKGROUND

There has been little research about the causes of death after congenital heart surgery.

METHODS

To determine whether mode of death differs after congenital heart surgery, we evaluated the cause of death for 100 consecutive postoperative deaths at our institution. Mode of death was determined based on retrospective chart review including available autopsy reports. Low output states were categorized into ventricular failure; inadequate postoperative physiology (technically adequate surgery and ventricular function, but persistent low cardiac output); pulmonary hypertension; and atrioventricular valve regurgitation.

RESULTS

There was considerable anatomic diversity among patients who died; 46 patients had single-ventricle physiology. The vast majority of patients (n = 79) were in the intensive care unit before surgery. Surgical repairs were revised at initial operation in 22 cases; 7 patients died in the operating room. Seventy-three patients had technically adequate surgical procedures, 23 had residual anatomic defects, and 4 were indeterminate. Thirty patients underwent additional surgical and 9 catheter-based procedures, although some were classified as rescue procedures performed to address minor anatomic or physiologic abnormalities as a last hope to rescue the patient from impending demise. Of 100 deaths, most (n = 52) were due to low cardiac output: 24 inadequate postoperative physiology, 19 ventricular failure, 8 pulmonary hypertension, and 1 valvar regurgitation. Other significant causes of death included sudden cardiac arrest (n = 11), sepsis (n = 11), and procedural complications (n = 8).

CONCLUSIONS

More than half of the deaths were due to low cardiac output, but not exclusively ventricular failure.

Trends and racial disparities in muscular dystrophy deaths in the United States, 1983-1998: an analysis of multiple cause mortality data

To identify trends and patterns associated with muscular dystrophy (MD)-associated deaths, we analyzed population-based data from death certificates in the Multiple Cause Mortality Files compiled by the National Center for Health Statistics. From 1983 to 1998, 14,499 deaths in the United States were associated with ICD-9 codes for MD. The mortality rate for MD in the general U.S. population over this time period was 0.365 per 100,000 persons per year. Stratification by age at death revealed a trimodal distribution with peaks at 0, 17, and 62 years. The male-to-female ratio varied with age at death, a pattern consistent with a mixture of autosomal and X-linked MDs with different prognoses. Deaths related to MD appeared to be equally divided between presumed autosomal and X-linked MDs. The mortality rate was higher in Whites than in Blacks, for both autosomal and X-linked MDs. The median age at death was lower in Blacks than Whites for both males and females. Cardiac complications were more commonly noted among MD-associated deaths in Blacks (38.9%) than Whites (28.6%). Respiratory infections were noted in about 20% of MD-associated deaths and were more common in winter than summer months. Potential reasons for the racial differences include differences in prevalence rates, rates of diagnosis, and reporting on death certificates. Additional studies are needed to resolve these issues. Challenges in the interpretation of these data include the lack of ICD-9 codes specific for individual MDs and potential recording biases in underlying cause of death and contributing factors. We also present a method for estimating autosomal and X-linked contributions to the overall mortality rate of a genetically heterogeneous condition such as MD.

Nuchal translucency measurement and congenital heart defects: modest association in low-risk pregnancies

OBJECTIVE

To assess the performance of nuchal translucency (NT) measurement in the first trimester of pregnancy as a marker for congenital heart defects (CHD) in the fetus in a low-risk obstetric population.

METHODS

Nuchal translucency screening was offered over a 3-year period to consecutive pregnant women without known a priori risk factors and attending midwife practices in three different areas in the Netherlands. In chromosomally normal fetuses and infants from the study population the NT measurements were matched with CHD detected either prenatally or postnatally.

RESULTS

NT screening was offered to 6132 women with an uptake of 83%. A total of 4876 NT measurements was performed. Pregnancy outcome data were available in 4181 cases (86%). Defects of the heart and great arteries (CHD) were diagnosed in 24 cases (prevalence 5.8/1000). Thirteen of these were classified as major (prevalence 3.1/1000). Two major CHD occurred in fetuses showing an increased NT at the first-trimester scan. The sensitivity of NT measurement > 95th and > 99th percentile for all CHD and for major CHD, was 8% and 15%, respectively. The positive likelihood ratios of NT > 95(th) and > 99th percentile for major CHD were 6, 5 and 33, respectively.

CONCLUSION

In pregnancies without known risk factors also, an increased NT is associated with major cardiac defects in the fetus and therefore represents an indication for specialized fetal echocardiography. However, this association is too weak to envisage a role for NT measurement as single screening strategy for the prenatal detection of cardiac defects.

An Overview Of Cardiovascular Disease Burden In The United States

Cardiovascular disease (CVD) is the leading cause of death and a major cause of disability worldwide. In the United States, CVD accounted for 34.4 percent of the 2.4 million deaths in 2003 and remain a major cause of health disparities and rising health care costs. In 2006, health care spending and lost productivity from CVD exceeded 400 billion dollars. The aging population, obesity epidemic, underuse of prevention strategies, and suboptimal control of risk factors could exacerbate the future CVD burden. Increased adherence to clinical and community-level guidelines and renewed emphasis on policy, environmental, and lifestyle changes will be crucial for its effective prevention and control.

Racial differences in infant mortality attributable to birth defects in the United States, 1989-2002

BACKGROUND

The objective is to study racial differences in infant mortality attributable to birth defects (IMBD) in the United States.

METHODS

We analyzed 1989-1991 and 1995-2002 linked birth/death files for trends and racial differences in IMBD by selected categories of birth defects for infants of non-Hispanic white, non-Hispanic black, and Hispanic mothers.

RESULTS

In 1989-2002, the IMBD rates declined. However, the decline in postneonatal mortality attributable to birth defects (PMBD) rate was significantly slower than that of overall postneonatal mortality. The adjusted rate ratio for non-Hispanic black and Hispanic versus non-Hispanic white for neonatal mortality attributable to birth defects (NMBD) remained unchanged from 1989-1991 through 2000-2002. For PMBD, it increased from 0.97 (95% confidence interval [CI], 0.90-1.13) in 1989-1991 to 1.12 (95% CI, 1.04-1.21) in 2001-2002 and from 1.08 (95% CI, 1.00-1.16) to 1.18 (95% CI, 1.10-1.27) for non-Hispanic black and Hispanic, respectively. Infant mortality due to cardiovascular and central nervous system defects were the main contributors to the increased racial disparities in PMBD rates.

CONCLUSIONS

The disparity in PMBD between infants of non-Hispanic black and Hispanic mothers and infants of non-Hispanic white mothers increased significantly from 1989-1991 to 2000-2002. Further studies are needed to assess the extent to which delays in care or lack of access to care for infants with birth defects might be contributing to the disparity in IMBD.

Heart rate response during exercise predicts survival in adults with congenital heart disease

OBJECTIVES

To assess the prognostic value of heart rate response to exercise in adult congenital heart disease (ACHD) patients.

BACKGROUND

An abnormal heart rate response to exercise is related to autonomic dysfunction and may have prognostic implications in ACHD.

METHODS

We identified 727 consecutive ACHD patients (mean age [+/- SD] 33 +/- 13 years) with varying diagnoses and without pacemakers. Peak oxygen consumption (peak VO2), resting heart rate, and the increase in heart rate from resting level to peak exercise ("heart rate reserve") were measured. We also quantified the decrease in heart rate ("heart rate recovery") after cessation of exercise.

RESULTS

During a median follow-up of 28 months, 38 patients died. Lower values of heart rate reserve, peak heart rate, heart rate recovery, and peak VO2 (p < 0.01 for each) were associated with increased mortality in univariate analysis. Furthermore, heart rate reserve predicted mortality independently of antiarrhythmic therapy, functional class, and peak VO2. Stratifying patients by diagnostic groups revealed that a lower heart rate reserve was also associated with a greater risk of death in patients with complex anatomy, Fontan circulation, and tetralogy of Fallot (p < 0.05 for each).

CONCLUSIONS

An abnormal heart rate response to exercise identifies ACHD patients with a higher risk of mortality in the midterm, even after accounting for antiarrhythmic medication and exercise capacity. Heart rate reserve is a simple and inexpensive way to identify ACHD patients at higher mortality risk.

A novel algorithm for comprehensive fetal echocardiography using 4-dimensional ultrasonography and tomographic imaging

OBJECTIVE

Tomographic ultrasound imaging (TUI) is a new display modality that allows simultaneous visualization of up to 8 parallel anatomic planes. This study was designed to determine the role of a novel algorithm combining spatiotemporal image correlation and TUI to visualize standard fetal echocardiographic planes.

METHODS

Volume data sets from fetuses with and without congenital heart defects (CHDs) were examined with a novel algorithm that allows simultaneous visualization of the 3-vessel and trachea view, the 4-chamber view, and outflow tracts. Visualization rates for these planes as well as the ductal arch and 5-chamber view were calculated.

RESULTS

(1) Two hundred twenty-seven volume data sets from fetuses without (n = 138) and with (n = 14) CHDs were reviewed; (2) among fetuses without CHDs, the 4-chamber view, 5-chamber view, ductal arch, 3-vessel and trachea view, left outflow tract, and short axis of the aorta were visualized in 99% (193/195), 96.9% (189/195), 98.5% (192/195), 88.2% (172/195), 93.3% (182/195), and 87.2% (170/195) of the volume data sets, respectively; (3) these views were visualized in 85% (17/20), 80% (16/20), 65% (13/20), 55% (11/20), 55% (11/20), and 70% (14/20) of the volume data sets, respectively, from fetuses with CHDs; and (4) simultaneous visualization of the short axis of the aorta, 3-vessel and trachea view, left outflow tract, and 4-chamber view was obtained in 78% (152/195) of the volume data sets from fetuses without CHDs and in 40% (8/20) of those with CHDs.

CONCLUSIONS

The 3-vessel and trachea view, the 4-chamber view, and both outflow tracts can be simultaneously visualized using a novel algorithm combining spatiotemporal image correlation and TUI.

Transition to adulthood in congenital heart disease: missed adolescent milestones

PURPOSE

To determine whether adults with congenital heart disease (CHD) are better adjusted than adults with acquired heart disease (AHD).

METHODS

Twenty-five adults with CHD completed the Patient Adjustment to Illness Self Report (PAIS-SR).

RESULTS

CHD patients had good adjustment for Heath Care Orientation and Family Relations, but poorer adjustment for Vocational, Social and Domestic Environment, Sexual Relations, and Psychological Distress.

CONCLUSIONS

The needs of CHD patients are not being met.

Survival in infants with Down syndrome, Metropolitan Atlanta, 1979-1998

OBJECTIVE

Factors influencing survival among persons with Down syndrome (DS) are not well understood. We sought to evaluate survival of infants with DS and potential prognostic factors.

STUDY DESIGN

Infants with DS who were born alive during 1979 to 1998 were identified using the Metropolitan Atlanta Congenital Defects Program (MACDP), a population-based surveillance system. To document vital status, we used data from hospital records, the National Death Index (NDI), and Georgia vital records. We estimated survival probability using the Kaplan-Meier product limit method and hazard ratios using a Cox proportional hazards model.

RESULTS

Survival probability to 1 year was 92.9% (95% CI: 90.9-94.9) and to 10 years was 88.6% (95% CI: 85.0-92.2). Univariate analysis demonstrated that black maternal race, low birth weight, preterm birth, lower paternal education, presence of heart defects, and presence of other major congenital anomalies were important prognostic factors. After multivariate analysis, maternal race, presence of heart defects, low birth weight, and an interaction between maternal race and presence of heart defects were significantly associated with mortality risk.

CONCLUSIONS

A racial disparity is apparent in survival for children with Down syndrome. Further study is needed to elucidate possible reasons for the racial disparity.

Health-related Quality of Life in Children and Adolescents after Invasive Treatment for Congenital Heart Disease

Since the 1980s treatment techniques for congenital heart disease (ConHD) have gradually evolved. Therefore, actual information on the outcomes, including quality of life is required. Health-related quality of life was assessed long-term in four diagnostic groups of children, who underwent invasive treatment for ConHD between 1990 and 1995. The scores on the TNO-AZL Child Quality of Life Questionnaire (TACQOL) of both children with ConHD and their parents were compared with those of a same-aged reference group. The total sample of ConHD children (n = 113, 8-15 years old) obtained significantly lower mean scores on motor functioning, cognitive functioning, and positive emotional functioning than reference peers, reflecting an experience of poorer functioning. ConHD children, aged 8-11 years, obtained lower mean scores on 5 of the 7 TACQOL scales than reference peers. They also had a lower score on positive emotional functioning than 12- to 15-year-old ConHD children. The total sample of ConHD children obtained lower outcomes compared to their parents on 4 of the 7 TACQOL scales. No significant differences were found in health-related quality of life between ConHD boys and girls, neither between different diagnostic groups. Overall, this sample of recently treated ConHD children showed a worse health-related quality of life compared to reference groups. These findings deserve further attention.

In-hospital mortality for children with hypoplastic left heart syndrome after stage I surgical palliation: teaching versus nonteaching hospitals

OBJECTIVES

Teaching hospitals are perceived to provide a higher quality of care for the treatment of rare disease and complex patients. A substantial proportion of stage I palliation for hypoplastic left heart syndrome (HLHS) may be performed in nonteaching hospitals. This study compares the in-hospital mortality of stage I palliation between teaching and nonteaching hospitals.

METHODS

The authors conducted a retrospective cohort study using the Kids' Inpatient Database 1997 and 2000. Patients with HLHS undergoing stage I palliation were identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes.

RESULTS

Seven hundred fifty-four and 880 discharges of children with HLHS undergoing stage I palliation in 1997 and 2000, respectively, were identified. The in-hospital mortality for the study population was 28% in 1997 and 24% in 2000. Twenty percent of stage I palliation operations were performed in nonteaching hospitals in 1997. Two percent of operations were performed in nonteaching hospitals in 2000. In 1997 only, in-hospital mortality remained higher in nonteaching hospitals after controlling for stage I palliation hospital volume and condition-severity diagnoses. Low-volume hospitals performing stage I palliation were associated with increased in-hospital mortality in 1997 and 2000.

CONCLUSIONS

Patients with HLHS undergoing stage I palliation in nonteaching hospitals experienced increased in-hospital mortality in 1997. A significant reduction in the number of stage I palliation procedures performed in nonteaching hospitals occurred between 1997 and 2000. This centralization of stage I palliation into teaching hospitals, along with advances in postoperative medical and surgical care for these children, was associated with a decrease in mortality. Patients in low-volume hospitals performing stage I palliation continued to experience increased mortality in 2000.