Pediatric inpatient hospital resource use for congenital heart defects

Financial Stressors for Parents of Children and Emerging Adults With Congenital Heart Disease: A Qualitative Study

INTRODUCTION

Congenital heart disease (CHD) is the most prevalent congenital disability globally. This study aimed to describe parents' perspectives on financial stressors related to having a child with CHD using a descriptive qualitative approach.

METHOD

Qualitative data were obtained from parents of children with CHD in a cross-sectional web-based survey study. Iterative data analysis was used to develop essential themes that enabled a rich description of 147 parents' perspectives.

RESULTS

Parents identified five financial stressors: perpetual worries about health insurance, facing the dilemma of "making too much money," struggling to balance work, worrying over having an emerging adult with CHD, and constant constraints because of financial needs.

DISCUSSION

As experts in pediatric care, pediatric advanced practice providers need to work with policymakers to provide further financial assistance and sufficient insurance coverage for families that struggle to balance finances for the whole family and children with CHD.

Hospital care in the first 10 years of life of children with congenital anomalies in six European countries: data from the EUROlinkCAT cohort linkage study

OBJECTIVE

To quantify the hospital care for children born with a major congenital anomaly up to 10 years of age compared with children without a congenital anomaly.

DESIGN, SETTING AND PATIENTS

79 591 children with congenital anomalies and 2 021 772 children without congenital anomalies born 1995-2014 in six European countries in seven regions covered by congenital anomaly registries were linked to inpatient electronic health records up to their 10th birthday.

MAIN OUTCOME MEASURES

Number of days in hospital and number of surgeries.

RESULTS

During the first year of life among the seven regions, a median of 2.4% (IQR: 2.3, 3.2) of children with a congenital anomaly accounted for 18% (14, 24) of days in hospital and 63% (62, 76) of surgeries. Over the first 10 years of life, the percentages were 17% (15, 20) of days in hospital and 20% (19, 22) of surgeries. Children with congenital anomalies spent 8.8 (7.5, 9.9) times longer in hospital during their first year of life than children without anomalies (18 days compared with 2 days) and 5 (4.1-6.1) times longer aged, 5-9 (0.5 vs 0.1 days). In the first year of life, children with gastrointestinal anomalies spent 40 times longer and those with severe heart anomalies 20 times longer in hospital reducing to over 5 times longer when aged 5-9.

CONCLUSIONS

Children with a congenital anomaly consume a significant proportion of hospital care resources. Priority should be given to public health primary prevention measures to reduce the risk of congenital anomalies.

Study on the trend of congenital heart disease inpatient costs and its influencing factors in economically underdeveloped areas of China, 2015-2020: a case study of Gansu Province

Background

Economic data on congenital heart disease are scarce in economically underdeveloped areas of China. Therefore, this study aimed to shed light on the level and changing trend of congenital heart disease inpatients' economic burden in underdeveloped areas.

Method

This study used a multi-stage stratified cluster sampling method to select 11,055 inpatients with congenital heart disease from 197 medical and health institutions in Gansu Province. Their medical records and expenses were obtained from the Hospital Information System. Univariate analysis was conducted using the rank sum test and Spearman rank correlation. Quantile regression and random forest were used to analyze the influencing factors.

Results

From 2015 to 2020, the average length of stay for congenital heart disease patients in Gansu Province was 10.09 days, with an average inpatient cost of USD 3,274.57. During this period, the average inpatient costs per time increased from USD 3,214.85 to USD 3,403.41, while the average daily inpatient costs increased from USD 330.05 to USD 376.56. The average out-of-pocket costs per time decreased from USD 2,305.96 to USD 754.77. The main factors that affected the inpatient costs included length of stay, cardiac procedure, proportion of medications, age, and hospital level.

Conclusion

Congenital heart disease causes a significant economic burden on both families and society. Therefore, to further reduce the patient's financial burden, the length of stay should be reasonably reduced, and the rational distribution of medical resources should be continuously promoted to ensure equitable access to healthcare services.

Cardiac Axis in Early Gestation and Congenital Heart Disease

Congenital heart defects represent the most common structural anomalies observed in the fetal population, and they are often associated with significant morbidity and mortality. The fetal cardiac axis, which indicates the orientation of the heart in relation to the chest wall, is formed by the angle between the anteroposterior axis of the chest and the interventricular septum of the heart. Studies conducted during the first trimester have demonstrated promising outcomes with respect to the applicability of cardiac axis measurement in fetuses with congenital heart defects as well as fetuses with extracardiac and chromosomal anomalies, which may result in improved health outcomes and reduced healthcare costs. The main aim of this review article was to highlight the cardiac axis as a reliable and powerful marker for the detection of congenital heart defects during early gestation, including defects that would otherwise remain undetectable through the conventional four-chamber view.

Evaluating variation in pre-operative evaluation and planning for children undergoing atrial or ventricular septal defect repair

BACKGROUND

CHD care is resource-intensive. Unwarranted variation in care may increase cost and result in poorer health outcomes. We hypothesise that process variation exists within the pre-operative evaluation and planning process for children undergoing repair of atrial septal defect or ventricular septal defect and that substantial variation occurs in a small number of care points.

METHODS

From interviews with staff of an integrated congenital heart centre, an initial process map was constructed. A retrospective chart review of patients with isolated surgical atrial septal defect and ventricular septal defect repair from 7/1/2018 through 11/1/2020 informed revisions of the process map. The map was assessed for points of consistency and variability.

RESULTS

Thirty-two surgical atrial septal defect/ventricular septal defect repair patients were identified. Ten (31%) were reviewed by interventional cardiology before surgical review. Of these, 6(60%) had a failed catheter-based closure and 4 (40%) were deemed inappropriate for catheter-based closure. Thirty (94%) were reviewed in case conference, all attended surgical clinic, and none were admitted prior to surgery. The process map from interviews alone identified surgery rescheduling as a point of major variability; however, chart review revealed this was not as prominent a source of variability as pre-operative interventional cardiology review.

CONCLUSIONS

Significant variation in the pre-operative evaluation and planning process for surgical atrial septal defect/ventricular septal defect patients was identified. If such process variation is widespread through CHD care, it may contribute to variations in outcome and cost previously documented within CHD surgery. Future research will focus on determining whether the variation is warranted or unwarranted, associated health outcomes and cost variation attributed to these variations in care processes.

ROR2 deficit may induce the tetralogy of Fallot via down-regulating of β-catenin/SOX3/HSPA6 in vitro and in vivo

Tetralogy of Fallot (TOF) is the highly conventional appearance of cyanotic congenital heart disease. Our study aimed to assess the involvement of receptor tyrosine kinase-like orphan receptor 2 (ROR2) in TOF and elucidate the specific mechanism. Upon investigation of human tissue samples, we observed a decrease in ROR2 expression in TOF patients compared to healthy control individuals. Transcriptome analysis revealed diminished ROR2 expression in TOF pathological samples relative to normal tissues. Of the 2246 genes that exhibited altered expression, 886 were upregulated, while 1360 were down-regulated. KEGG analysis and GO analysis of the differentially expressed genes indicated that these genes were significantly enriched in the Wnt signalling pathway, apoptosis and cardiac development function. Importantly, ROR2 was the only gene shared among the three pathways. Furthermore, interference with ROR2 promotes apoptosis and curtails cell proliferation in vitro. The knockdown of the ROR2 gene in AC16 cells resulted in a significant decrease in Edu-positive cells. Flow cytometry studies indicated an increase in the percentage of cells in the S phase. In contrast, the G2/M cell cycle transition was blocked in the ROR2-knockdown group, leading to a significant increase in apoptosis. Moreover, the CCK-8 cell viability assay demonstrated a reduced proliferation in the ROR2-knockdown group. Furthermore, both in vivo and in vitro data indicated that the expression of HSPA6 (Recombinant Heat Shock 70 kDa Protein6), an essential gene enriched in cardiac tissue and associated with apoptosis, was down-regulated following ROR2 knockdown mediated by the β-catenin/SOX3 signalling pathway. In conclusion, low expression of ROR2 plays a crucial role in the occurrence and development of TOF, which may be related to the downregulation of HSPA6 through the β-catenin/SOX3 signalling pathway.

Mutations in genes related to myocyte contraction and ventricular septum development in non-syndromic tetralogy of Fallot

Objective

Eighty percent of patients with a diagnosis of tetralogy of Fallot (TOF) do not have a known genetic etiology or syndrome. We sought to identify key molecular pathways and biological processes that are enriched in non-syndromic TOF, the most common form of cyanotic congenital heart disease, rather than single driver genes to elucidate the pathogenesis of this disease.

Methods

We undertook exome sequencing of 362 probands with non-syndromic TOF and their parents within the Pediatric Cardiac Genomics Consortium (PCGC). We identified rare (minor allele frequency <1 × 10-4), de novo variants to ascertain pathways and processes affected in this population to better understand TOF pathogenesis. Pathways and biological processes enriched in the PCGC TOF cohort were compared to 317 controls without heart defects (and their parents) from the Simons Foundation Autism Research Initiative (SFARI).

Results

A total of 120 variants in 117 genes were identified as most likely to be deleterious, with CHD7, CLUH, UNC13C, and WASHC5 identified in two probands each. Gene ontology analyses of these variants using multiple bioinformatic tools demonstrated significant enrichment in processes including cell cycle progression, chromatin remodeling, myocyte contraction and calcium transport, and development of the ventricular septum and ventricle. There was also a significant enrichment of target genes of SOX9, which is critical in second heart field development and whose loss results in membranous ventricular septal defects related to disruption of the proximal outlet septum. None of these processes was significantly enriched in the SFARI control cohort.

Conclusion

Innate molecular defects in cardiac progenitor cells and genes related to their viability and contractile function appear central to non-syndromic TOF pathogenesis. Future research utilizing our results is likely to have significant implications in stratification of TOF patients and delivery of personalized clinical care.

Patch Materials for Pulmonary Artery Arterioplasty and Right Ventricular Outflow Tract Augmentation: A Review

Patch augmentation of the right ventricular outflow tract (RVOT) and pulmonary artery (PA) arterioplasty are relatively common procedures in the surgical treatment of patients with congenital heart disease. To date, several patch materials have been applied with no agreed upon clinical standard. Each patch type has unique performance characteristics, cost, and availability. There are limited data describing the various advantages and disadvantages of different patch materials. We performed a review of studies describing the clinical performance of various RVOT and PA patch materials and found a limited but growing body of literature. Short-term clinical performance has been reported for a multitude of patch types, but comparisons are limited by inconsistent study design and scarce histologic data. Standard clinical criteria for assessment of patch efficacy and criteria for intervention need to be applied across patch types. The field is progressing with improvements in outcomes due to newer patch technologies focused on reducing antigenicity and promoting neotissue formation which may have the ability to grow, remodel, and repair.

Tissue Engineering of Vascular Grafts: A Case Report From Bench to Bedside and Back

For over 25 years, our group has used regenerative medicine strategies to develop improved biomaterials for use in congenital heart surgery. Among other applications, we developed a tissue-engineered vascular graft (TEVG) by seeding tubular biodegradable polymeric scaffolds with autologous bone marrow-derived mononuclear cells. Results of our first-in-human study demonstrated feasibility as the TEVG transformed into a living vascular graft having an ability to grow, making it the first engineered graft with growth potential. Yet, outcomes of this first Food and Drug Administration-approved clinical trial evaluating safety revealed a prohibitively high incidence of early TEVG stenosis, preventing the widespread use of this promising technology. Mechanistic studies in mouse models provided important insight into the development of stenosis and enabled advanced computational models. Computational simulations suggested both a novel inflammation-driven, mechano-mediated process of in vivo TEVG development and an unexpected natural history, including spontaneous reversal of the stenosis. Based on these in vivo and in silico discoveries, we have been able to rationally design strategies for inhibiting TEVG stenosis that have been validated in preclinical large animal studies and translated to the clinic via a new Food and Drug Administration-approved clinical trial. This progress would not have been possible without the multidisciplinary approach, ranging from small to large animal models and computational simulations. This same process is expected to lead to further advances in scaffold design, and thus next generation TEVGs.

Prenatally diagnosed congenital heart disease: the cost of maternal care

OBJECTIVE

Little is known regarding the effects of a prenatal diagnosis of congenital heart disease (CHD) on the cost of antenatal and delivery care. We sought to compare the maternal costs of care in pregnancies where the fetus or child was diagnosed prenatally vs. postnatally.

METHODS

Costs of maternal care were determined for pregnancies in which the fetus or child was diagnosed with CHD between 1997 and 2012 in the state of Utah. Cases of CHD were identified via a statewide birth defect surveillance program which included data on the timing of diagnosis, maternal demographic and clinical data, and linked to statewide inpatient maternal hospital discharge records. Antenatal testing costs were determined using Medicaid fee estimates and total facility costs were determined for all hospitalizations including delivery. The association of timing of diagnosis of CHD with costs was analyzed using univariable and multivariable models.

RESULTS

Of 2128 pregnancies included in the study, 36% had a fetus prenatally diagnosed with CHD. The prenatal diagnosis group was more likely to have a termination or stillbirth and were younger at delivery (gestational age 37.3 vs 38.0 weeks, p < .001). Labor induction and cesarean delivery rates were similar between groups. Antenatal testing and delivery hospitalization costs were higher in the prenatal diagnosis group: $5819 vs $4041 (p < .001) and $10,509 vs $7802 (p < .001), respectively. Patients in the prenatal diagnosis group had longer lengths of hospital stays (3.5 vs 2.4 d, p > .001). After controlling for significant differences between the groups, including lesion severity, the prenatal diagnosis remained directly associated with antenatal testing costs (+$1472), maternal hospitalization costs (+$2713), and maternal hospital length of stay (+1.0 d).

CONCLUSION

A prenatal diagnosis of fetal CHD was associated with increased prenatal costs, hospitalization costs, and hospital length of stay for affected pregnant patients.

An Exploratory Analysis of Maternal Health Variables Increasing the Severity of Congenital Heart Disease in Infants

BACKGROUND

Congenital heart defects (CHD) are the most prevalent birth anomaly and leading cause of infant morbidity and mortality worldwide. Heart defects are often attributed to chromosomal abnormality or environmental factors, but most causes remain unknown. The purpose of this analysis was to explore maternal health variables and the relationships to birth outcomes in infants with CHD.

METHODS

Secondary analysis of data from the Wisconsin Pediatric Cardiac Registry.

RESULTS

Maternal history of CHDs (odds ratio [OR] = 2.38; 95% confidence interval [CI], 1.42-3.98) and serious health conditions (OR = 1.537; 95%: CI, 1.08-2.17) increase infant risk and CHD severity. Maternal history of hypertension, serious health conditions, CHD, obesity, and income were predictors of birth weight (R² = 0.049, P < .05). Maternal history of hypertension, influenza, serious health conditions, and housing were predictors of gestational age (R2 = 0.045, P < .05). Birth weight (BW) and gestational age (GA) did not correlate to the severity of CHD in this study (simple vs complex, BW = -0.014, GA = 0.011, r).

DISCUSSION

Maternal well-being influences the health of infants born with CHD. Positive maternal health contributes to near-normal birth weight and gestational age.

CONCLUSION

Nurses must discuss optimal reproductive life planning strategies for decreasing risk of CHD and other infant disorders.

Health Care Usage Among Adolescents With Congenital Heart Defects at 5 Sites in the United States, 2011 to 2013

Background

We sought to characterize health care usage for adolescents with congenital heart defects (CHDs) using population‐based multisite surveillance data.

Methods and Results

Adolescents aged 11 to 18 years with ≥1 CHD‐related diagnosis code and residing in 5 US sites were identified in clinical and administrative data sources for the years 2011 to 2013. Sites linked data on all inpatient, emergency department (ED), and outpatient visits. Multivariable log‐binomial regression models including age, sex, unweighted Charlson comorbidity index, CHD severity, cardiology visits, and insurance status, were used to identify associations with inpatient, ED, and outpatient visits. Of 9626 eligible adolescents, 26.4% (n=2543) had severe CHDs and 21.4% had Charlson comorbidity index >0. At least 1 inpatient, ED, or outpatient visit was reported for 21%, 25%, and 96% of cases, respectively. Cardiology visits, cardiac imaging, cardiac procedures, and vascular procedures were reported for 38%, 73%, 10%, and 5% of cases, respectively. Inpatient, ED, and outpatient visits were consistently higher for adolescents with severe CHDs compared with nonsevere CHDs. Adolescents with severe and nonsevere CHDs had higher health care usage compared with the 2011 to 2013 general adolescent US population. Adolescents with severe CHDs versus nonsevere CHDs were twice as likely to have at least 1 inpatient visit when Charlson comorbidity index was low (Charlson comorbidity index =0). Adolescents with CHDs and public insurance, compared with private insurance, were more likely to have inpatient (adjusted prevalence ratio, 1.5 [95% CI, 1.3–1.7]) and ED (adjusted prevalence ratio, 1.6 [95% CI, 1.4–1.7]) visits.

Conclusions

High resource usage by adolescents with CHDs indicates a substantial burden of disease, especially with public insurance, severe CHDs, and more comorbidities.

Factors associated with Medicaid participation among infants born with birth defects in Texas, 2010-2014

BACKGROUND

Birth defects are major contributors to healthcare resource use, disability, and mortality, particularly during the perinatal period. As the nation's public insurance program for low-income individuals, Medicaid funds a large proportion of healthcare costs associated with birth defects. Here, we explore birth defect-related factors associated with Medicaid participation in the first year of life.

METHODS

Infants born with birth defects between 2010 and 2014 were linked from the Texas Birth Defects Registry to the state's Medicaid claims database. Variation in Medicaid participation was examined by individual birth defect and by birth defect characteristics. The associations between covariates and Medicaid participation are described using percentages and adjusted prevalence ratios (APR).

RESULTS

Of the 107,968 infants included in this study, 55,172 (51.1%) participated in Medicaid. Medicaid participation ranged from 12.1% for anencephaly to 77.8% for total anomalous pulmonary venous connection. An indicator of defect severity was associated with an increased likelihood of participation (APR = 1.22, 95% CI: 1.20-1.23). Medicaid participation was 60.8% for individuals with multiple major defects, compared with 45.4% for those without (APR = 1.24, 95% CI: 1.22-1.25). Among individual birth defects, Medicaid participation was almost universally higher for those co-occurring with other major defects.

CONCLUSIONS

We detected large variations in Medicaid participation by individual birth defect. Infants participating in Medicaid tended to have more severe defects and were more likely to have multiple major defects. Medicaid claims databases can serve as valuable sources of data for surveillance efforts and observational studies, but care should be taken when generalizing findings.

Effect of Nitric Oxide via Cardiopulmonary Bypass on Ventilator-Free Days in Young Children Undergoing Congenital Heart Disease Surgery: The NITRIC Randomized Clinical Trial

IMPORTANCE

In children undergoing heart surgery, nitric oxide administered into the gas flow of the cardiopulmonary bypass oxygenator may reduce postoperative low cardiac output syndrome, leading to improved recovery and shorter duration of respiratory support. It remains uncertain whether nitric oxide administered into the cardiopulmonary bypass oxygenator improves ventilator-free days (days alive and free from mechanical ventilation).

OBJECTIVE

To determine the effect of nitric oxide applied into the cardiopulmonary bypass oxygenator vs standard care on ventilator-free days in children undergoing surgery for congenital heart disease.

DESIGN, SETTING, AND PARTICIPANTS

Double-blind, multicenter, randomized clinical trial in 6 pediatric cardiac surgical centers in Australia, New Zealand, and the Netherlands. A total of 1371 children younger than 2 years undergoing congenital heart surgery were randomized between July 2017 and April 2021, with 28-day follow-up of the last participant completed on May 24, 2021.

INTERVENTIONS

Patients were assigned to receive nitric oxide at 20 ppm delivered into the cardiopulmonary bypass oxygenator (n = 679) or standard care cardiopulmonary bypass without nitric oxide (n = 685).

MAIN OUTCOMES AND MEASURES

The primary end point was the number of ventilator-free days from commencement of bypass until day 28. There were 4 secondary end points including a composite of low cardiac output syndrome, extracorporeal life support, or death; length of stay in the intensive care unit; length of stay in the hospital; and postoperative troponin levels.

RESULTS

Among 1371 patients who were randomized (mean [SD] age, 21.2 [23.5] weeks; 587 girls [42.8%]), 1364 (99.5%) completed the trial. The number of ventilator-free days did not differ significantly between the nitric oxide and standard care groups, with a median of 26.6 days (IQR, 24.4 to 27.4) vs 26.4 days (IQR, 24.0 to 27.2), respectively, for an absolute difference of -0.01 days (95% CI, -0.25 to 0.22; P = .92). A total of 22.5% of the nitric oxide group and 20.9% of the standard care group developed low cardiac output syndrome within 48 hours, needed extracorporeal support within 48 hours, or died by day 28, for an adjusted odds ratio of 1.12 (95% CI, 0.85 to 1.47). Other secondary outcomes were not significantly different between the groups.

CONCLUSIONS AND RELEVANCE

In children younger than 2 years undergoing cardiopulmonary bypass surgery for congenital heart disease, the use of nitric oxide via cardiopulmonary bypass did not significantly affect the number of ventilator-free days. These findings do not support the use of nitric oxide delivered into the cardiopulmonary bypass oxygenator during heart surgery.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12617000821392.

The associations between resilience and socio-demographic factors in parents who care for their children with congenital heart disease

Objective

To examine the resilience of parents of children with congenital heart disease and to investigate socio-demographic factors that may influence parents’ resilience.

Methods

This is a web-based survey study using a cross-sectional design. A purposive sampling method was utilized to recruit 515 parents who care for children with congenital heart disease. Resilience was assessed using the Dispositional Resilience Scale-Ⅱ. Based on expert-interviews, a questionnaire was designed to collect socio-demographic data. Descriptive statistics, factor analysis, and linear regressions were used to analyze data.

Results

A total of 413 parents completed the survey study. The mean resilience score was 3.75 (SD = 0.61; range = 1.89–4.89) with higher scores indicating higher resilience. The linear regression models demonstrated that parents who had lower education levels and lower gross household income had lower resilience (P < 0.05).

Conclusions

Parents reported resilience that reflected their ability to cope with stressful events and mitigate stressors associated with having and caring for children with congenital heart disease. Lower education levels and lower gross household income are associated with lower resilience. To increase parents’ resilience, nursing practice and nurse-led interventions should target screening and providing support for parents at-risk for lower resilience. As lower education level and financial hardship are factors that are difficult to modify through personal efforts, charitable foundations, federal and state governments should consider programs that would provide financial and health literacy support for parents at-risk for lower resilience.

Epidemiology of Congenital Heart Disease in Jinan, China From 2005 to 2020: A Time Trend Analysis

Background

Although congenital heart defect (CHD) was the dominating birth defect, the time trend analysis of CHD was largely unknown. In our study, the time trend analysis of CHD from 2005 to 2020 in Jinan was conducted, aimed to reveal the epidemiological characteristics in a city and provided the data basis for the government to make a policy intervention.

Methods

A multi-institutional and retrospective review of CHD for all births from January 1, 2005 to December 31, 2020 was performed. Proportioner prevalence was used to describe the distribution of CHD. Comparisons of CHD characteristics among different groups were assessed with Chi-squares tests. Cochran-Armitage tests (CAT) were used to track changes in CHD prevalence.

Results

About 322,374 births and 5,180 CHD in Jinan were included from 2005 to 2020, and the total CHD prevalence was 3.92 per 1,000 births. The CHD prevalence showed an upward trend, with a total increase of 227.66% from 2005 to 2020. The CHD prevalence in urban areas was 34.17% higher than that in rural areas, but the gap was narrowing. Atrial septal defect (3.07 per 1,000 births), patent ductus arteriosus (1.62 per 1,000 births), ventricular septal defect (1.18 per 1,000 births), tetralogy of Fallot (0.62 per 1,000 births), and atrioventricular septal defect (0.47 per 1,000 births) were the 5 most common subtypes.

Conclusion

The prevalence of CHD in Jinan was gradually on the rise, which needs to be highly focused on by the health management department. Older pregnant women and women in rural areas should be concerned, and targeted measures need to be introduced.

Respiratory viral infections are prevalent but uncomplicated in single ventricle CHD

BACKGROUND

Patients with single ventricle CHD have significant morbidity and healthcare utilisation throughout their lifetime, including non-cardiac hospital admissions. Respiratory viral infections are the main cause of hospitalisation in children, but few data exist for single ventricle patients. We sought to identify how respiratory viral infections impact patients with single ventricle CHD and potential differences between Glenn and Fontan circulation.

METHODS

We conducted a retrospective study of patients seen from 01/01/2011-12/31/2020. We identified patients with a history of single ventricle CHD and Glenn palliation, and a normoxic control group with isolated atrial septal defect requiring surgical closure. We compared viral-related clinical presentations, admissions, and admission characteristics.

RESULTS

A total of 312 patients were included (182 single ventricle, 130 atrial septal defect). Single ventricle patients were more likely than children with isolated atrial septal defect to be admitted with a respiratory virus (odds ratio 4.15 [2.30-7.46]), but there was no difference in mechanical ventilation or hospital length of stay (p = 0.4709). Single ventricle patients with Glenn circulation were more likely than those with Fontan circulation to present and be admitted (odds ratio 3.25 [1.62-6.52]), but there was no difference in ICU admission, mechanical ventilation, or hospital length of stay (p = 0.1516).

CONCLUSIONS

Respiratory viral infections are prevalent but uncomplicated in patients with single ventricle CHD. Viral-related presentations and admissions are more prevalent during the period of Glenn circulation compared to Fontan circulation; however, rate of mechanical ventilation and hospital length of stay are similar.

Tissue engineering: Relevance to neonatal congenital heart disease

Congenital heart disease (CHD) represents a large clinical burden, representing the most common cause of birth defect-related death in the newborn. The mainstay of treatment for CHD remains palliative surgery using prosthetic vascular grafts and valves. These devices have limited effectiveness in pediatric patients due to thrombosis, infection, limited endothelialization, and a lack of growth potential. Tissue engineering has shown promise in providing new solutions for pediatric CHD patients through the development of tissue engineered vascular grafts, heart patches, and heart valves. In this review, we examine the current surgical treatments for congenital heart disease and the research being conducted to create tissue engineered products for these patients. While much research remains to be done before tissue engineering becomes a mainstay of clinical treatment for CHD patients, developments have been progressing rapidly towards translation of tissue engineering devices to the clinic.

Association of Alcohol Use Diagnostic Codes in Pregnancy and Offspring Conotruncal and Endocardial Cushion Heart Defects

Background

The pathogenesis of congenital heart disease (CHD) remains largely unknown, with only a small percentage explained solely by genetic causes. Modifiable environmental risk factors, such as alcohol, are suggested to play an important role in CHD pathogenesis. We sought to evaluate the association between prenatal alcohol exposure and CHD to gain insight into which components of cardiac development may be most vulnerable to the teratogenic effects of alcohol.

Methods and Results

This was a retrospective analysis of hospital discharge records from the California Office of Statewide Health Planning and Development and linked birth certificate records restricted to singleton, live‐born infants from 2005 to 2017. Of the 5 820 961 births included, 16 953 had an alcohol‐related International Classification of Diseases, Ninth and Tenth Revisions (ICD‐9; ICD‐10) code during pregnancy. Log linear regression was used to calculate risk ratios (RR) for CHD among individuals with an alcohol‐related ICD‐9 and ICD10 code during pregnancy versus those without. Three models were created: (1) unadjusted, (2) adjusted for maternal demographic factors, and (3) adjusted for maternal demographic factors and comorbidities. Maternal alcohol‐related code was associated with an increased risk for CHD in all models (RR, 1.33 to 1.84); conotruncal (RR, 1.62 to 2.11) and endocardial cushion (RR, 2.71 to 3.59) defects were individually associated with elevated risk in all models.

Conclusions

Alcohol‐related diagnostic codes in pregnancy were associated with an increased risk of an offspring with a CHD, with a particular risk for endocardial cushion and conotruncal defects. The mechanistic basis for this phenotypic enrichment requires further investigation.

Maternal Smoking and Congenital Heart Defects, National Birth Defects Prevention Study, 1997-2011

OBJECTIVES

To assess associations between maternal smoking and congenital heart defects (CHDs) in offspring.

STUDY DESIGN

We performed a retrospective case-control study using data for cases of CHD (n = 8339) and nonmalformed controls (n = 11 020) from all years (1997-2011) of the National Birth Defects Prevention Study. Maternal self-reported smoking 1 month before through 3 months after conception was evaluated as a binary (none, any) and categorical (light, medium, heavy) exposure. Multivariable logistic regression was used to estimate aOR and 95% CIs. Stratified analyses were performed for septal defects according to maternal age, prepregnancy body mass index, and maternal race/ethnicity.

RESULTS

Multiple CHDs displayed modest associations with any level of maternal periconceptional smoking independent of potential confounders; the strongest associations were for aggregated septal defects (OR, 1.5; 95% CI, 1.3-1.7), tricuspid atresia (OR, 1.7; 95% CI, 1.0-2.7), and double outlet right ventricle (DORV) (OR, 1.5; 95% CI, 1.1-2.1). Tricuspid atresia and DORV also displayed dose-response relationships. Among heavy smokers, the highest odds were again observed for tricuspid atresia (aOR 3.0; 95% CI, 1.5-6.1) and DORV (aOR 1.5; 95% CI, 1.1-2.2). Heavy smokers ≥35 years old more frequently had a child with a septal defect when compared with similarly aged nonsmokers (aOR 2.3; 95% CI, 1.4-3.9).

CONCLUSIONS

Maternal periconceptional smoking is most strongly associated with septal defects, tricuspid atresia, and DORV; the risk for septal defects is modified by maternal age.

A mouse model of hypoplastic left heart syndrome demonstrating left heart hypoplasia and retrograde aortic arch flow

In hypoplastic left heart syndrome (HLHS), the mechanisms leading to left heart hypoplasia and their associated fetal abnormalities are largely unknown. Current animal models have limited utility in resolving these questions as they either do not fully reproduce the cardiac phenotype, do not survive to term and/or have very low disease penetrance. Here, we report the development of a surgically induced mouse model of HLHS that overcomes these limitations. Briefly, we microinjected the fetal left atrium of embryonic day (E)14.5 mice with an embolizing agent under high-frequency ultrasound guidance, which partially blocks blood flow into the left heart and induces hypoplasia. At term (E18.5), all positively embolized mice exhibit retrograde aortic arch flow, non-apex-forming left ventricles and hypoplastic ascending aortas. We thus report the development of the first mouse model of isolated HLHS with a fully penetrant cardiac phenotype and survival to term. Our method allows for the interrogation of previously intractable questions, such as determining the mechanisms of cardiac hypoplasia and fetal abnormalities observed in HLHS, as well as testing of mechanism-based therapies, which are urgently lacking.

Health Care Policy and Congenital Heart Disease: 2020 Focus on Our 2030 Future

The congenital heart care community faces a myriad of public health issues that act as barriers toward optimum patient outcomes. In this article, we attempt to define advocacy and policy initiatives meant to spotlight and potentially address these challenges. Issues are organized into the following 3 key facets of our community: patient population, health care delivery, and workforce. We discuss the social determinants of health and health care disparities that affect patients in the community that require the attention of policy makers. Furthermore, we highlight the many needs of the growing adults with congenital heart disease and those with comorbidities, highlighting concerns regarding the inequities in access to cardiac care and the need for multidisciplinary care. We also recognize the problems of transparency in outcomes reporting and the promising application of telehealth. Finally, we highlight the training of providers, measures of productivity, diversity in the workforce, and the importance of patient-family centered organizations in advocating for patients. Although all of these issues remain relevant to many subspecialties in medicine, this article attempts to illustrate the unique needs of this population and highlight ways in which to work together to address important opportunities for change in the cardiac care community and beyond. This article provides a framework for policy and advocacy efforts for the next decade.

On the shape and structure of the murine pulmonary heart valve

Murine animal models are an established standard in translational research and provides a potential platform for studying heart valve disease. To date, studies on heart valve disease using murine models have been hindered by a lack of appropriate methodologies due to their small scale. In the present study, we developed a multi-scale, imaging-based approach to extract the functional structure and geometry for the murine heart valve. We chose the pulmonary valve (PV) to study, due to its importance in congenital heart valve disease. Excised pulmonary outflow tracts from eleven 1-year old C57BL/6J mice were fixed at 10, 20, and 30 mmHg to simulate physiological loading. Micro-computed tomography was used to reconstruct the 3D organ-level PV geometry, which was then spatially correlated with serial en-face scanning electron microscopy imaging to quantify local collagen fiber distributions. From the acquired volume renderings, we obtained the geometric descriptors of the murine PV under increasing transvalvular pressures, which demonstrated remarkable consistency. Results to date suggest that the preferred collagen orientation was predominantly in the circumferential direction, as in larger mammalian valves. The present study represents a first step in establishing organ-level murine models for the study of heart valve disease.

Engineering Perspective on Cardiovascular Simulations of Fontan Hemodynamics: Where Do We Stand with a Look Towards Clinical Application

BACKGROUND

Cardiovascular simulations for patients with single ventricles undergoing the Fontan procedure can assess patient-specific hemodynamics, explore surgical advances, and develop personalized strategies for surgery and patient care. These simulations have not yet been broadly accepted as a routine clinical tool owing to a number of limitations. Numerous approaches have been explored to seek innovative solutions for improving methodologies and eliminating these limitations.

PURPOSE

This article first reviews the current state of cardiovascular simulations of Fontan hemodynamics. Then, it will discuss the technical progress of Fontan simulations with the emphasis of its clinical impact, noting that substantial improvements have been made in the considerations of patient-specific anatomy, flow, and blood rheology. The article concludes with insights into potential future directions involving clinical validation, uncertainty quantification, and computational efficiency. The advancements in these aspects could promote the clinical usage of Fontan simulations, facilitating its integration into routine clinical practice.

Murine Model of Cardiac Defects Observed in Adams-Oliver Syndrome Driven by Delta-Like Ligand-4 Haploinsufficiency

Heterozygous loss-of-function mutation in Delta-like ligand-4 (Dll4) is an important cause of Adams-Oliver syndrome (AOS). Cardiac defects, in particular outflow tract (OFT) alignment defects, are observed in about one-fourth of patients with this syndrome. The mechanism underlying this genotype-phenotype correlation has not yet been established. Dll4-mediated Notch signaling is known to play a crucial role in second heart field (SHF) progenitor cell proliferation. We hypothesized that the depletion of the SHF progenitor pool of cells due to partial loss of Dll4 is responsible for the OFT alignment defects seen in AOS. To demonstrate this, we studied Dll4 expression by murine SHF progenitor cells around E9.5, a crucial time-point in SHF biology. We used SHF-specific (Islet1-Cre) conditional knockout of Dll4 to bypass the early embryonic lethality seen in global Dll4 heterozygotes. Dll4-mediated Notch signaling is critically required for SHF proliferation such that Dll4 knockout results in a 33% reduction in proliferation and a fourfold increase in apoptosis in SHF cells, leading to a 56% decline in the size of the SHF progenitor pool. A reduction in SHF cells available for incorporation into the developing heart leads to underdevelopment of the SHF-derived right ventricle and OFT. Similar to the clinical syndrome, 32% of SHF-specific Dll4 heterozygotes demonstrate foreshortened and misaligned OFT, resulting in a double outlet right ventricle. Our murine model provides a molecular mechanism to explain the cardiac defects observed in AOS and establishes a novel clinical role for Dll4-mediated Notch signaling in SHF progenitor biology.

Spontaneous reversal of stenosis in tissue-engineered vascular grafts

We developed a tissue-engineered vascular graft (TEVG) for use in children and present results of a U.S. Food and Drug Administration (FDA)-approved clinical trial evaluating this graft in patients with single-ventricle cardiac anomalies. The TEVG was used as a Fontan conduit to connect the inferior vena cava and pulmonary artery, but a high incidence of graft narrowing manifested within the first 6 months, which was treated successfully with angioplasty. To elucidate mechanisms underlying this early stenosis, we used a data-informed, computational model to perform in silico parametric studies of TEVG development. The simulations predicted early stenosis as observed in our clinical trial but suggested further that such narrowing could reverse spontaneously through an inflammation-driven, mechano-mediated mechanism. We tested this unexpected, model-generated hypothesis by implanting TEVGs in an ovine inferior vena cava interposition graft model, which confirmed the prediction that TEVG stenosis resolved spontaneously and was typically well tolerated. These findings have important implications for our translational research because they suggest that angioplasty may be safely avoided in patients with asymptomatic early stenosis, although there will remain a need for appropriate medical monitoring. The simulations further predicted that the degree of reversible narrowing can be mitigated by altering the scaffold design to attenuate early inflammation and increase mechano-sensing by the synthetic cells, thus suggesting a new paradigm for optimizing next-generation TEVGs. We submit that there is considerable translational advantage to combined computational-experimental studies when designing cutting-edge technologies and their clinical management.

An early health technology assessment of 3D anatomic models in pediatric congenital heart surgery: potential cost-effectiveness and decision uncertainty

Background: Three-dimensional anatomic models have been used for surgical planning and simulation in pediatric congenital heart surgery. This research is the first to evaluate the potential cost-effectiveness of 3D anatomic models with the intent to guide surgeons and decision makers on its use.Method: A decision tree and subsequent Markov model with a 15-year time horizon was constructed and analyzed for nine cardiovascular surgeries. Epidemiological, clinical, and economic data were derived from databases. Literature and experts were consulted to close data gaps. Scenario, one-way, threshold, and probabilistic sensitivity analysis captured methodological and parameter uncertainty.Results: Incremental costs of using anatomical models ranged from -366€ (95% credibility interval: -2595€; 1049€) in the Norwood operation to 1485€ (95% CI: 1206€; 1792€) in atrial septal defect repair. Incremental health-benefits ranged from negligible in atrial septal defect repair to 0.54 Quality Adjusted Life Years (95% CI: 0.06; 1.43) in truncus arteriosus repair. Variability in the results was mainly caused by a temporary postoperative quality-adjusted life years gain.Conclusion: For complex operations, the implementation of anatomic models is likely to be cost-effective on a 15 year time horizon. For the right indication, these models thus provide a clinical advantage at an acceptable cost.

Resource Use and Outcomes of Pediatric Congenital Heart Disease Admissions: 2003 to 2016

Background

Children with congenital heart disease (CHD) are known to consume a disproportionate share of resources, yet there are limited data concerning trends in resource use and mortality among admitted children with CHD. We hypothesize that charges in CHD‐related admissions increased but that mortality improved over time.

Methods and Results

This study, including patients <18 years old with CHD, examined inpatient admissions from the nationally representative Kids' Inpatient Database from 2003 to 2016 in order to assess the frequency, medical complexity, and outcomes of CHD hospital admissions. A total of 859 843 admissions of children with CHD were identified. CHD admissions increased by 31.8% from 2003 to 2016, whereas overall pediatric admissions decreased by 13.4%. Compared with non‐CHD admissions, those with CHD were more likely to be <1 year of age (80.5% versus 63.3%), and to have ≥1 complex chronic condition (39.7% versus 9.3%). For CHD admissions, mortality was higher (2.97% versus 0.31%) and adjusted median charges greater ($48 426 [interquartile range (IQR), $11.932–$161 048] versus $4697 [IQR, $2551–$12 301]) (P<0.0001 for all). Among CHD admissions, whereas adjusted median charges increased from $35 577 (IQR, $9303–$110 439) to $61 696 (IQR, $15 212–$219 237), mortality decreased from 3.2% to 2.7% (P for trend <0.0001). CHD admissions accounted for an increased proportion of all inpatient deaths, from 18.0% in 2003 to 24.5% in 2016.

Conclusions

Children admitted with CHD are 10 times more likely to die than those without CHD and have higher charges. Although the rate of mortality in CHD admissions decreased, children with CHD accounted for an increasing proportion of all pediatric inpatient deaths. Effective resource allocation is critical to optimize outcomes in these high‐risk patients.

Mental Health Disorders in Children With Congenital Heart Disease

BACKGROUND

Data on anxiety, depression, and attention-deficit/hyperactivity disorder (ADHD) are lacking for youth with congenital heart disease (CHD), particularly those with simple CHD. This study aims to characterize these disorders in youth with CHD compared to those without CHD.

METHODS

A comparative cross-sectional study was conducted by using the electronic medical records of a large tertiary care hospital between 2011 and 2016. Inclusion criteria were youth aged 4 to 17 years with >1 hospitalization or emergency department visits. Exclusion criteria were patients with arrhythmias or treatment with clonidine and/or benzodiazepines. The primary predictor variable was CHD type: simple, complex nonsingle ventricle, and complex single ventricle. The primary outcome variable was a diagnosis and/or medication for anxiety and/or depression or ADHD. Data were analyzed by using logistic regression (Stata v15; Stata Corp, College Station, TX).

RESULTS

We identified 118 785 patients, 1164 with CHD. Overall, 18.2% (n = 212) of patients with CHD had a diagnosis or medication for anxiety or depression, compared with 5.2% (n = 6088) of those without CHD. All youth with CHD had significantly higher odds of anxiety and/or depression or ADHD. Children aged 4 to 9 years with simple CHD had ∼5 times higher odds (odds ratio: 5.23; 95% confidence interval: 3.87-7.07) and those with complex single ventricle CHD had ∼7 times higher odds (odds ratio: 7.46; 95% confidence interval: 3.70-15.07) of diagnosis or treatment for anxiety and/or depression. Minority and uninsured youth were significantly less likely to be diagnosed or treated for anxiety and/or depression or ADHD, regardless of disease severity.

CONCLUSIONS

Youth with CHD of all severities have significantly higher odds of anxiety and/or depression and ADHD compared to those without CHD. Screening for these conditions should be considered in all patients with CHD.

Status of Comorbid Congenital Anomalies and Their Influence on Resource Use in Pediatric Inpatients: A Serial Cross-Sectional Study in Shanghai, China

Objectives: The status of children with comorbid congenital anomalies (CAs) and their effects on related hospital resource utilization have been minimally investigated. We aimed to describe the congenital anomalies comorbidity status and their effects on hospital resource utilization (length of stay, cost) by pediatric patients.

Setting: This study was conducted in five tertiary care children's hospitals in Shanghai, China.

Participants: Data were obtained from the inpatients' electronic health records; diagnoses were recorded using International Classification of Disease, Ninth Revision codes. In total, 7,890 children were diagnosed with congenital anomalies (13.13%), which were either primary or secondary.

Primary and secondary outcome measures: The dependent variables were length of stay and cost. The independent variables were demographic and clinical characteristics and CA status.

Results: In total, 50.98% of the hospitalized patients had comorbid CA conditions. Medical+CA patients were associated with a longer LOS (β = 2.656, P < 0.001), and CA+medical patients were associated with higher costs (β = 7.222, P < 0.001). Cardiovascular, musculoskeletal, and genitourinary diseases were the top three comorbid diseases. The average LOS for the top three comorbid diseases was longest in the medical+CA group, followed by CA+medical group. Cardiovascular disease was the most frequent comorbidity (ranking 1 in the medical+CA group and 2 in the CA+medical group), and the cost of cardiovascular disease was highest in all groups.

Conclusions: A high prevalence of comorbid CA conditions was observed among pediatric inpatients in the sampled tertiary hospitals in China. Strategic planning should be improved to guide resource utilization for complex comorbid CA care.

Pulse oximetry screening for critical congenital heart defects in Ontario, Canada: a cost-effectiveness analysis

OBJECTIVE

Previously conducted cost-effectiveness analyses of pulse oximetry screening (POS) for critical congenital heart defects (CCHDs) have shown it to be a cost-effective endeavour, but the geographical setting of Ontario in relation to its vast yet sparsely populated regions presents unique challenges. The objective of this study was to estimate the cost-effectiveness of POS for CCHD in Ontario, Canada.

METHODS

A cost-effectiveness analysis, comparing POS to no POS, was conducted from the Ontario healthcare payer perspective using a Markov model. The base case was defined as a well-appearing newborn at 24 h of age. Outcome measures, including quality-adjusted life months (QALMs), lifetime costs, and incremental cost-effectiveness ratios (ICER) [ΔCost/ΔQALMs], were calculated over a lifetime horizon. All outcomes were discounted at 1.5% per year. Cost-effectiveness was assessed using an a priori ICER threshold of CAD$4166.67 per QALM (equivalent to CAD$50,000 per quality-adjusted life year). Deterministic and probabilistic sensitivity analyses were conducted to assess parameter uncertainty.

RESULTS

Implementation of POS is expected to lead to timely diagnosis of 51 CCHD cases annually. The incremental cost of performing POS was estimated to be $27.27 per screened individual, with a gain of 0.02455 QALMs. This yielded an ICER of CAD$1110.79 per QALM, well below the pre-determined threshold. The probabilistic sensitivity analysis estimated a 92.3% chance of routine implementation of POS being cost-effective.

CONCLUSION

Routine implementation of POS for CCHD in Ontario is expected to be cost-effective.

Cost-Effectiveness Analysis of Pulse Oximetry Screening in the Full-Term Neonates for Diagnosis of Congenital Heart Disease: A Systematic Review

Context: Congenital heart disease (CHD) is a leading cause of mortality by birth defects with significant social and economic burden. Pulse oximetry as a safe and non-invasive screening method, and with its potential for early detection of CHD has improved neonatal health outcomes. Objectives: The aim of this study was to systematically review economic evaluation studies that compared pulse oximetry with current programs to diagnose early detection of CHD in full-term newborns. Data Sources: A systematic review was conducted according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, and related articles published from 1995 up to March 2020 were searched in different databases (MEDLINE, EMBASE, PubMed, Science Direct, Google Scholar, Scopus, NHS EED, Science Citation Index, MagIran, Cochrane Library, EconLit and SID). The articles were selected based on inclusion and exclusion criteria. Consolidated health economic evaluation reporting standards (CHEERS) statement checklist was used to qualitatively evaluate the papers. Overall, 7 articles were included in the study. Results: Timely diagnosis was considered as main effectiveness health outcome in most studies. The highest and lowest values of incremental cost-effectiveness ratio (in two-phase studies) were €139,000 and $100 per infant in the Netherlands and Colombia respectively; and (in one-phase studies) were £24,000 and £1,489 per infant both belonging to the UK. Implementing pulse oximetry method concurrent with the clinical examination is more cost-effective. The reviewed studies had been conducted in high-income and upper middle-income countries; therefore, when the results are generalizing by policy makers in different health systems, a substantial precaution approach is needed.

Factors That Contribute to Cost Differences Based on ICU of Admission in Neonates Undergoing Congenital Heart Surgery: A Novel Decomposition Analysis

OBJECTIVES

We leveraged decomposition analysis, commonly used in labor economics, to understand determinants of cost differences related to location of admission in children undergoing neonatal congenital heart surgery.

DESIGN

A retrospective cohort study.

SETTING

Pediatric Health Information Systems database.

PATIENTS

Neonates (<30 d old) undergoing their index congenital heart surgery between 2004 and 2013.

MEASUREMENTS AND MAIN RESULTS

A decomposition analysis with bootstrapping determined characteristic (explainable by differing covariate levels) and structural effects (if covariates are held constant) related to cost differences. Covariates included center volume, age at admission, prematurity, sex, race, genetic or major noncardiac abnormality, Risk Adjustment for Congenital Heart Surgery-1 score, payor, admission year, cardiac arrest, infection, and delayed sternal closure.Of 19,984 infants included (10,491 [52%] to cardiac ICU/PICU and 9,493 [48%] to neonatal ICU), admission to the neonatal ICU had overall higher average costs ($24,959 ± $3,260; p < 0.001) versus cardiac ICU/PICU admission. Characteristic effects accounted for higher costs in the neonatal ICU ($28,958 ± $2,044; p < 0.001). Differing levels of prematurity, genetic syndromes, hospital volume, age at admission, and infection contributed to higher neonatal ICU costs, with infection rate providing the most significant contribution ($13,581; p < 0.001). Aggregate structural effects were not associated with cost differences for those admitted to the neonatal ICU versus cardiac ICU/PICU (p = 0.1). Individually, prematurity and age at admission were associated with higher costs due to structural effects for infants admitted to the neonatal ICU versus cardiac ICU/PICU.

CONCLUSIONS

The difference in cost between neonatal ICU and cardiac ICU/PICU admissions is largely driven by differing prevalence of risk factors between these units. Infection rate was a modifiable factor that accounted for the largest difference in costs between admitting units.

Pediatric Cardiac Intensive Care Distribution, Service Delivery, and Staffing in the United States in 2018

OBJECTIVES

To assess the distribution, service delivery, and staffing of pediatric cardiac intensive care in the United States.

DESIGN

Based on a 2016 national PICU survey, and verified through online searching and clinician networking, medical centers were identified with a separate cardiac ICU or mixed ICU. These centers were sent a structured web-based survey up to four times, with follow-up by mail and phone for nonresponders.

SETTING

Cardiac ICUs were defined as specialized units, specifically for the treatment of children with life-threatening primary cardiac conditions. Mixed ICUs were defined as separate units, specifically for the treatment of children with life-threatening conditions, including primary cardiac disease.

PARTICIPANTS

Cardiac ICU or mixed ICU physician medical directors or designees.

MEASUREMENTS AND MAIN RESULTS

One-hundred twenty ICUs were identified: 61 (51%) were mixed ICUs and 59 (49%) were cardiac ICUs. Seventy five percent of institutions at least sometimes used a neonatal ICU prior to surgery. The most common temporary cardiac support beyond extracorporeal membrane oxygenation was a centrifugal pump such as Centrimag. Durable cardiac support devices were far more common in separate cardiac ICUs (84% vs 20%; p < 0.0001). Significantly less availability of electrophysiology, heart failure, and cardiac anesthesia consultation was available in mixed ICUs (p = 0.0003, p < 0.0001, p = 0.042 respectively). ICU attending physicians were in-house day and night 98% of the time in mixed ICUs and 87% of the time in cardiac ICUs. Nurse practitioners were consistent front-line providers in the ICUs caring for children with primary cardiac disease staffing 88% of cardiac ICUs and 56% of mixed ICUs. Mixed ICUs were more commonly staffed with pediatric residents, and critical care fellows were found in more cardiac ICUs (83% vs 77%; p < 0.0001).

CONCLUSIONS

Mixed ICUs and cardiac ICUs have statistically different staffing models and available services. More evaluation is needed to understand how this may impact patient outcomes and training programs of physicians and nurses.

Factors affecting adolescents' participation in randomized controlled trials evaluating the effectiveness of healthcare interventions: the case of the STEPSTONES project

Background

Recruitment of adolescents to intervention studies is a known challenge. For randomized controlled trials (RCT) to be generalizable, reach must be assessed, which means ascertaining how many of the intended population actually participated in the trial. The aim of this study was to evaluate the reach and representativeness of an RCT evaluating the effectiveness of a complex intervention for adolescents with chronic conditions.

Methods

A mixed methods sequential explanatory design was employed. Firstly, quantitative cross-sectional data from the RCT, patient registries and medical records were collected and analysed regarding baseline differences between participants and non-participants in the trial. Secondly, qualitative data on their reasons for participating or not were collected and analysed with content analysis to explain the quantitative findings.

Results

Participants showed larger differences in effect sizes and a significantly more complex chronic condition than non-participants. No other statistically significant differences were reported, and effect sizes were negligible. Reasons for declining or accepting participation were categorized into three main categories: altruistic reasons, personal reasons and external reasons and factors.

Conclusions

Integration of quantitative and qualitative findings showed that participation in the RCT was affected by disease complexity, the perceived need to give back to healthcare and research and the adolescents’ willingness to engage in their illness. To empower adolescents with chronic conditions and motivate them to participate in research, future intervention studies should consider developing tailored recruitment strategies and communications with sub-groups that are harder to reach.

Resource Utilization in the First 2 Years Following Operative Correction for Tetralogy of Fallot: Study Using Data From the Optum's De-Identified Clinformatics Data Mart Insurance Claims Database

Background

Despite excellent operative survival, correction of tetralogy of Fallot frequently is accompanied by residual lesions that may affect health beyond the incident hospitalization. Measuring resource utilization, specifically cost and length of stay, provides an integrated measure of morbidity not appreciable in traditional outcomes.

Methods and Results

We conducted a retrospective cohort study, using de‐identified commercial insurance claims data, of 269 children who underwent operative correction of tetralogy of Fallot from January 2004 to September 2015 with ≥2 years of continuous follow‐up (1) to describe resource utilization for the incident hospitalization and subsequent 2 years, (2) to determine whether prolonged length of stay (>7 days) in the incident hospitalization was associated with increased subsequent resource utilization, and (3) to explore whether there was regional variation in resource utilization with both direct comparisons and multivariable models adjusting for known covariates. Subjects with prolonged incident hospitalization length of stay demonstrated greater resource utilization (total cost as well as counts of outpatient visits, hospitalizations, and catheterizations) after hospital discharge (P<0.0001 for each), though the number of subsequent operative and transcatheter interventions were not significantly different. Regional differences were observed in the cost of incident hospitalization as well as subsequent hospitalizations, outpatient visits, and the costs associated with each.

Conclusions

This study is the first to report short‐ and medium‐term resource utilization following tetralogy of Fallot operative correction. It also demonstrates that prolonged length of stay in the initial hospitalization is associated with increased subsequent resource utilization. This should motivate research to determine whether these differences are because of modifiable factors.

First-Trimester Maternal Folic Acid Supplementation Reduced Risks of Severe and Most Congenital Heart Diseases in Offspring: A Large Case-Control Study

Background Maternal folic acid supplementation (FAS) reduces the risk of neural tube defects in offspring. However, its effect on congenital heart disease (CHDs), especially on the severe ones remains uncertain. This study aimed to assess the individual and joint effect of first-trimester maternal FAS and multivitamin use on CHDs in offspring. Methods and Results This is a case-control study including 8379 confirmed CHD cases and 6918 controls from 40 healthcare centers of 21 cities in Guangdong Province, China. Adjusted odds ratios (aORs) of FAS and multivitamin use between CHD cases (overall and specific CHD phenotypes) and controls were calculated by controlling for parental confounders. The multiplicative interaction effect of FAS and multivitamin use on CHDs was estimated. A significantly protective association was detected between first-trimester maternal FAS and CHDs among offspring (aOR, 0.69; 95% CI, 0.62-0.76), but not for multivitamin use alone (aOR, 1.42; 95% CI, 0.73-2.78). There was no interaction between FAS and multivitamin use on CHDs (P=0.292). Most CHD phenotypes benefited from FAS (aORs ranged from 0.03-0.85), especially the most severe categories (ie, multiple critical CHDs [aOR, 0.16; 95% CI, 0.12-0.22]) and phenotypes (ie, single ventricle [aOR, 0.03; 95% CI, 0.004-0.21]). Conclusions First-trimester maternal FAS, but not multivitamin use, was substantially associated with lower risk of CHDs, and the association was strongest for the most severe CHD phenotypes. We recommend that women of childbearing age should supplement with folic acid as early as possible, ensuring coverage of the critical window for fetal heart development to prevent CHDs.

Gene-by-gene interactions associated with the risk of conotruncal heart defects

BACKGROUND

The development of conotruncal heart defects (CTDs) involves a complex relationship among genetic variants and maternal lifestyle factors. In this article, we focused on the interactions between 13 candidate genes within folate, homocysteine, and transsulfuration pathways for potential association with CTD risk.

METHODS

Targeted sequencing was used for 328 case-parental triads enrolled in the National Birth Defects Prevention Study (NBDPS). To evaluate the interaction of two genes, we applied a conditional logistic regression model for all possible SNP pairs within two respective genes by contrasting the affected infants with their pseudo-controls. The findings were replicated in an independent sample of 86 NBDPS case-parental triads genotyped by DNA microarrays. The results of two studies were further integrated by a fixed-effect meta-analysis.

RESULTS

One SNP pair (i.e., rs4764267 and rs6556883) located in gene MGST1 and GLRX, respectively, was found to be associated with CTD risk after multiple testing adjustment using simpleM, a modified Bonferroni correction approach (nominal p-value of 4.62e-06; adjusted p-value of .04). Another SNP pair (i.e., rs11892646 and rs56219526) located in gene DNMT3A and MTRR, respectively, achieved marginal significance after multiple testing adjustment (adjusted p-value of .06).

CONCLUSION

Further studies with larger sample sizes are needed to confirm and elucidate these potential interactions.

Hospital-Acquired Pressure Injuries in Children With Congenital Heart Disease: Prevalence and Associated Factors

OBJECTIVES

To explore the prevalence, location, and clinical factors associated with hospital-acquired pressure injuries among pediatric patients with congenital heart disease.

DESIGN

Secondary analysis of data from a multicenter prospective cohort study of pediatric pressure injury risk, including patients with congenital heart disease.

SETTING

Eight acute care academic pediatric hospitals.

PATIENTS

Patients were preterm to 21 years old with congenital heart disease and on bed rest for at least 24 hours after hospital admission with a medical device attached to or traversing the skin or mucous membrane.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were evaluated for a maximum of eight observations during a 4-week period to identify Braden QD risk and pressure injury development. Hospital-acquired pressure injuries were staged according to the National Pressure Ulcer Advisory Panel guidelines. Stepwise logistic regression was used to explore risk factors associated with hospital-acquired pressure injuries development, accounting for site as a cluster variable using generalized estimating equations. Overall, 279 pediatric cardiac patients provided 919 observations (median, 2 per patient [interquartile range, 2-5 per patient]). Thirty-eight hospital-acquired pressure injuries occurred in 27 patients (9.7%). Most injuries (28/38 [74%]) were related to medical devices. The most common medical devices that caused injury were oxygen saturation probes. The remaining hospital-acquired pressure injuries were immobility-related pressure injuries (10/38 [26%]) located primarily on the buttock, sacrum, or coccyx (5/10 [50%]). In multivariable analyses, being non-Hispanic white (odds ratio, 3.54; 95% CI, 2.15-5.84), experiencing operating room time greater than 4 hours (odds ratio, 2.91; 95% CI, 1.13-7.49), having oxygen saturation levels less than 85% (odds ratio, 2.65; 95% CI, 1.01-6.96), and having worse Braden QD scores (odds ratio, 1.25 per 1 point increase; 95% CI, 1.17-1.34) were significantly associated with hospital-acquired pressure injuries development.

CONCLUSIONS

In this multicenter observational study of pediatric patients with congenital heart disease, we describe a hospital-acquired pressure injury prevalence of 9.7% with approximately 75% of injuries related to medical devices. These data can be used to inform practice and target interventions to decrease pressure injury risk and prevent pressure injuries in this vulnerable pediatric population.

3D bioprinting of vascular conduits for pediatric congenital heart repairs

In children with congenital heart defects, surgical correction often involves the use of valves, patches or vascular conduits to establish anatomic continuity. Due to the differences between the pediatric and adult populations, tissue reconstruction in pediatric patients requires a substantially different approach from those in adults. Cardiovascular anatomy of children with congenital heart defect vary, which requires tailored surgical operations for each patient. Since grafts used in these palliative surgeries are sensitive to the local hemodynamic environments, their geometries need to be precisely designed to ensure long-term performance. Tissue engineered vascular grafts (TEVGs) have made tremendous progress over the past decade, but it remains difficult to fabricate patient- and operation-specific vascular grafts. This review summarizes historical milestones of TEVG development for repairing pediatric congenital defects and current clinical outcomes. We also highlight ongoing works on 3D bioprinting of TEVGs with complex geometries and address the current limitations of each technique. Although 3D bioprinted vascular grafts with appropriate functions are yet to be developed, some of the current researches are promising to create better patient specific tissue engineered vascular grafts in the future.

Congenital Heart Disease in East Africa

Congenital Heart Disease (CHD) is an enormous problem in Low Middle Income Countries and particularly in sub-Saharan Africa. There is an estimated 500,000 children born in Africa with CHD each year with a major proportion of this in sub-Saharan Africa. The vast majority of these children receive sub-optimal or no care at all. In East Africa: Kenya, Tanzania, and Uganda have all attempted to create a CHD service for the last 20 years with minimal success due to various factors. Visiting cardiac missions have made considerable contributions in the development of CHD services in these countries, however there remains a significant number of children with lack of care. We explore the positive aspects of the current projects, the various factors that hinder growth in this area, and what can be done to promote CHD service growth in these countries.

Analysis of the Seasonal Trend of Congenital Heart Defects

OBJECTIVE

To determine the seasonal trend of congenital heart defects (CHDs) in China using hospital-based clinical data.

STUDY DESIGN

We included 40 501 patients with CHD hospitalized at the Shanghai Children Medical Center between 2006 and 2017. The birth rate of CHD in each month was adjusted by sex, year of birth, and monthly birth rate of the general population. Negative binomial regression models were used to assess the seasonal trend of CHD.

RESULTS

The included patients consisted of 22 600 boys (55.8%), resulting in a male-to-female ratio of 1.26:1. Among subtypes of CHDs, ventricular septal defects and atrial septal defects were the most common, accounting for 39.7% and 12.6%, respectively. A statistically significant seasonal trend in the monthly birth rate of patients with CHDs was found; the highest relative rate of CHD was found in October and the lowest in April. After adjusting for the potential confounders, the highest relative rate of CHD was found in October and the lowest in November.

CONCLUSIONS

There seems to be a significant monthly birth rate variation of CHDs in China. The highest relative rate of CHDs occurred in October, suggesting possible maternal exposure to environmental hazards from January to March. These hazards may include air pollution, virus infection, and unhealthy lifestyle behaviors during the Spring Festival.

The Evolution of Tissue Engineered Vascular Graft Technologies: From Preclinical Trials to Advancing Patient Care

Currently available synthetic grafts have contributed to improved outcomes in cardiovascular surgery. However, the implementation of these graft materials at small diameters have demonstrated poor patency, inhibiting their use for coronary artery bypass surgery in adults. Additionally, when applied to a pediatric patient population, they are handicapped by their lack of growth ability. Tissue engineered alternatives could possibly address these limitations by producing biocompatible implants with the ability to repair, remodel, grow, and regenerate. A tissue engineered vascular graft (TEVG) generally consists of a scaffold, seeded cells, and the appropriate environmental cues (i.e., growth factors, physical stimulation) to induce tissue formation. This review critically appraises current state-of-the-art techniques for vascular graft production. We additionally examine current graft shortcomings and future prospects, as they relate to cardiovascular surgery, from two major clinical trials.

Direct Medical Costs of Pediatric Congenital Heart Disease Surgery in a Belgian University Hospital

Objectives:

The recent trend to optimize the efficiency of health-care systems requires objective clinical and economic data. European data on the cost of surgical procedures to repair or palliate congenital heart disease in pediatric patients are lacking.

Methods:

A single-center study was conducted. Bootstrap analysis of variance and bootstrap independent t test assessed the excess direct medical costs associated with minor and major complications in nine surgical procedure types, from a health-care payer perspective. Generalized linear models with log-link function and inverse Gaussian family were used to determine associated covariates with the total hospitalization cost. Descriptive statistics show the repartition between out-of-pocket expenditures and reimbursed costs.

Results:

Four hundred thirty-seven patients were included. Mean hospitalization costs ranged from €11,106 (atrial septal defect repair) to €33,865 (Norwood operation). Operations with major complications yielded excess costs compared to operations with no complications, ranging from €7,105 (+65.2%) for a truncus arteriosus repair to €27,438 (+251.7%) for a tetralogy of Fallot repair. Differences in costs were limited between operations with minor versus no complications. Age at procedure, intensive care unit stay, procedure risk category, reintervention, and postoperative mechanical circulatory support were associated with higher total hospitalization costs. Out-of-pocket expenditures represented 6% of total hospitalization costs.

Conclusion:

Operations with major complications yield excess costs, compared to operations with minor or no complications. Cost data and attribution are important to improve clinical practice in a cost-effective manner. The health-care system benefits from strategies and technological advancements that have an impact on modifiable cost-affecting parameters.

Early Childhood Inpatient Costs of Critical Congenital Heart Disease

OBJECTIVE

To assess longitudinal estimates of inpatient costs through early childhood in patients with critical congenital heart defects (CCHDs), for whom reliable estimates are scarce, using a population-based cohort of clinically validated CCHD cases.

STUDY DESIGN

Longitudinal retrospective cohort of infants with CCHDs live born from 1997 to 2012 in Utah. Cases identified from birth defect registry data were linked to inpatient discharge abstracts and vital records to track inpatient days and costs through age 10 years. Costs were adjusted for inflation and discounted by 3% per year to generate present value estimates. Multivariable models identified infant and maternal factors potentially associated with higher resource utilization and were used to calculate adjusted costs by defect type.

RESULTS

The final statewide cohort included 1439 CCHD cases among 803 509 livebirths (1.8/1000). The average cost per affected child through age 10 years was $136 682 with a median of $74 924 because of a small number of extremely high cost children; costs were highest for pulmonary atresia with ventricular septal defect and hypoplastic left heart syndrome. Inpatient costs increased by 1.6% per year during the study period. A single birth year cohort (~50 000 births/year) had estimated expenditures of $11 902 899 through age 10 years. Extrapolating to the US population, inpatient costs for a single birth year cohort through age 10 years were ~$1 billion.

CONCLUSIONS

Inpatient costs for CCHDs throughout childhood are high and rising. These revised estimates will contribute to comparative effectiveness research aimed at improving the value of care on a patient and population level.

Newborn blood DNA epigenetic variations and signaling pathway genes associated with Tetralogy of Fallot (TOF)

Tetralogy of Fallot (TOF) is the most common Critical Congenital Heart Defect (CCHD). The etiology of TOF is unknown in most cases. Preliminary data from our group and others suggest that epigenetic changes may play an important role in CHD. Epidemiologically, a significant percentage of CHD including TOF fail to be diagnosed in the prenatal and early newborn period which can negatively affect health outcomes. We performed genome-wide methylation assay in newborn blood in 24 non-syndromic TOF cases and 24 unaffected matched controls using Illumina Infinium HumanMethylation450 BeadChips. We identified 64 significantly differentially methylated CpG sites in TOF cases, of which 25 CpG sites had high predictive accuracy for TOF, based on the area under the receiver operating characteristics curve (AUC ROC) ≥ 0.90). The CpG methylation difference between TOF and controls was ≥10% in 51 CpG targets suggesting biological significance. Gene ontology analysis identified significant biological processes and functions related to these differentially methylated genes, including: CHD development, cardiomyopathy, diabetes, immunological, inflammation and other plausible pathways in CHD development. Multiple genes known or plausibly linked to heart development and post-natal heart disease were found to be differentially methylated in the blood DNA of newborns with TOF including: ABCB1, PPP2R5C, TLR1, SELL, SCN3A, CREM, RUNX and LHX9. We generated novel and highly accurate putative molecular markers for TOF detection using leucocyte DNA and thus provided information on pathogenesis of TOF.