Congenital cardiac disease in the newborn infant: past, present, and future

Short-Term Surgical Outcomes and Definitive Diagnosis in Patients With Congenital Cardiac Defects: A Single-Center Analysis

Background With the rising number of children with congenital heart disease (CHD) reaching adulthood, surgical intervention has become a critical aspect of their long-term management. This study presents a six-year overview of early postoperative outcomes and mortality in CHD surgeries at a single center, underscoring advancements and challenges in treating this complex population. Objective As more children with CHD grow into adulthood, we are gaining critical insights from our extensive experience in performing cardiac surgery for this population. This report details our six-year experience at a single center, highlighting short-term outcomes and in-hospital mortality rates. Methods We collected data on all consecutive patients with CHD who underwent surgery between July 2018 and September 2024 in the Cardiac Surgery Department at Hayatabad Medical Complex, Peshawar, Pakistan. We evaluated early outcomes, including ventilation duration, length of intensive care unit (ICU) stay, total hospital stay, and mortality rates. Results A total of 250 procedures were performed on patients, with a mean age of 22.98 years (Range 1-78 years); 48.4% were male and 51.6% were female. Re-do procedures accounted for 2.4% of the total procedures. The most common procedures involved repair of septal defects (43.8%), right heart lesions (19.2%), and thoracic arterial and venous surgeries (16.8%). While the primary procedures involved less complex cases, they included 15.2% tetralogy of Fallot repairs, 4.0% aortic coarctation repairs, and 1.2% repairs for Ebstein's disease. In-hospital mortality was recorded at 1.6%, with an overall survival rate of 98.4%. Conclusion Surgery in patients with CHD can be performed with low operative mortality and favorable clinical outcomes. Our findings demonstrate that, despite the complexities inherent to this population, most procedures yield successful results, contributing to a high overall survival rate. This underscores the importance of specialized surgical approaches and continuous management for CHD patients, emphasizing the potential for positive long-term outcomes in this growing demographic.

A Comparison for Infantile Mortality of Crucial Congenital Heart Defects in Korea over a Five-Year Period

Background: Nearly half of congenital heart defects (CHDs) related to mortality occur during infancy although advancements in treatments have increased the survival rates. This study comprehensively examined overall and surgical mortality in CHD infants with the highest mortality rates in an effort to improve our understanding of CHD epidemiology. Methods: Participants were drawn from a dataset of 1,964,691 infants born between 2014 and 2018 in Korea. Crucial CHDs are defined here as including diverse categorical defects and classical critical CHDs but excluding simple shunt defects. Overall mortality (procedural and natural mortality) and procedural mortality (interventional and surgical mortality) for infants were analyzed. Results: The performance rate for multiple procedures in infants with crucial CHDs was 16%. The overall and surgical mortalities of crucial CHDs were 8% and 7%. The mortalities of palliative procedures were relatively high. Procedural mortalities for infants were significantly decreased in the tetralogy of Fallot (TOF), atrioventricular septal defects, and total anomalous pulmonary venous return (TAPVR) compared with overall mortalities for infants. Surgical mortalities for infants involving TOF and TAPVR were significantly lower, but those for infants involving hypoplastic left heart syndrome (HLHS) were higher than those for all ages. Conclusions: Palliative procedural techniques in infants must be improved to obtain better outcomes, particularly in the palliative surgery of HLHS. The infantile procedural outcomes for TOF and TAPVR are excellent and important in order to overcome disastrous circumstances during infancy. This comprehensive study of the overall and procedural mortalities of CHDs may have laid a cornerstone for CHD epidemiology in Korean infants.

Discovery of a novel mutation F184S (c.551T>C) in GATA4 gene causing congenital heart disease in a consanguineous Saudi family

Background & aim

Congenital heart disease (CHD) is the most common cause of non-infectious deaths in infants worldwide. However, the molecular mechanisms underlying CHD remain unclear. Approximately 30 % of the causes are believed to be genetic mutations and chromosomal abnormalities. In this study, we aimed to identify the genetic causes of CHD in consanguineous families.

Methods

Fourth-generation pedigrees with CHD were recruited. The main cardiac features of the patient included absence of the right pulmonary artery and a large dilated left pulmonary artery. To determine the underlying genetic cause, whole-exome sequencing was performed and subsequently confirmed using Sanger sequencing and different online databases to study the pathogenesis of the identified gene mutation. An in-silico homology model was created using the Alphafold homology model structure of GATA4 (AF-P43694-F1). The missense3D online program was used to evaluate the structural alterations.

Results

We identified a deleterious mutation c.551T > C (p.Phe184Ser) in GATA4. GATA4 is a highly conserved zinc-finger transcription factor, and its continuous expression is essential for cardiogenesis during embryogenesis. The in-silico model suggested a compromised binding efficiency with other proteins. Several variant interpretation algorithms indicated that the F184S missense variant in GATA4 is damaging, whereas HOPE analysis indicated the functional impairment of DNA binding of transcription factors and zinc-ion binding activities of GATA4.

Conclusion

The variant identified in GATA4 appears to cause recessive CHD in the family. In silico analysis suggested that this variant was damaging and caused multiple structural and functional aberrations. This study may support prenatal screening of the fetus in this family to prevent diseases in new generations.

Identifying novel data-driven subgroups in congenital heart disease using multi-modal measures of brain structure

Individuals with congenital heart disease (CHD) have an increased risk of neurodevelopmental impairments. Given the hypothesized complexity linking genomics, atypical brain structure, cardiac diagnoses and their management, and neurodevelopmental outcomes, unsupervised methods may provide unique insight into neurodevelopmental variability in CHD. Using data from the Pediatric Cardiac Genomics Consortium Brain and Genes study, we identified data-driven subgroups of individuals with CHD from measures of brain structure. Using structural magnetic resonance imaging (MRI; N = 93; cortical thickness, cortical volume, and subcortical volume), we identified subgroups that differed primarily on cardiac anatomic lesion and language ability. In contrast, using diffusion MRI (N = 88; white matter connectivity strength), we identified subgroups that were characterized by differences in associations with rare genetic variants and visual-motor function. This work provides insight into the differential impacts of cardiac lesions and genomic variation on brain growth and architecture in patients with CHD, with potentially distinct effects on neurodevelopmental outcomes.

Green Synthesis of Silver Nanoparticles using Coriandrum sativum and Murraya koenigii Leaf Extract and its Thrombolytic Activity

BACKGROUND

Plants have been used for ages in traditional medicine, and it is exciting to perceive how recent research has recognized the bioactive compounds liable for their beneficial effects. Green synthesis of metal nanoparticles is a hastily emergent research area in nanotechnology. This study describes the synthesis of silver nanoparticles (AgNPs) using Coriandrum sativum and Murraya koenigii leaf extract and its thrombolytic activity.

OBJECTIVE

The aim of the study was to determine the clot lysis activity of Coriandrum sativum and Murraya koenigii synthesized silver nanoparticles.

METHODS

Leaves of Coriandrum sativum and Murraya koenigii were collected. Methanolic extraction of the plant sample was done through a Soxhlet extractor. The methanolic extract obtained from both the leaves was subjected to GC-MS analysis. The synthesized NPs from leaf extracts were monitored for analysis, where the typical X-ray diffraction pattern and its diffraction peaks were identified. 3D image of the NPs was analysed by Atomic Force Microscopy. The surface charge of nanoparticles was identified by Zeta potential. The Clot lysis activity of Coriandrum sativum and Murraya koenigii synthesized silver nanoparticles were analysed by the modified Holmstorm method.

RESULTS

The thrombolytic property of the methanolic extract of plants Coriandrum sativum showed clot lysis activity at 2.5 mg/mL with 45.99% activity, and Murraya koenigii extract with 66.56% activity. The nanoparticles (Nps) from Coriandrum sativum showed clot lysis activity at 2.5 mg/mL with 58.29% activity, and NPs from Murraya koenigii with 54.04% activity. Coriandrum sativum in GC-MS exhibited 3 peaks, whereas Murraya koenigii extract showed five peaks with notable bioactive compounds.

CONCLUSION

These NPs were further used for biomedical applications after being fixed by an organic encapsulation agent. The present research reveals the usefulness of Coriandrum sativum and Murraya koenigii for the environmentally friendly manufacture of silver nanoparticles.

Neurodevelopment outcomes in the first 5 years of the life of children with transposition of the great arteries surgically corrected in the neonatal period: systematic review and meta-analysis

OBJECTIVES

In patients with transposition of the great arteries, surgical correction may achieve definitive treatment, so a thorough knowledge of the long-term outcomes, particularly neurodevelopment outcomes, is essential. Therefore, we conducted a systematic review and meta-analysis to study the neurodevelopment outcomes in the first 5 years of the life of children submitted to corrective surgery for transposition of the great arteries in the neonatal period.

METHODS

A total of 17 studies from 18 reports were included, assessing 809 individuals with surgically corrected transposition of the great arteries. The neurodevelopmental outcomes were assessed with the Bayley Scales of Infant and Toddler Development (BSID) and the Wechsler Intelligence Scale for Children (WISC).

RESULTS

Mean Mental Development Index (MDI) and Psychomotor Development Index (PDI) were within the average values from 1 to 3 years of age, although the proportion of children scoring more than 1 standard deviation below the mean in PDI, MDI, motor, and language composite scores was significantly higher than in the general population. From 4 to 5 years, mean full-scale global intelligence quotient (IQ), verbal IQ, and performance IQ scores did not differ significantly from the general population.

CONCLUSION

This study revealed neurodevelopment scores within the normal range at 5 years of age in children submitted to corrective surgery for transposition of the great arteries in the neonatal period. However, these early outcomes may not adequately predict long-term outcomes. Further studies are needed to identify specific risk factors and early markers of later impairment to guide the establishment of early interventions.

Population-based prevalence and trend of birth defects in Costa Rica from 2000 to 2019

BACKGROUND

We aimed to analyze the prevalence and trend of birth defects (BDs) in Costa Rica, where BDs are the second leading cause of infant and under-five mortality.

METHODS

A descriptive analysis of selected BDs prevalence and trends from 2000 to 2019 was performed, based on data from the Costa Rican Birth Defects Register Center, the national BDs surveillance system with coverage of 98% of live births in the country. We used Joinpoint regression to identify any calendar year where a significant change in trend occurred; the annual percent change (APC) and the average annual percent change (AAPC) were determined. Marginal means and prevalence ratios by subperiod (2000-2009 as referent and 2010-2019) were estimated using Poisson regression, and compared using Wald's chi-square tests (alpha ≤0.05).

RESULTS

From 2000 to 2019, BDs occurred in 2.3% of live births (95% CI: 2.3-2.4); 73% of which were major BDs. Males presented a significantly higher prevalence (sex ratio 1.13 males/females). The trend showed an AAPC of +3.7 (p < .05) with two joinpoints, 2005 and 2013. A significant APC (+11.3) was observed during 2005-2013, within the context of improvements in the surveillance system, such as the increase in the reporting age, and the incorporation of other data sources in addition to maternity hospitals. Most of the BDs groups presented a significant upward trend. The highest AAPC was observed for the respiratory system (+11.7), congenital heart defects (+9.5), and nervous system (+8.5).

CONCLUSIONS

The BDs present a clear upward trend in the last two decades due, among other things, to a significant improvement in the surveillance system.

Congenital hypothyroidism and thyroid function in a Japanese birth cohort: data from The Japan Environment and Children's Study

The most common hormonal and metabolic disease in early childhood is congenital hypothyroidism (CH). This study aimed to describe CH in large-scale birth cohort data and summarize the results of serum thyroid-stimulating hormone (TSH) and free thyroxine (fT4) levels in 2-yr-old children. Data were obtained from the Japan Environment and Children's Study (JECS), and we identified 171 children with CH detected in newborn screenings or medical records (170.5 per 100,000 population). Infants with CH are at higher risk of developing congenital diseases than those without CH. Of 171 children with CH, 20 (11.7%) were diagnosed with congenital heart defects, 33 (19.3%) had chromosomal or other congenital abnormalities, and 23 (13.5%) had Down syndrome. At the age of 2 yr old, the median and 95% reference range values for TSH and fT4 were 2.13 (0.78-5.52) μIU/mL and 1.2 (1.0-1.5) ng/dL, respectively. Moreover, boys had slightly higher TSH and fT4 levels than did girls. Data on the distribution of TSH and fT4 in 2-yr-old children should be useful for decreasing the misclassification of thyroid disorders in the pediatric population. Trial-off treatment and re-evaluation of thyroid function are needed to classify permanent congenital hypothyroidism and transient congenital hypothyroidism after 3 yr of age.

Heart Disease Screening and False Hypoxemia in the Neonate

BACKGROUND

Screening for congenital heart diseases by pulse oximetry is used for the initial assessment of the neonate. Variants of hemoglobin F can compromise light absorbance, inducing erroneous results.

CASE REPORT

Two infants screened for congenital heart disease showed an asymptomatic low peripheral oxygen saturation. Arterial blood gases analysis revealed a normal arterial pressure of oxygen and oxygen saturation. More likely and/or severe causes of hypoxemia were ruled out. This "artifact" with SpO2-SaO2 dissociation, and after exclusion of other common etiologies of hypoxemia, raised the clinical suspicion of hemoglobinopathy. Hemoglobin molecular and genetic studies identified specific mutations in gamma chains from hemoglobin F, named hemoglobin F Sardinia.

CONCLUSION

Hemoglobin F variants may result in low peripheral oxygen saturation readings by pulse oximetry, explaining the discordance in the clinical appearance and low peripheral oxygen saturation readings.

Epidemiological characteristics and trends in postoperative death in children with congenital heart disease (CHD): a single-center retrospective study from 2005 to 2020

OBJECTIVES

To analyze the epidemiological characteristics and trends in death after thoracotomy in children with congenital heart disease (CHD).

METHODS

The clinical data of children with CHD aged 0-14 years who died after thoracotomy in our hospital from January 1, 2005, to December 31, 2020, were retrospectively collected to analyze the characteristics of and trends in postoperative death.

RESULTS

A total of 502 patients (365 males; 72.7%) died from January 1, 2005, to December 31, 2020, with an average of 31 deaths per year. For these patients, the median age was 2.0 months, the median length of hospital stay was 16.0 days, the median postoperative time to death was 5.0 days, and the median risk adjustment in congenital heart surgery-1 (RACHS-1) score was 3.0. 29.5% underwent emergency surgery, 16.9% had postoperative ECMO support, and 15.9% received postoperative blood purification treatment. In the past 16 years, the deaths of children with CHD under 1 year old accounted for 80.5% of all deaths among children with CHD aged 0-14 years, and deaths (349 cases) under 6 kg accounted for 69.5% of all deaths. Age at death, weight, and disease type were characterized by annual changes.

CONCLUSIONS

The postoperative deaths of children with CHD mainly occurred in infants and toddlers who weighed less than 6.0 kg, and TGA and PA were the most lethal CHDs. The proportion of deaths has been increasing across the years among patients who are young, have a low body weight, and have complex cyanotic CHD.

Reduction of infant mortality from congenital heart defects in a middle-income country: Costa Rican experience

BACKGROUND

We aimed to analyze recent infant and neonatal mortality from congenital heart defects (CHD) in Costa Rica, a middle-income country where CHD mortality was above expectations.

METHODS

A descriptive analysis of infant and neonatal mortality rates from CHD (IMR-CHD and NMR-CHD) during 2000-2019 was performed, according to province, sex, specific CHD, and sub-period, using data from the National Institute of Statistics and Censuses. We used joinpoint regression to identify any calendar-year where a significant change in trend occurred; the average annual percent change (AAPC) was determined. Using Poisson regression, marginal means and mortality ratios (MR) for IMR-CHD and NMR-CHD by sub-period (2000-2006-referent-, 2007-2013, 2014-2019) were estimated and compared using Wald's chi-square tests (α ≤ .05).

RESULTS

During 2000-2019, CHD accounted for 12% of overall infant mortality. IMR-CHD and NMR-CHD decreased linearly over the study period (AAPC = -3.4; p < .01). IMR-CHD decreased by 41%, from 13.6 per 10,000 in 2000-2006 (13.4% of infant mortality) to 8.1 per 10,000 in 2014-2019 (10% of infant mortality) (MR = 0.59; 95% confidence intervals [CI] = 0.52-0.68). NMR-CHD decreased by 38%, from 7.9 per 10,000 in 2000-2006 (11.1% of neonatal mortality) to 4.9 per 10,000 in 2014-2019 (7.9% of infant mortality) (MR = 0.59; 95% CI = 0.52-0.68). Male presented significantly higher NMR-CHD. The main causes of mortality (2014-2019) were total anomalous pulmonary venous connections, hypoplastic left heart syndrome, and double inlet ventricle.

CONCLUSIONS

IMR-CHD, NMR-CHD, and their proportional contribution to mortality by all causes and by birth defects decreased significantly, demonstrating that all improvements implemented in the last decades have yielded favorable results.

Large scale application of pulse oximeter and auscultation in screening of neonatal congenital heart disease

Purpose

To conduct a retrospective evaluation of a large clinical implementation of combined pulse oximeter (POX) and cardiac auscultation as a fast-screening device for congenital heart disease (CHD).

Methods

Every newborn in a large maternity healthcare center received auscultation and POX screening within 24 hours after delivery. When an abnormal heart murmur or SpO₂ level was detected, an echocardiogram was ordered to confirm the diagnosis of CHD.

Results

From January 1, 2018 to December 31, 2019, there were 44,147 livebirths at the studied hospital where 498 suspected CHD were identified: 27 newborns by POX screening and 471 by cardiac auscultation. The diagnosis was further confirmed in 458 neonates through echocardiogram. This result put forth an overall diagnosis rate of 92.0%. Cardiac auscultation detected the majority of CHD cases 438 (95.6%) while POX only screened 20 (4.4%) cases. Interestingly, no CHD case was detected by both auscultation examination and POX screening. Auscultation detected most of the common types of CHD, but POX excelled in identifying rare and critical cases. POX screening alone had a very low accuracy of 74.07% in positive predict value (PPV). On the other hand, auscultation functioned well in terms of PPV and negative predict value (NPV) (92.99 and 99.95%, respectively), but the addition of POX improved the overall screening performance resulting in 100% NPV. We also validate the finding with the data 6 months after the study period.

Conclusion

Our study demonstrated that addition of pulse oximetry to routine cardiac auscultation could be used as an accurate and feasible screening for early screening of CHD in newborns in large-scale clinical practice.

Reliability and validity of the FFQ and feeding index for 7-to 24-month-old children after congenital heart disease surgery

Background

Congenital heart disease (CHD) is the most common congenital defect in neonates. Infants with CHD often have more nutritional difficulties, but currently, there is no unified Food Frequency Questionnaire (FFQ) for infants and young children aged 7–24 months in China. Therefore, we designed this study to assess the reliability and validity of the FFQ and feeding index for 7-to 24-month-old children after congenital heart disease surgery.

Methods

From July to October 2018, infants and young children aged 7–24 months after congenital heart disease surgery in Guangzhou were selected. Participants were categorized into two groups, in the first group (n = 95), the FFQ was completed twice at intervals of 7–10 days to assess reproducibility. In the second group (n = 98), participants accomplished both the FFQ and the 24-h diet records from 3 consecutive days to assess validity. The score of the Infant and Child Feeding Index (ICFI) and its qualified rate were caculated. Intraclass correlation coefficients (ICC) and Spearman correlation coefficient (SCC) were calculated for reliability and validity, respectively.

Results

The average intraclass correlation coefficients and spearman correlation coefficient of the FFQ were 0.536 and 0.318, all with statistical significance except the frequency of meat added. The ICFI of the first group was 8.61 (± 3.20), the qualified rate was 0.06% (6/95). The intraclass correlation coefficients of the ICFI ranged from 0.374 to 0.958; and the spearman correlation of the ICFI was -0.066 to -0.834.

Conclusions

The FFQ possesses satisfactory reliability and moderate validity. The reliability of the ICFI is acceptable, but the validity results are quite different, indicating that the questionnaire is limited in the evaluation of the ICFI.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03357-4.

Genetic mouse models of autism spectrum disorder present subtle heterogenous cardiac abnormalities

Autism spectrum disorder (ASD) and congenital heart disease (CHD) are linked on a functional and genetic level. Most work has investigated CHD‐related neurodevelopmental abnormalities. Cardiac abnormalities in ASD have been less studied. We investigated the prevalence of cardiac comorbidities relative to ASD genetic contributors. Using high frequency ultrasound imaging, we screened 9 ASD‐related genetic mouse models (Arid1b^(+/−), Chd8^(+/−), 16p11.2 (deletion), Sgsh^(+/−), Sgsh^(−/−), Shank3 Δexon 4–9^(+/−), Shank3 Δexon 4–9^(−/−), Fmr1^(−/−), Vps13b^(+/−)), and pooled wild‐type littermates (WTs). We measured heart rate (HR), aorta diameter (AoD), thickness and thickening of the left‐ventricular (LV) anterior and posterior walls, LV chamber diameter, fractional shortening, stroke volume and cardiac output, mitral inflow Peak E and A velocity ratio, ascending aorta velocity time integral (VTI). Mutant groups presented small‐scale alterations in cardiac structure and function compared to WTs (LV anterior wall thickness and thickening, chamber diameter and fractional shortening, HR). A greater number of significant differences was observed among mutant groups than between mutant groups and WTs. Mutant groups differed primarily in structural measures (LV chamber diameter and anterior wall thickness, HR, AoD). The mutant groups with most differences to WTs were 16p11.2 (deletion), Fmr1^(−/−), Arid1b^(+/−). The mutant groups with most differences from other mutant groups were 16p11.2 (deletion), Sgsh^(+/−), Fmr1^(−/−). Our results recapitulate the associated clinical findings. The characteristic ASD heterogeneity was recapitulated in the cardiac phenotype. The type of abnormal measures (morphological, functional) can highlight common underlying mechanisms. Clinically, knowledge of cardiac abnormalities in ASD can be essential as even non‐lethal abnormalities impact normal development.

Association of Birth Defects With Child Mortality Before Age 14 Years

IMPORTANCE

Causes of death in children with birth defects are poorly understood.

OBJECTIVE

To determine mortality rates by cause of death in children with and without birth defects.

DESIGN, SETTING, AND PARTICIPANTS

This longitudinal cohort study included a population-based sample of 1 037 688 children and was conducted in all hospitals in Quebec, Canada, with 7 700 596 person-years of follow-up between birth and age 14 years (April 1, 2006, to March 31, 2020).

EXPOSURES

Presence or absence of a birth defect.

MAIN OUTCOMES AND MEASURES

Outcomes were all-cause and cause-specific mortality. Hazard ratios (HRs) and 95% CIs were computed for the association between birth defects and mortality with Cox proportional hazards models adjusted for patient characteristics.

RESULTS

Among the 1 037 688 children in the cohort, 95 566 had birth defects (56.5% boys). There were 532 542 boys in the cohort (51.3%), and mean (SD) age at the end of follow-up was 7.42 (3.72) years. There were 918 deaths among children with defects, and the mean (SD) age was 0.93 (2.07) years at death; there were 1082 deaths among the 942 122 children without defects, and the mean (SD) age at death was 0.50 (1.51) years. Mortality rates were higher for children with birth defects compared with no defect (1.3 vs 0.2 deaths per 1000 person-years, respectively). Girls (HR, 5.66; 95% CI, 4.96-6.47) and boys (HR, 4.69; 95% CI, 4.15-5.29) with birth defects had an elevated risk of death before 14 years compared with unaffected children. Birth defects were associated with mortality from circulatory (HR, 26.59; 95% CI, 17.73-39.87), respiratory (HR, 23.03; 95% CI, 15.09-35.14), and digestive causes (HR, 31.77; 95% CI, 11.87-85.04), but anomalies were rarely listed as the cause of death. Compared with children with no defect, those with birth defects were at greatest risk of death between 28 and 364 days of life.

CONCLUSIONS AND RELEVANCE

This cohort study of 1 037 688 children suggests that birth defects were strongly associated with mortality owing to circulatory, respiratory, and digestive causes. This finding suggests that the contribution of birth defects may be underestimated in mortality statistics.

Hematological indices in pediatric patients with acyanotic congenital heart disease: a cross-sectional study of 248 patients

Background

Congenital heart disease CHD is a significant cause of mortality and morbidity in children worldwide. Patients with congenital heart disease may develop hematological problems, including thrombocytopenia and neutropenia. In addition, several studies indicate the higher frailty of patients with CHDs to infections and malignancies. Nevertheless, the mechanisms of immune system changes in these patients have remained in the shadow of uncertainty. Moreover, very few studies have worked on cytopenia in CHD. This study has assessed the frequency of thrombocytopenia, neutropenia, lymphopenia, and anemia in pediatric patients with acyanotic congenital heart disease ACHD prior to open-heart surgery.

Methods

This cross-sectional study was handled in the Pediatric Cardiology Clinic, Tehran University of Medical Sciences, during pre-operation visits from 2014 till 2019. Two hundred forty-eight children and adolescents with acyanotic congenital heart disease before open-heart surgery met the criteria to enter the study.

Results

A total of 191 (76.7%) patients with Ventricular Septal Defects (VSD), 37 (14.85%) patients with Atrial Septal Defects (ASD), and 20 (8.11%) patients with Patent Ductus Arteriosus (PDA) were enrolled in this study. The median age was 23.87 months. Thrombocytopenia and neutropenia were found, respectively, in 3 (1.2) and 23 (9.2%) patients. Hemoglobin level and lymphocyte count were significantly lower in patients with neutropenia than patients with normal neutrophil count (P value = 0.024 and P value = 0.000). Significant positive correlations were found between neutropenia and anemia. There were no correlations between neutrophil count and Platelets. Also, anemia was found in 48 patients (19.3%). The study also found a statistically significant correlation between the co-existence of VSD and neutropenia in the patients (P value = 0.000).

Conclusion

Although most were mildly neutropenic, there was a significant correlation between neutropenia and Ventricular Septal Defect compared to PDA and ASD groups. Regarding the importance of neutropenia to affect the prognosis of congenital heart defects in infections, it is important to consider further studies on the status of immune system function in these patients.

Characteristics of in-hospital mortality of congenital heart disease (CHD) after surgical treatment in children from 2005 to 2017: a single-center experience

Background

To evaluate trends in the in-hospital mortality rate for pediatric cardiac surgery procedures between 2005 and 2017 in our center, and to discuss the mortality characteristics of children’s CHD after thoracotomy.

Methods

This retrospective data were collected from medical records of children underwent CHD surgery between 2005 and 2017.

Results

A total of 19,114 children with CHD underwent surgery and 444 children died, with the in-hospital mortality was 2.3%. Complex mixed defect CHD had the highest fatality rate (8.63%), left obstructive lesion CHD had the second highest fatality rate (4.49%), right to left shunt CHD had the third highest mortality rate (3.51%), left to right shunt CHD had the lowest mortality rate (χ2 = 520.3,P < 0.05). The neonatal period has the highest mortality rate (12.17%), followed by infant mortality (2.58%), toddler age mortality (1.16%), and preschool age mortality (0.94%), the school age and adolescent mortality rate was the lowest (χ2 = 529.3,P < 0.05). In addition, the fatality rate in boys was significantly higher than that in girls (2.77% versus 1.62%, χ2 = 26.4, P < 0.05).

Conclusions

The mortality rate of CHD surgery in children decreased year by year. The younger the age and the more complicated the cyanotic heart disease, the higher the mortality rate may be.

MiR-23b targets GATA6 to down-regulate IGF-1 and promote the development of congenital heart disease

BACKGROUND

Congenital heart disease (CHD) is the most universal congenital defect disease. This study explores the interrelationship between miR-23b and GTAT6 in the development of CHD.

METHODS

We collected clinical samples and constructed in vitro cell models to evaluate the expression of miR-23b, GATA6, and IGF-1. CHD cell models were constructed by hypoxia in H9C2 cells. The expression levels of GATA6 and IGF-1 in H9C2 cells were determined by western blot and qPCR. MiR-23b was knocked down by transfection miR-23b inhibitor. GATA6 knockdown or overexpression vectors were established by the lentiviral approach and cell transfection, respectively. According to the CCK-8 assay and flow cytometry analysis, the proliferation and apoptosis of H9C2 cells were detected. The binding relationship between GATA6 and miR-23b was detected by luciferase reporter assay.

RESULTS

The expression level of miR-23b was escalated abnormally, while the expression levels of GATA6 and IGF-1 were decreased in the serum of CHD clinical patients and cell models. miR-23b knockdown in H9C2 cells could up-regulate the expression of GATA6, thus improved the proliferation and decreased apoptosis of H9C2 cells. Overexpression of GATA6 could up-regulate IGF-1 to promote proliferation and inhibit apoptosis in H9C2 cells. MiR-23b could target GATA6 and regulated IGF-1, thus affecting cell proliferation and apoptosis.

CONCLUSION

The expression level of miR-23b was remarkably up-regulated in serum of CHD patients and H9C2 cells in vitro, while the expression of GATA6 and IGF-1 was significantly decreased. MiR-23b could influence the proliferation and apoptosis of cardiomyocytes by targeting the down-regulation of the GATA6/IGF-1 axis.

Congenital Heart Disease in Non-Diabetic Large-for-Gestational-Age (LGA) Neonates

BACKGROUND

Congenital heart diseases are the most prevalent congenital abnormalities in the neonates, caused by environmental and genetic factors and contributing to the leading cause of death. This study aims to evaluate the relationship between neonates with large for gestational age and increased risk of congenital heart diseases among non-diabetic mothers.

METHODS

In this study, 179 neonates with large gestational age in Khorramabad were enrolled where heart abnormalities were evaluated using echocardiography.

RESULTS

87 neonates had more than 4000 g of birth weight with no heart abnormalities and 92 (51%) macrosomic neonates had congenital heart diseases. Statistical analysis revealed a significant relationship between birth weight and increased risk of acquiring congenital heart disease between the two groups. There was no significant relationship between birth weight, maternal age, gender, labor type and blood group between the two groups. The highest incidence of congenital heart anomalies was related to 38% of arterial septal defect (ASD) and 15.2% of ASD and VSD, respectively.

CONCLUSION

The most prevalent abnormality was arterial septal ASD. None of these abnormalities were associated with maternal age, birth weight and neonate gender. Future studies for congenital heart disease and neonatal birth weight are, therefore, recommended.

Guards! Guards! How innate lymphoid cells ensure local law and order

This special issue of the Biomedical Journal is dedicated to the latest official recruits in the field of immunology: innate lymphoid cells, the tissue-resident sentinels and first responders to damage or invasion. Subsequently, we consider extracellular vesicle release during bacterial infection, how immunomodulation can avoid compromising Mycobacterium tuberculosis clearance, and how innate immunity jeopardises the organism during rheumatoid arthritis. Moreover, we ponder over the predictive value of cardiac troponin in influenza, the virtues of cashew nuts and bilirubin, as well as holes in the heart. Finally, we learn that mandibular movement during swallowing increases with the vertical dimension of occlusion, and that early controlled relaxation incisions restore the blood supply to the extremities in harlequin ichthyosis neonates.

Development of an international standard set of clinical and patient-reported outcomes for children and adults with congenital heart disease: a report from the International Consortium for Health Outcomes Measurement Congenital Heart Disease Working Group

AIMS

Congenital heart disease (CHD) is the most common congenital malformation. Despite the worldwide burden to patient wellbeing and health system resource utilization, tracking of long-term outcomes is lacking, limiting the delivery and measurement of high-value care. To begin transitioning to value-based healthcare in CHD, the International Consortium for Health Outcomes Measurement aligned an international collaborative of CHD experts, patient representatives, and other stakeholders to construct a standard set of outcomes and risk-adjustment variables that are meaningful to patients.

METHODS AND RESULTS

The primary aim was to identify a minimum standard set of outcomes to be used by health systems worldwide. The methodological process included four key steps: (i) develop a working group representative of all CHD stakeholders; (ii) conduct extensive literature reviews to identify scope, outcomes of interest, tools used to measure outcomes, and case-mix adjustment variables; (iii) create the outcome set using a series of multi-round Delphi processes; and (iv) disseminate set worldwide. The Working Group established a 15-item outcome set, incorporating physical, mental, social, and overall health outcomes accompanied by tools for measurement and case-mix adjustment variables. Patients with any CHD diagnoses of all ages are included. Following an open review process, over 80% of patients and providers surveyed agreed with the set in its final form.

CONCLUSION

This is the first international development of a stakeholder-informed standard set of outcomes for CHD. It can serve as a first step for a lifespan outcomes measurement approach to guide benchmarking and improvement among health systems.

Epidemiological Research of Microtia Combined With Congenital Heart Disease

Congenital heart disease (CHD) is one of the most common combined malformations of microtia. There is currently no specific study that investigates the relationship between microtia and CHD.

METHODS

This study collected microtia inpatients admitted from May 1, 2015 to July 31, 2016. The diagnosis of CHD was based on patient's symptoms, past history, and echocardiography. Pearson χ test was used to analyze the correlation between CHD and microtia.

RESULTS

A total of 30 cases (3.35%) were documented with CHD, including atrial septal defect (12/40.00%), ventricular septal defect (7/23.30%), patent ductus arteriosus (2/6.70%), complex congenital heart disease (3/10.00%), combined CHD (2/6.70%) and other malformations (4/13.30%). Analysis showed no statistically significant relation between CHD and the side of affected ear or gender.

CONCLUSIONS

The occurrence of CHD in microtia patients was higher than that in the general population. The relationship between them was explored mainly from the etiological perspective. Microtia and CHD were often combined in syndromes such as Goldenhar syndrome, 22q11 deletion syndrome, and CHARGE syndrome. Absence of genes or abnormal embryo development associated with these syndromes leads to the occurrence of both.

Junctional Ectopic Tachycardia: Recognition and Modern Management Strategies

Junctional ectopic tachycardia is a common dysrhythmia after congenital heart surgery that is associated with increased perioperative morbidity and mortality. Risk factors for development of junctional ectopic tachycardia include young age (neonatal and infant age groups); hypomagnesemia; higher-complexity surgical procedure, especially near the atrioventricular node or His bundle; and use of exogenous catecholamines such as dopamine and epinephrine. Critical care nurses play a vital role in early recognition of dysrhythmias after congenital heart surgery, assessment of hemodynamics affecting cardiac output, and monitoring the effects of antiarrhythmic therapy. This article reviews the underlying mechanisms of junctional ectopic tachycardia, incidence and risk factors, and treatment options. Currently, amiodarone is the pharmacological treatment of choice, with dexmedetomidine increasingly used because of its anti-arrhythmic properties and sedative effect.

Down-regulation of the insulin signaling pathway by SHC may correlate with congenital heart disease in Chinese populations

BACKGROUND/AIMS

Congenital heart disease (CHD) is one of the most common and severe congenital defects. The incidence of fetal cardiac malformation is increased in the context of maternal gestational diabetes mellitus (GDM). Therefore, we wanted to determine whether abnormalities in the insulin signaling pathway are associated with the occurrence of nonsyndromic CHD (ns-CHD).

METHODS

We used digital gene expression profiling (DGE) of right atrial myocardial tissue samples from eight ns-CHD patients and four controls. The genes potentially associated with CHD were validated by real-time fluorescence quantitative PCR analysis of right atrial myocardial tissues from 37 patients and 10 controls and the H9C2 cell line.

RESULTS

The results showed that the insulin signaling pathway, which is mediated by the SHC gene family, was inhibited in the ns-CHD patients. The expression levels of five genes (PTPRF, SHC4, MAP2K2, MKNK2, and ELK1) in the pathway were significantly down-regulated in the patients' atrial tissues (P<0.05 for all). In vitro, the H9C2 cells cultured in high glucose (33 mmol/l) expressed less SHC4, MAP2K2, and Elk-1 than those cultured in low glucose (25 mmol/l). Furthermore, the high glucose concentration down-regulated the 25 genes associated with blood vessel development based on Gene Ontology (GO) term enrichment analyses of RNA-seq data.

CONCLUSION

We considered that changes in the insulin signaling pathway mediated by SHC might be involved in the heart development process. This mechanism might account for the increase in the incidence of fetal cardiac malformations in the context of GDM.

Role of lncRNA uc.457 in the differentiation and maturation of cardiomyocytes

Congenital heart disease (CHD) is the most common type of birth defect, and the leading cause of fetal mortality. The long noncoding RNA (lncRNA) uc.457 is differentially expressed in cardiac tissue from patients with a ventricular septal defect; however, its role in cardiac development and CHD remains unknown. In the present study, the role of uc.457 in the differentiation and maturation of cardiomyocytes was investigated. Bioinformatics approaches were employed to analyze putative transcription factor (TF) regulation, histone modifications and the biological functions of uc.457. Subsequently, uc.457 overexpression and small interfering RNA‑mediated knockdown were performed to evaluate the functional role of the lncRNA in the dimethyl sulfoxide‑induced differentiation of P19 cells into cardiomyocytes. Bioinformatics analyses predicted that uc.457 binds to TFs associated with cardiomyocyte growth and cardiac development. Cell Counting Kit‑8 assays demonstrated that uc.457 overexpression inhibited cell proliferation, whereas knockdown of uc.457 enhanced the proliferation of differentiating cardiomyocytes. Additionally, reverse transcription‑quantitative polymerase chain reaction and western blot analyses revealed that overexpression of uc.457 suppressed the mRNA and protein expression of histone cell cycle regulation defective homolog A, natriuretic peptide A, cardiac muscle troponin T and myocyte‑specific enhancer factor 2C. Collectively, the results indicated that overexpression of uc.457 inhibited the differentiation and proliferation of cardiomyocytes, suggesting that dysregulated uc.457 expression may be associated with CHD.

Supporting Optimal Neurodevelopmental Outcomes in Infants and Children With Congenital Heart Disease

Improved survival has led to increased recognition of developmental delays in infants and children with congenital heart disease. Risk factors for developmental delays in congenital heart disease survivors may not be modifiable; therefore, it is important that lifesaving, high-technology critical care interventions be combined with nursing interventions that are also developmentally supportive. Implementing developmental care in a pediatric cardiac intensive care unit requires change implementation strategies and widespread support from all levels of health care professionals. This manuscript reviews developmentally supportive interventions such as massage, developmentally supportive positioning, kangaroo care, cue-based feeding, effective pain/anxiety management, and procedural preparation and identifies strategies to implement developmentally supportive interventions in the care of infants and children with congenital heart disease. Improving developmental support for these infants and children at high risk for developmental delay may improve their outcomes and help promote family-centered care.

3D printing for congenital heart disease: a single site's initial three-yearexperience

Background

3D printing is an ideal manufacturing process for creating patient-matched models (anatomical models) for surgical and interventional planning. Cardiac anatomical models have been described in numerous case studies and journal publications. However, few studies attempt to describe wider impact of the novel planning augmentation tool. The work here presents the evolution of an institution’s first 3 full years of 3D prints following consistent integration of the technology into clinical workflow (2012–2014) - a center which produced 79 models for surgical planning (within that time frame). Patient outcomes and technology acceptance following implementation of 3D printing were reviewed.

Methods

A retrospective analysis was designed to investigate the anatomical model’s impact on time-based surgical metrics. A contemporaneous cohort of standard-of-care pre-procedural planning (no anatomical models) was identified for comparative analysis. A post-surgery technology acceptance assessment was also employed in a smaller subset to measure perceived efficacy of the anatomical models. The data was examined.

Results

Within the timeframe of the study, 928 primary-case cardiothoracic surgeries (encompassing both CHD and non-CHD surgeries) took place at the practicing pediatric hospital. One hundred sixty four anatomical models had been generated for various purposes. An inclusion criterion based on lesion type limited those with anatomic models to 33; there were 113 cases matching the same criterion that received no anatomical model. Time-based metrics such as case length-of-time showed a mean reduction in overall time for anatomical models. These reductions were not statistically significant. The technology acceptance survey did demonstrate strong perceived efficacy. Anecdotal vignettes further support the technology acceptance.

Discussion & conclusion

The anatomical models demonstrate trends for reduced operating room and case length of time when compared with similar surgeries in the same time-period; in turn, these reductions could have significant impact on patient outcomes and operating room economics. While analysis did not yield robust statistical powering, strong Cohen’s d values suggest poor powering may be more related to sample size than non-ideal outcomes. The utility of planning with an anatomical model is further supported by the technology acceptance study which demonstrated that surgeons perceive the anatomical models to be an effective tool in surgical planning for a complex CHD repair. A prospective multi-center trial is currently in progress to further validate or reject these findings.

Neonatal echocardiogram in duodenal obstruction is unnecessary after normal fetal cardiac imaging

BACKGROUND

Duodenal obstruction (DO) is associated with congenital cardiac anomalies that may complicate the delivery of anesthesia during surgical repair. As most infants undergo fetal ultrasounds that identify cardiac anomalies, our aim was to determine the utility of obtaining preoperative neonatal echocardiograms in all DO patients.

METHODS

We conducted a retrospective cohort study of all DO patients treated at two tertiary care children's hospitals between January 2005 and February 2016. Prenatal ultrasounds were compared to neonatal echocardiograms to determine concordance. Binomial exact analyses were used to estimate the negative predictive value (NPV) of prenatal imaging.

RESULTS

We identified 65 infants with DO. The majority of patients (93.8%) had prenatal ultrasounds, including twenty patients that underwent fetal echocardiogram. Fourteen (21.5%) were diagnosed with cardiac lesions in utero, and neonatal echocardiograms confirmed 12 lesions, without identifying any new lesions. No changes to anesthetic management were made because of cardiac lesions. The NPV of prenatal imaging was 100% (95% Confidence Interval: 91.0-100.0).

CONCLUSIONS

Neonatal echocardiogram is unlikely to identify new cardiac lesions in DO patients with negative fetal imaging and delays in surgical care are unwarranted.

LEVELS OF EVIDENCE

Study of Diagnostic Test-Level II.

Three-dimensional printing: changing clinical care or just a passing fad?

PURPOSE OF REVIEW

Advances in medical imaging and three-dimensional (3D) reconstruction software have enabled a proliferation of 3D modeling and 3D printing for clinical applications. In particular, 3D printing has garnered an extraordinary media presence over the past few years. There is growing optimism that 3D printing can address patient specificity and complexity for improved interventional and surgical planning. Will this relatively untested technology bring about a paradigm shift in the clinical environment, or is it just a transient fad?

RECENT FINDINGS

Case studies and series centered around 3D printing are omnipresent in clinical and engineering journals. These primarily qualitative studies support the potential efficacy of the emerging technology. Few studies analyze the value of 3D printing, weighing its potential benefits against increasing costs (e.g., institutional overhead, labor, and materials).

SUMMARY

Clinical integration of 3D printing is growing rapidly, and its adoption into clinical practice presents unique workflow challenges. There are numerous clinical trials on the horizon that will finally help to elucidate the measured impact of 3D printing on clinical outcomes through quantitative analyses of clinical and economic metrics. The contrived integration of 3D printing into clinical practice seems all but certain as the value of this technology becomes more and more evident.

[Association of single nucleotide polymorphisms of transcription factors with congenital heart diseases in the Chinese population: a Meta analysis]

OBJECTIVE

To study the association of single nucleotide polymorphisms (SNPs) of transcription factors (NKX2.5, GATA4, TBX5, and FOG2) with congenital heart disease (CHD) in the Chinese population.

METHODS

PubMed, Google Scholar, CNKI, Wanfang Data, and Weipu Data were searched for articles on the association of SNPs of target genes with CHD in the Chinese population. If one locus was mentioned in at least two articles, the random or fixed effect model was used to perform a pooled analysis of study results and to calculate the pooled OR and its 95%CI. If a locus was mentioned in only one article, related data were extracted from this article to analyze the association between the SNPs of this locus and CHD.

RESULTS

Twenty-three articles were included. The Meta analysis showed that there were significant differences between the CHD and control groups in the genotype and allele frequencies of GATA4 rs1139244 and rs867858 and the genotype frequency of GATA4 rs904018, while there were no significant differences in the SNPs of the other genetic loci between the two groups. The single-article analysis showed that there were significant differences between the two groups in the allele frequencies of NKX2.5 rs118026695/rs703752, GATA4 rs884662/rs12825/rs12458/rs3203358/rs4841588, and TBX5 rs6489956. There were no significant differences in the SNPs of FOG2 locus between the two groups.

CONCLUSIONS

The SNPs of some loci in NKX2.5, GATA4, and TBX5 are associated with CHD in the Chinese population, but the association between the SNPs of FOG2 locus and the development of CHD has not been found yet.

An automatic method to calculate heart rate from zebrafish larval cardiac videos

Background

Zebrafish is a widely used model organism for studying heart development and cardiac-related pathogenesis. With the ability of surviving without a functional circulation at larval stages, strong genetic similarity between zebrafish and mammals, prolific reproduction and optically transparent embryos, zebrafish is powerful in modeling mammalian cardiac physiology and pathology as well as in large-scale high throughput screening. However, an economical and convenient tool for rapid evaluation of fish cardiac function is still in need. There have been several image analysis methods to assess cardiac functions in zebrafish embryos/larvae, but they are still improvable to reduce manual intervention in the entire process. This work developed a fully automatic method to calculate heart rate, an important parameter to analyze cardiac function, from videos. It contains several filters to identify the heart region, to reduce video noise and to calculate heart rates.

Results

The proposed method was evaluated with 32 zebrafish larval cardiac videos that were recording at three-day post-fertilization. The heart rate measured by the proposed method was comparable to that determined by manual counting. The experimental results show that the proposed method does not lose accuracy while largely reducing the labor cost and uncertainty of manual counting.

Conclusions

With the proposed method, researchers do not have to manually select a region of interest before analyzing videos. Moreover, filters designed to reduce video noise can alleviate background fluctuations during the video recording stage (e.g. shifting), which makes recorders generate usable videos easily and therefore reduce manual efforts while recording.

Electronic supplementary material

The online version of this article (10.1186/s12859-018-2166-6) contains supplementary material, which is available to authorized users.

Undiagnosed Congenital Heart Defects as a Cause of Sudden, Unexpected Death in Children

Despite advances in the diagnosis and treatment of congenital heart defects (CHDs), these defects are still an important cause of sudden, unexpected death in young children. This retrospective study identified 64 cases of CHDs presenting as a cause of sudden, unexpected death in a busy, urban Medical Examiner's Office pediatric population between 2006 and 2016. The majority of cases (52 of 64, 81%) were infants. Interestingly, 52% of cases were undiagnosed prior to autopsy. Ventricular septal defects and atrioventricular septal defects were the most common simple (14%) and complex (17%) malformations observed, respectively. In many cases, there were coexistent simple and/or complex defects. Most of the cases diagnosed with CHD prior to autopsy (48%) had undergone some type of surgical repair. This study highlights the importance of considering undiagnosed CHDs as a cause of sudden, unexpected death, particularly in young children.

Landmark lecture in nursing: a life-cycle perspective on CHD: What happens beyond your clinic?

Over the past decades, survival of patients with CHD improved significantly, making it a life-cycle disease. Hence, there is a need for a workforce that can take up the care for afflicted individuals in the different phases of the life spectrum. Each life phase is associated with specific challenges. Topics that should receive more attention in clinical care or in CHD research are parenting styles of parents of children, transfer and transition of adolescents, cumulative burden of injury in the brain in adults, and geriatric care for older persons with CHD. Nurses, along with other healthcare professionals, will play a pivotal role in building up expertise in these areas and taking up these challenges.

Association Analysis of Nonsyndromic Congenital Heart Disease and Tag Single Nucleotide Polymorphisms of TBX20 and Genes in the Ras-MAPK Pathway

AIMS

The present study was performed to determine whether there are variants in TBX20 and genes of the Ras-MAPK pathway associated with nonsyndromic congenital heart disease (ns-CHD).

MATERIALS AND METHODS

A total of 223 ns-CHD patients and 273 healthy controls from China were selected as study subjects to perform an association analysis using 22 tag single-nucleotide polymorphisms (tag SNPs) located either in one of three genes in the Ras-MAPK pathway (MAP2K2, BRAF, and RAF1) or the TBX20 gene that have previously been associated with syndromic congenital heart disease.

RESULTS

The results showed that none of these tag SNPs are associated with ns-CHD.

CONCLUSIONS

The results suggested that these disease-causing genes, which were previously discovered in familial cases, might not be the major genetic factors causing the development of ns-CHD in Chinese.

Associations of GATA4 genetic mutations with the risk of congenital heart disease: A meta-analysis

BACKGROUND

GATA4 gene is a cardiac transcriptional factor playing important role in cardiac formation and development. Three GATA4 gene mutations, 99 G>T, 487 C>T, and 354 A>C, have been reported in congenital heart disease (CHD). Therefore, a meta-analysis was performed to explore the associations between 99 G>T, 487 C>T, or 354 A>C mutations and the risk of CHD.

METHODS

We searched the relevant studies in electronic databases, including ISI Science Citation Index, Embase, PubMed, CNKI, and Wan fang, from January 2006 to March 2016. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to estimate the associations between 99 G>T, 487 C>T, or 354 A>C mutations and the risk of CHD.

RESULTS

A total of 11 studies including 2878 CHD cases and 3339 controls were evaluated. There was no significant association between GATA4 99 G>T (OR = 1.22, 95% CI = 0.74-2.01, P = .43) or 487 C>T (OR = 1.16, 95% CI = 0.48-2.78, P = .74) mutations and the risk of CHD, whereas GATA4 354 A>C (OR = 1.49, 95% CI = 1.15-1.93, P = .003) mutation was significantly associated with CHD risk. Subgroup analysis was further performed for GATA4 99 G>T, 487 C>T, and 354 A>C mutations based on sample size and ethnicity, and no significant association between GATA4 99 G>T or 487 C>T mutations and the risk of CHD was found in all subgroups, whereas GATA4 354 A>C mutation was significantly associated with CHD risk in large-sample-size and Asian subgroups. However, subgroup analysis by types of CHD indicated that there was no significant association between GATA4 354 A>C mutation and the risk of ventricular septal defects.

CONCLUSIONS

Our findings suggested that GATA4 99 G>T and 487 C>T mutations may not be related to the incidence of CHD. However, GATA4 354 A>C mutation was significantly associated with CHD risk.

[Effect of histone acetylation/deacetylation imbalances on key gene of planar cell polarity pathway]

OBJECTIVE

To investigate the effect of histone acetylation/deacetylation imbalances on embryonic hearts of mice and its effect on key genes of planar cell polarity (PCP) pathway-Vangl2, Scrib and Rac1 in H9C2 cells.

METHODS

Forty pregnant C57/B6 mice were randomly assigned into three groups: blank group (n=10), vehicle group (n=10), and valproic acid (VPA)-treated group (n=20). In the VPA-treated group, VPA, a histone deacetylase (HDAC) inhibitor, was administered to each individual dam intraperitoneally at a single dose of 700 mg/kg on embryonic day 10.5 (E10.5). The vehicle and blank groups received equivalent saline or no interventions, respectively. Dams were sacrificed on E15.5, and death rates of embryos were evaluated. Subsequently, embryonic hearts of survival fetus were removed to observe cardiac abnormalities by hematoxylin-eosin (HE) staining. H9C2 cells were cultured and allotted to the blank, vehicle, and VPA-treated groups: the VPA treated group received VPA exposure at concentrations of 2.0, 4.0 and 8.0 mmol/L; the vehicle and blank groups received equivalent saline or no interventions, respectively. HDAC1-3 as well as Vangl2, Scrib and Rac1 mRNA and protein expression levels were determined by quantitative real-time PCR and Western blot, respectively. The total HDAC activity was analyzed by colorimetric assay.

RESULTS

The fetus mortality rate after VPA treatment was 31.7%, with a significantly higher rate of cardiac abnormalities in comparison with the controls (P<0.05). In comparison with the blank and vehicle groups, HDAC1 mRNA was significantly increased at various concentrations of VPA treatment at all time points of exposure (P<0.05), together with a reduction of protein level after 48 and 72 hours of exposure (P<0.05). The inhibition of HDAC2 mRNA after various concentrations of VPA incubation was pronounced at 24 hours of exposure (P<0.05), while the protein levels were reduced at all time points (P<0.05). HDAC3 mRNA was prominently induced by VPA (4.0 and 8.0 mmol/L) at all time points of treatment (P<0.05). In contrast, the protein level was inhibited after VPA treatment (P<0.05). In comparison with the blank and vehicle groups, Vangl2 mRNA as well as Scrib mRNA/protein expression levels were markedly reduced after 48 and 72 hours of VPA treatment (P<0.05), together with a reduction of protein level in Vangl2 at 72 hours (P<0.05). Compared with the blank and vehicle groups, a significant repression in the total HDAC activity was observed in the VPA-treated group at concentrations of 4.0 and 8.0 mmol/L after 24 hours of treatment (P<0.05), and the effect persisted up to 48 and 72 hours, exhibiting pronounced inhibition at all concentrations (P<0.05).

CONCLUSIONS

VPA might result in acetylation/deacetylation imbalances by inhibiting HDAC1-3 protein expression and total HDAC activity, leading to the down-regulation of mRNA and protein expression of Vangl2 and Scrib. This could be one of the mechanisms contributing to congenital heart disease.

Prevalence and patterns of congenital heart diseases in Africa: a systematic review and meta-analysis protocol

INTRODUCTION

Congenital heart diseases (CHD) are common causes of cardiovascular morbidity and mortality among young children and adolescents living in Africa. Accurate epidemiological data are needed in order to evaluate and improve preventive strategies. This review aims to determine the prevalence of CHD and their main patterns in Africa.

METHODS AND ANALYSIS

This systematic review and meta-analysis will include cross-sectional, case-control and cohort studies of populations residing inside African countries, which have reported the prevalence of CHD, confirmed by an echocardiographic examination and/or describing different patterns of these abnormalities in Africa. Relevant abstracts published without language restriction from 1 January 1986 to 31 December 2016 will be searched in PubMed, Exerpta Medica Database and online African journals as well as references of included articles and relevant reviews. Two review authors will independently screen, select studies, extract data and assess the risk of bias in each study. The study-specific estimates will be pooled through a random-effects meta-analysis model to obtain an overall summary estimate of the prevalence of CHD across studies. Clinical and statistical heterogeneity will be assessed, and we will pool studies judged to be clinically homogeneous. On the other hand, statistical heterogeneity will be evaluated by the χ2 test on Cochrane's Q statistic. Funnel-plots analysis and Egger's test will be used to detect publication bias. Results will be presented by geographic region (central, eastern, northern, southern and western Africa).

ETHICS AND DISSEMINATION

The current study will be based on published data, and thus ethical approval is not required. This systematic review and meta-analysis is expected to serve as a base which could help in estimating and evaluating the burden of these abnormalities on the African continent. The final report of this study will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42016052880.

A Meta-Analysis of the Relationship Between Maternal Folic Acid Supplementation and the Risk of Congenital Heart Defects

Controversial opinions exist with respect to the relationship between maternal folic acid (FA) supplementation and birth prevalence of congenital heart defects (CHDs).Eligible articles were retrieved by searching databases, including PubMed, Cochrane library, EMBASE, CNKI, and WanFang up to September 2015. A meta-analysis was performed to evaluate the effects of FA on CHDs. Odds ratios (ORs) and 95% confidence interval (CIs) were merged using STATA 12.0. Meta-regression analysis was used to explore the possible sources of heterogeneity. Subgroup analysis according to the selected sources was also performed. Publication bias was assessed by Egger's test.Twenty studies were included in the meta-analysis. The overall analysis showed that FA supplementation was significantly associated with decreased risk of CHDs. The meta-regression analysis showed that geographical area could be an important source of heterogeneity. The subgroup analysis based on the geographical area revealed that FA supplementation during pregnancy was a protective factor against CHDs in Chinese and European patients, but not in American patients. Subgroup analysis according to literature quality also displayed positive associations between FA supplementation and the decreased risk of CHDs of China.FA supplementation during pregnancy significantly decreases the risk of CHDs in newborns in China and Europe.

Use of Oxandrolone to Promote Growth in Neonates following Surgery for Complex Congenital Heart Disease: An Open-Label Pilot Trial

OBJECTIVE

Malnutrition and poor weight gain, common in neonates following repair of complex congenital heart disease (CHD), are associated with increased morbidity and mortality. Oxandrolone, an anabolic steroid, improves weight gain in older children at high-risk for growth failure. We sought to determine feasibility, safety, and efficacy of oxandrolone therapy in neonates following surgery for complex CHD.

DESIGN

Neonates with RACHS-1 score >3 were eligible to receive open-label oxandrolone for 28 days in this prospective pilot trial. There were 3 cohorts of 5 subjects receiving oxandrolone therapy under 3 specified dosage and preparation protocols: 0.1 mg/kg/day aqueous solution, 0.2 mg/kg/day aqueous solution, and 0.1 mg/kg/day preparation in medium chain triglyceride (MCT) oil. Age- and diagnosis-matched neonates who underwent surgery, but received no oxandrolone, served as a control cohort. Anthropometric measurements, physical examination for virilization, safety labs, and adverse events were monitored.

RESULTS

Of 25 eligible patients, 15 consented (60%, 13/15 with Norwood procedure). There was no evidence of virilization, no changes in safety labs, and no serious adverse events related to oxandrolone among subjects receiving therapy. No subject met criteria for termination of study drug. There was a significant difference in change in weight-for-age z-score among the four cohorts, with subjects receiving 0.1 mg/kg/day in MCT oil having the lowest decline during the study period (-1.8 ± 0.5 for controls, -1.7 ± 0.4 for 0.1 mg/kg/day aqueous, -1.0 ± 0.4 for 0.2 mg/kg/day aqueous, and -0.6 ± 0.7 for 0.1 mg/kg/day MCT oil, P = .012).

CONCLUSIONS

Oxandrolone therapy at the doses studied appears safe in neonates after surgery for complex CHD. The decline in weight-for-age z-score was lowest in those receiving the MCT oil preparation suggesting better bioavailability of this preparation and a potential growth benefit with oxandrolone therapy. Further investigation is needed to define optimal dosing and assess efficacy.

Pharmacotherapy of obsessive-compulsive disorder during pregnancy: a clinical approach

Obsessive-compulsive disorder (OCD) is a relatively common psychiatric disorder in the perinatal period. However, specific pharmacological treatment approaches for patients with OCD during pregnancy have not been satisfactorily discussed in the literature. In addition, there are no randomized controlled studies on the treatment of this disorder during pregnancy. The present paper discusses the pharmacological treatment of OCD in the light of data on the safety of antipsychotics and serotonergic antidepressants during pregnancy and their efficacy in the non-perinatal period. Treatment decisions should be individualized because the risk-benefit profile of pharmacotherapy is an important issue in the treatment of pregnant women with any psychiatric diagnosis.

Walking the "Emotional Tightrope" From Pregnancy to Parenthood: Understanding Parental Motivation to Manage Health Care and Distress After a Fetal Diagnosis of Complex Congenital Heart Disease

Advances in medical technology account for increasingly more couples receiving fetal diagnoses of complex congenital heart disease. Theory on internal working models of caregiving during parenting transitions informed this prospective, exploratory study. Data included conjoint interviews and measures of anxiety, trauma, and depression collected from six couples after diagnosis and after birth. Severity of illness was described using infant health records. Directed content analysis furthered understanding of the caregiving motivation to manage health care that included three categories of parental efforts: (a) to determine expectations of health care providers, (b) to reconcile illness- and non-illness-related care, and (c) to express agency as a parent. Synthesis of qualitative findings transformed into categorical ratings with parents' levels of distress resulted in two profiles characterizing types of internal working models. Findings extend theory on internal working models of caregiving and offer direction for future research regarding parental management of health care for their chronically ill offspring. Implications for practice with families are offered.

The Association among Feeding Mode, Growth, and Developmental Outcomes in Infants with Complex Congenital Heart Disease at 6 and 12 Months of Age

OBJECTIVE

To assess the association between early anthropometric measurements, device-assisted feeding, and early neurodevelopment in infants with complex congenital heart diseases (CHDs).

STUDY DESIGN

Bayley Scales of Infant Development II were used to assess cognitive and motor skills in 72 infants with CHD at 6 and 12 months of age. Linear regression models were used to assess the association between mode of feeding and anthropometric measurements with neurodevelopment at 6 and 12 months of age.

RESULTS

Of the 72 infants enrolled in the study, 34 (47%) had single-ventricle physiology. The mean Mental Developmental Index (MDI) and Psychomotor Developmental Index (PDI) scores at 6 months of age were 92 ± 10 and 81 ± 14, respectively. At 12 months of age, the mean MDI and PDI scores were 94 ± 12 and 80 ± 16, respectively. Lower length-for-age z score (P < .01) and head circumference-for-age z score (P < .05) were independently associated with lower MDI at 6 months, and both increased hospital length of stay (P < .01) and lower length-for-age z score (P = .04) were associated independently with lower MDI at 12 months. Device-assisted feeding at 3 months (P = .04) and lower length-for-age z score (P < .05) were independently associated with lower PDI at 6 months. Both lower weight-for-age z score (P = .04) and lower length-for-age z score (P = .04) were associated independently with PDI at 12 months.

CONCLUSION

Neonates with complex CHD who required device-assisted feeding and those with lower weight and length and head circumference z scores at 3 months were at risk for neurodevelopmental delay at 6 and 12 months of age.

Intrauterine Tobacco Smoke Exposure and Congenital Heart Defects

Tobacco use and second-hand smoke exposure during pregnancy are linked to a host of deleterious effects on the pregnancy, fetus, and infant. Health outcomes improve when women quit smoking at any time during the pregnancy. However, the developing heart is vulnerable to noxious stimuli in the early weeks of fetal development, a time when many women are not aware of being pregnant. Congenital heart defects are the most common birth defects. Research shows an association between maternal tobacco exposure, both active and passive, and congenital heart defects. This article presents recent evidence supporting the association between intrauterine cigarette smoke exposure in the periconceptional period and congenital heart defects and discusses clinical implications for practice for perinatal and neonatal nurses.

Frequency and pattern of congenital heart defects in a tertiary care cardiac hospital of Karachi

OBJECTIVE

To determine the current frequency and pattern of distribution of congenital heart defects (CHD) at National Institute of Cardiovascular Diseases (NICVD), with the age at which initial diagnosis of CHD was made and the age at which the participant first visited the study center.

METHODS

This is a descriptive and prospective hospital based study conducted in the pediatric cardiology unit outpatient department of NICVD. This study included all the patients, irrespective of age, having confirmed diagnosis of CHD on the basis of echocardiographic report. The collected data was entered and analyzed by using Statistical Package for Social Sciences v 20.0.

RESULTS

Out of 1100 cases of congenital heart defects 1003 could be analyzed. There are 565 males (56.3%) and 438 females (43.6%). Total 609 cases (60.6%) were of simple acyanotic lesions and 387 (38.6%) were complex cyanotic lesions. In simple lesions septal defects constitute 64.9% and obstructive lesions were 11.0%. Tetralogy of fallot(TOF) was the commonest CHD and cyanotic lesion accounted for 24.4% of the total 1003 cases followed by Ventricular septal defect (VSD) 21.5%, Atrial septal defect (ASD) 9.3% and Patent ductus arteriosus (PDA) 8.6%. Pulmonary stenosis(PS) was the most common obstructive lesion making 3.1% of the CHD. In 147 (14.5%) cases combination of simple defects were encountered and the commonest combination was ASD with VSD in 34 cases.

CONCLUSION

Congenital Heart Defects are very common in our setup and early detection of CHD is increasing. Overall burden of CHD is also increasing therefore a proper population based study on a large scale is needed to estimate the prevalence accurately.

A Case Study of Infant Physiologic Response to Skin-to-Skin Contact After Surgery for Complex Congenital Heart Disease

BACKGROUND

Infants with complex congenital heart disease requiring surgical intervention within the first days or weeks of life may be the most seriously ill infants needing intensive nursing and medical care. Skin-to-skin contact (SSC) is well accepted and practiced as a positive therapeutic intervention in premature infants but is not routinely offered to infants in cardiac intensive care units. The physiologic effects of SSC in the congenital heart disease population must be examined before recommending incorporation of SSC into standard care routines.

OBJECTIVE

The purpose of this case study was to describe the physiologic response to a single session of SSC in an 18-day-old infant with hypoplastic left heart syndrome.

METHODS

Repeated measures of heart rate, respiratory rate, oxygen saturation, blood pressure, and temperature were recorded 30 minutes before SSC, during SSC (including interruptions for bottle and breast feedings), and 10 minutes after SSC was completed.

RESULTS

All physiologic parameters were clinically acceptable throughout the 135-minute observation.

CONCLUSION

This case study provides beginning evidence that SSC is safe in full-term infants after surgery for complex congenital heart disease. Further research with a larger sample is needed to examine the effects of SSC on infant physiology before surgery and earlier in the postoperative time period as well as on additional outcomes such as length of stay, maternal-infant interaction, and neurodevelopment.

Relationship of thymic changes and complications after congenital heart surgery

BACKGROUND

The true role of thymic function in children with congenital heart defects is largely unknown.

AIM

To study the possible role of thymic CD3 (T-lymphocyte marker) and CD20 (B-lymphocyte marker) expression and thymic histopathological changes in complications after surgery for congenital heart defects.

METHODS

Between January and July 2014, thymic tissue samples were obtained from 13 (69% male, 31% female, mean age 10.9 ± 2 years) of 25 Iraqi patients who underwent open heart surgery with partial thymectomy for correction of congenital heart defects. The samples were evaluated for thymic expression of CD markers (CD3 and CD20) and histopathological changes. For up to 6 months after surgery, data on complications were collected from each patient, including wound infection, cardiac arrhythmias, heart failure, rehospitalization, chest infection, and death.

RESULTS

The prevalence of thymic hypoplasia was 15% and it occurred more frequently in patients with absent thymic CD3 expression (p = 0.005). Only wound infection (n = 2) and atrial fibrillation (n = 1) comprised the postoperative complications in our patients. Absence of thymic CD20 expression correlated significantly with postoperative complications and obstructive cardiac defects (p = 0.04), whereas no significant correlations were found between thymic hypoplasia with CD3 expression and postoperative complications (p > 0.05).

CONCLUSION

Patients with absent thymic CD20 expression had significantly more postoperative complications and cardiac obstructive defects than those with positive CD20 expression.

Lncing epigenetic control of transcription to cardiovascular development and disease

Transcriptional and epigenetic regulation is critical for proper heart development, cardiac homeostasis, and pathogenesis. Long noncoding RNAs have emerged as key components of the transcriptional regulatory pathways that govern cardiac development as well as stress response, signaling, and remodeling in cardiac pathologies. Within the past few years, studies have identified many long noncoding RNAs in the context of cardiovascular biology and have begun to reveal the key functions of these transcripts. In this review, we discuss the growing roles of long noncoding RNAs in different aspects of cardiovascular development as well as pathological responses during injury or disease. In addition, we discuss diverse mechanisms by which long noncoding RNAs orchestrate cardiac transcriptional programs. Finally, we explore the exciting potential of this novel class of transcripts as biomarkers and novel therapeutic targets for cardiovascular diseases.