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Rao PS. Therapy of Patients with Cardiac Malposition. CHILDREN (BASEL, SWITZERLAND) 2023; 10:739. [PMID: 37189988 PMCID: PMC10137016 DOI: 10.3390/children10040739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 03/31/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023]
Abstract
Positional abnormalities per se do not require treatment, but in their place, the accompanying pulmonary pathology in dextroposition patients and pathophysiologic hemodynamic abnormalities resulting from multiple defects in patients with cardiac malposition should be the focus of treatment. At the time of the first presentation, treating the pathophysiologic aberrations caused by the defect complex, whether it is by improving the pulmonary blood flow or restricting it, is the first step. Some patients with simpler or single defects are amenable to surgical or transcatheter therapy and should be treated accordingly. Other associated defects should also be treated appropriately. Biventricular or univentricular repair dependent on the patient's cardiac structure should be planned. Complications in-between Fontan stages and after conclusion of Fontan surgery may occur and should be promptly diagnosed and addressed accordingly. Several other cardiac abnormalities unrelated to the initially identified heart defects may manifest in adulthood, and they should also be treated.
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Affiliation(s)
- P Syamasundar Rao
- Children's Heart Institute, Children's Memorial Hermann Hospital, McGovern Medical School, University of Texas-Houston, 6410 Fannin Street, UTPB Suite # 425, Houston, TX 77030, USA
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Assadi A, Laussen PC, Freire G, Ghassemi M, Trbovich P. Decision-centered design of a clinical decision support system for acute management of pediatric congenital heart disease. Front Digit Health 2022; 4:1016522. [DOI: 10.3389/fdgth.2022.1016522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/12/2022] [Indexed: 11/15/2022] Open
Abstract
Background and ObjectivesChildren with congenital heart disease (CHD), have fragile hemodynamics and can deteriorate due to common childhood illnesses and the natural progression of their disease. During these acute periods of deterioration, these children often present to their local emergency departments (ED) where expertise in CHD is limited, and appropriate intervention is crucial to their survival. Previous studies identified that determining the appropriate intervention for CHD patients can be difficult for ED physicians, particularly since key components of effective decision making are not being met. Although key components of effective decision making for ED physicians have been identified, they have yet to be transformed into actionable guidance. We used decision centered design (DCD) to translate key components of decision making into decision requirements and associated design concepts, that we subsequently incorporated into a prototype clinical decision support system (CDSS).MethodsUsing framework analysis, transcripts from Critical Decision Method interviews of CHD experts and ED physicians were inductively coded to identify key decision requirements for ED physicians that are currently not well supported, and their associated design concepts. A design workshop was held to refine the identified key decision requirements and design concepts as well as to sketch information that would satisfy the identified requirements. These were iteratively incorporated into a prototype CDSS.ResultsThree decision requirements: (1) distinguish the patient's unique physiology based on their unique cardiac anatomy, (2) explicitly consider CHD specific differential diagnoses to allow a more structured reflection of diagnosis, and (3) select CHD appropriate interventions for each patient, were identified. These requirements along with design concepts and information needs identified through the design workshop were incorporated into the CDSS prototype.ConclusionWe identified key decision requirements and associated design concepts, that informed the design of a CDSS to provide actionable guidance for ED physicians when managing CHD patients. Meeting ED physicians' decision components with a CDSS requires the translation of their key decision requirements in its design. If not, we risk creating designs that interfere with clinician performance.
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Vergales J, Figueroa M, Frommelt M, Putschoegl A, Singh Y, Murray P, Wood G, Allen K, Villafane J. Transitioning Neonates With CHD to Outpatient Care: A State-of-the-Art Review. Pediatrics 2022; 150:189880. [PMID: 36317969 DOI: 10.1542/peds.2022-056415m] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
Affiliation(s)
- Jeffrey Vergales
- Division of Pediatric Cardiology, University of Virginia, Charlottesville, Virginia
| | - Mayte Figueroa
- Divisions of Pediatric Cardiology and Pediatric Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Michele Frommelt
- Children's Wisconsin, Division of Pediatric Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Adam Putschoegl
- Division of Pediatric Cardiology, Children's Hospital and Medical Center, Omaha, Nebraska
| | - Yogen Singh
- Division of Pediatric Cardiology and Neonatology, Cambridge University Hospitals, University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
| | - Peter Murray
- Division of Neonatology, University of Virginia, Charlottesville, Virginia
| | - Garrison Wood
- Division of Pediatric Cardiology, University of Virginia, Charlottesville, Virginia
| | - Kiona Allen
- Division of Pediatric Cardiology and Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Juan Villafane
- Cincinnati Children's Hospital, Division of Pediatric Cardiology, University of Cincinnati, Cincinnati, Ohio
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Rao PS. Double-Inlet Left Ventricle. CHILDREN 2022; 9:children9091274. [PMID: 36138583 PMCID: PMC9497213 DOI: 10.3390/children9091274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 08/15/2022] [Accepted: 08/21/2022] [Indexed: 11/16/2022]
Abstract
Double-inlet left ventricle (DILV) is most frequent among univentricular atrioventricular connections. In DILV, there is a single functioning ventricle, most commonly with left ventricular structure. This chamber receives both atrioventricular valves and is connected to an outlet chamber with morphologic features of the right ventricle. The great vessels are often transposed, and pulmonary stenosis is seen in two-thirds of patients. The anatomy and pathophysiology can be defined by echo-Doppler studies with a rare need for other imaging studies. The management is mostly related to the nature of associated heart defects and the degree of pathophysiological abnormality. When the infants present initially, treatment to address the hemodynamic issues is undertaken. Subsequently, these babies need staged total cavo-pulmonary connection, i.e., the Fontan procedure which is undertaken in three stages; these stages are described in this review. The existence of inter-stage mortality and post-Fontan complications is recognized and was reviewed. The paper concludes that DILV can be successfully diagnosed with echo-Doppler studies and this heart anomaly can be effectively treated with the currently prevailing medical, catheter interventional, and surgical treatment practices.
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Affiliation(s)
- P Syamasundar Rao
- Children's Heart Institute, Children's Memorial Hermann Hospital, McGovern Medical School, University of Texas-Houston, Houston, TX 77030, USA
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Mitral Atresia with Normal Aortic Root. CHILDREN 2022; 9:children9081148. [PMID: 36010040 PMCID: PMC9406580 DOI: 10.3390/children9081148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 07/27/2022] [Accepted: 07/28/2022] [Indexed: 11/17/2022]
Abstract
Mitral atresia with normal aortic root is a rare complex congenital heart defect (CHD) and constitute less than 1% of all CHDs. In this anomaly, the mitral valve is atretic, a patent foramen ovale provides egress of the left atrial blood, either a single ventricle or two ventricles with left ventricular hypoplasia are present, and the aortic valve/root are normal by definition. Clinical, roentgenographic and electrocardiographic features are non-distinctive, but echo-Doppler studies are useful in defining the anatomic and pathophysiologic components of this anomaly with rare need for other imaging studies. Treatment consists of addressing the pathophysiology resulting from defect and associated cardiac anomalies at the time of initial presentation, usually in the early infancy. These children eventually require staged total cavo-pulmonary connection (Fontan) in three stages. Discussion of each of these stages were presented. Complications are observed in-between the stages of Fontan surgery and following completion of Fontan procedure. Attempts to monitor for early detection of these complications and promptly addressing the complications are recommended.
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Assadi A, Laussen PC, Freire G, Trbovich P. Understanding Clinician Macrocognition to Inform the Design of a Congenital Heart Disease Clinical Decision Support System. Front Cardiovasc Med 2022; 9:767378. [PMID: 35187118 PMCID: PMC8850471 DOI: 10.3389/fcvm.2022.767378] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 01/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Objectives Children with congenital heart disease (CHD) are at risk of deterioration in the face of common childhood illnesses, and their resuscitation and acute treatment requires guidance of CHD experts. Many children with CHD, however, present to their local emergency departments (ED) with gastrointestinal and respiratory symptoms that closely mimic symptoms of CHD related heart failure. This can lead to incorrect or delayed diagnosis and treatment where CHD expertise is limited. An understanding of the differences in cognitive decision-making processes between CHD experts and ED physicians can inform how best to support ED physicians when treating CHD patients. Methods Cardiac intensivists (CHD experts) and pediatric emergency department physicians (ED physicians) in a major academic cardiac center were interviewed using the critical decision method. Interview transcripts were coded deductively based on Schubert and Klein's macrocognitive frameworks and inductively to allow for new or modified characterization of dimensions. Results In total, 6 CHD experts and 7 ED physicians were interviewed for this study. Although both CHD experts and ED physicians spent a lot of time sensemaking, their approaches to sensemaking differed. CHD experts reported readily recognizing the physiology of complex congenital heart disease and focused primarily on ruling out cardiac causes for the presenting illness. ED physicians reported a delay in attributing the signs and symptoms of the presenting illness to congenital heart disease, because these clinical findings were often non-specific, and thus explored different diagnoses. CHD experts moved quickly to treatment and more time anticipating potential problems and making specific contingency plans, while ED physicians spent more time gathering a range of data prior to arriving at a diagnosis. These findings were then applied to develop a prototype web-based decision support application for patients with CHD. Conclusion There are differences in the cognitive processes used by CHD experts and ED physicians when managing CHD patients. An understanding of differences in the cognitive processes used by CHD experts and ED physicians can inform the development of potential interventions, such as clinical decision support systems and training pathways, to support decision making pertaining to the acute treatment of pediatric CHD patients.
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Affiliation(s)
- Azadeh Assadi
- Department of Critical Care Medicine, Labatt Family Heart Centre, Toronto, ON, Canada
- Department of Engineering and Applied Sciences, Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
- *Correspondence: Azadeh Assadi
| | - Peter C. Laussen
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
- Executive Vice President for Health Affairs, Boston Children's Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Gabrielle Freire
- Division of Emergency Medicine, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Patricia Trbovich
- Department of Engineering and Applied Sciences, Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Research and Innovation, North York General Hospital, Toronto, ON, Canada
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Assadi A, Laussen PC, Freire G, Ghassemi M, Trbovich PC. Effect of clinical decision support systems on emergency medicine physicians' decision-making: A pilot scenario-based simulation study. Front Pediatr 2022; 10:1047202. [PMID: 36589162 PMCID: PMC9798305 DOI: 10.3389/fped.2022.1047202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 11/17/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Children with congenital heart disease (CHD) are predisposed to rapid deterioration in the face of common childhood illnesses. When they present to their local emergency departments (ED) with acute illness, rapid and accurate diagnosis and treatment is crucial to recovery and survival. Previous studies have shown that ED physicians are uncomfortable caring for patients with CHD and there is a lack of actionable guidance to aid in their decision making. To support ED physicians' key decision components (sensemaking, anticipation, and managing complexity) when managing CHD patients, a Clinical Decision Support System (CDSS) was previously designed. This pilot study evaluates the effect of this CDSS on ED physicians' decision making compared to usual care without clinical decision support. METHODS In a pilot scenario-based simulation study with repeated measures, ED physicians managed mock CHD patients with and without the CDSS. We compared ED physicians' CHD-specific and general decision-making processes (e.g., recognizing sepsis, starting antibiotics, and managing symptoms) with and without the use of CDSS. The frequency of participants' utterances related to each key decision components of sensemaking, anticipation, and managing complexity were coded and statistically analyzed for significance. RESULTS Across all decision-making components, the CDSS significantly increased ED physicians' frequency of "CHD specific utterances" (Mean = 5.43, 95%CI: 3.7-7.2) compared to the without CDSS condition (Mean = 2.05, 95%CI: 0.3-3.8) whereas there was no significant difference in frequencies of "general utterances" when using CDSS (Mean = 4.62, 95%CI: 3.1-6.1) compared to without CDSS (Mean = 5.14 95%CI: 4.4-5.9). CONCLUSION A CDSS that integrates key decision-making components (sensemaking, anticipation, and managing complexity) can trigger and enrich communication between clinicians and enhance the clinical management of CHD patients. For patients with complex and subspecialized diseases such as CHD, a well-designed CDSS can become part of a multifaceted solution that includes knowledge translation, broader communication around interpretation of information, and access to additional expertise to support CHD specific decision-making.
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Affiliation(s)
- Azadeh Assadi
- Labatt Family Heart Centre, Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada.,HumanEra, Institute of Biomaterials and Biomedical Engineering, Department of Engineering and Applied Sciences, University of Toronto, Toronto, ON, Canada
| | - Peter C Laussen
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada.,Executive Vice President for Health Affairs, Boston Children's Hospital, Boston, MA, United States.,Professor of Anaesthesia, Harvard Medical School, Boston, MA, United States
| | - Gabrielle Freire
- Division of Emergency Medicine, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Marzyeh Ghassemi
- Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Boston, MA, United States.,Institute for Medical Engineering & Science, Massachusetts Institute of Technology, Boston, MA, United States.,Vector Institute, Toronto, ON, Canada.,CIFAR AI Chair, Vector Institute, Toronto, ON, Canada
| | - Patricia C Trbovich
- HumanEra, Institute of Biomaterials and Biomedical Engineering, Department of Engineering and Applied Sciences, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Research and Innovation, North York General Hospital, Toronto, ON, Canada
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Strobel AM, Alblaihed L. Cardiac Emergencies in Kids. Emerg Med Clin North Am 2021; 39:605-625. [PMID: 34215405 DOI: 10.1016/j.emc.2021.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Encountering a child with congenital heart disease after surgical palliation in the emergency department, specifically the single-ventricle or ventricular assist device, without a basic familiarity of these surgeries can be extremely anxiety provoking. Knowing what common conditions or complications may cause these children to visit the emergency department and how to stabilize will improve the chance for survival and is the premise for this article, regardless of practice setting.
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Affiliation(s)
- Ashley M Strobel
- Department of Emergency Medicine, University of Minnesota Medical School, Hennepin County Medical Center, University of Minnesota Masonic Children's Hospital, 701 South Park Avenue R2.123, Minneapolis, MN 55414, USA.
| | - Leen Alblaihed
- Department of Emergency Medicine, University of Maryland School of Medicine, University of Maryland Upper Chesapeake Medical System, 500 Upper Chesapeake Drive, Bel Air, MD 21014, USA
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Abstract
BACKGROUND We aimed to conduct a multi-centre study characterising emergency department utilisation and critical readmissions experienced by children with Fontan circulation. METHODS We conducted a retrospective review of children who underwent the Fontan operation at three institutions (i.e., centres A, B, and C) between 2009 and 2014, with follow-up through December 2015. Multi-variable analyses were performed to determine factors associated for emergency department utilisation within 1 year of surgery, emergency department utilisation at any time following surgery, or critical readmission (defined as admission to ICU, operating room, or cardiac catheterisation). RESULTS We reviewed 297 patients, of which 147 patients (49%) had 607 emergency department encounters. Forty-six patients (15%) required 71 critical readmissions. Multi-variable analyses revealed centre C (p = 0.02) and post-operative hospitalisation ≥ 14 days (p = 0.03) to be significantly associated with emergency department utilisation within 1 year, whereas centre B (p < 0.001), post-operative hospitalisation ≥ 14 days (p = 0.002), and African-American/Black race (p = 0.04) were significantly associated with critical readmission. CONCLUSIONS In this multi-centre study, nearly half of patients with Fontan circulation received emergency department care, often presenting with high disease acuity requiring readmission. Emergency department utilisation and need for critical readmission were independently influenced by the centre at which surgery was performed, prolonged post-operative hospitalisation, and racial background. These data could help guide quality improvement efforts aimed at reducing morbidity in this unique patient population.
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Assadi A, Laussen P, Trbovich P. Mixed-methods approach to understanding clinician macrocognition in the design of a clinical decision support tool: a study protocol. BMJ Open 2020; 10:e035313. [PMID: 32213525 PMCID: PMC7170622 DOI: 10.1136/bmjopen-2019-035313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The anatomic variants of congenital heart disease (CHD) are multiple. The increased survival of these patients and disposition into communities has led to an increase in their acute presentation to non-CHD experts in primary care clinics and emergency departments. Given the vulnerability and fragility of these patients in the face of acute illness, new clinical decision support systems (CDSS) are urgently needed to better translate the best practice recommendations for the care of these patients. This study aims to understand the perceived confidence and macrocognitive processes of non-CHD experts (emergency medicine physicians) and CHD experts (paediatric cardiac intensivists) when treating children with CHD during acute illness and apply this to optimise the design of a CDSS (MyHeartPass™) for these patients. METHODS AND ANALYSIS The first phase of the study involves a survey of non-CHD experts and CHD experts to understand their perceived confidence as it relates to treating acutely ill patients with CHD. The second phase is a qualitative cognitive task analysis using critical decision method to characterise and compare the macrocognitive processes used by non-CHD experts and CHD experts during the critical decision making. In phases 3 and 4, heuristic evaluation and usability testing of the CDSS will be completed. These results will be used to inform design changes to the chosen CDSS (MyHeartPass™). In the final phase, a within-participant simulation design will be used to study the effect of the CDSS on clinical decision making compared with baseline (without use of CDSS). ETHICS AND DISSEMINATION Ethics approval from The Hospital for Sick Children in Toronto, Ontario, Canada has been obtained for all phases. Results will be published in peer-reviewed journals and presented at relevant conferences. On successful completion of these studies, it is anticipated that there will be a controlled implementation of the redesigned CDSS.
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Affiliation(s)
- Azadeh Assadi
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Biomaterials and Biomedical Engineering, University of Toronto Faculty of Applied Science and Engineering, Toronto, Ontario, Canada
| | - Peter Laussen
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Patricia Trbovich
- Human Era, Department of Research and Innovation, North York General Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Yabrodi M, Mastropietro CW. Hypoplastic left heart syndrome: from comfort care to long-term survival. Pediatr Res 2017; 81:142-149. [PMID: 27701379 PMCID: PMC5313512 DOI: 10.1038/pr.2016.194] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 08/09/2016] [Indexed: 12/16/2022]
Abstract
The management of hypoplastic left heart syndrome (HLHS) has changed substantially over the past four decades. In the 1970s, children with HLHS could only be provided with supportive care. As a result, most of these unfortunate children died within the neonatal period. The advent of the Norwood procedure in the early 1980s has changed the prognosis for these children, and the majority now undergoing a series of three surgical stages that can support survival beyond the neonatal period and into early adulthood. This review will focus on the Norwood procedure and the other important innovations of the last half century that have improved our outlook toward children born with HLHS.
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Affiliation(s)
- Mouhammad Yabrodi
- Department of Pediatrics, Section of Critical Care, Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine, Indianapolis, Indiana
| | - Christopher W. Mastropietro
- Department of Pediatrics, Section of Critical Care, Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine, Indianapolis, Indiana
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Fontan Operation: Indications, Short and Long Term Outcomes. Indian J Pediatr 2015; 82:1147-56. [PMID: 26088549 DOI: 10.1007/s12098-015-1803-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 05/25/2015] [Indexed: 10/23/2022]
Abstract
Fontan operation, since its original description, has undergone a number of modifications so that it is now a staged, total cavo-pulmonary connection with fenestration. Stage I is palliation, depending upon the pathophysiology of the defect complex in early life, Stage II is bidirectional Glenn at about the age of 6 mo and Stage III is transfer of inferior vena caval blood to the pulmonary circuit along with fenestration between 2 to 4 y. Any patient that has only one functioning ventricle is a candidate for Fontan surgery. The morbidity and mortality have remarkably improved since the institution of staged, total cavo-pulmonary connection with fenestration. Complications during follow up continue to occur, though diminished with the newer modifications, and should be promptly addressed.
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Chauhan M, Mastropietro CW. Hypoplastic left heart syndrome in the emergency department: an update. J Emerg Med 2013; 46:e51-4. [PMID: 24188609 DOI: 10.1016/j.jemermed.2013.08.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 06/10/2013] [Accepted: 08/15/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Among currently available surgical options for the first stage of surgery for infants with hypoplastic left heart syndrome (HLHS), the hybrid procedure is relatively new and less well known among primary care and emergency physicians. This procedure involves placement of a stent within the ductus arteriosus to maintain systemic blood flow and bands around both pulmonary arteries to prevent pulmonary overcirculation. As the number of infants undergoing this procedure increases, emergency physicians will likely encounter them in their practice and should be familiar with their unique physiology and potential complications. OBJECTIVES Review various emergency department (ED) presentations and management of a patient after the hybrid procedure. CASE REPORT A 4-month-old male infant with HLHS who had undergone an uncomplicated hybrid procedure in the neonatal period presented to a community ED with severe metabolic acidosis and poor perfusion. He was intubated and received mechanical ventilation with an inspired oxygen concentration of 60%. Initial capillary blood gas revealed PO2 59 torr, which, in the context of his clinical presentation, was suggestive of pulmonary overcirculation with "systemic steal." Approximately 60 min after presentation to the ED, he experienced a bradycardic arrest. He expired 40 min later. CONCLUSION This case highlights the potential of infants who undergo the hybrid procedure for HLHS to present to the ED with high acuity and, accordingly, the importance of adding this disease process to the vast burden of knowledge facing ED physicians.
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Affiliation(s)
- Monika Chauhan
- Department of Pediatrics, Division of Critical Care, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, Michigan
| | - Christopher W Mastropietro
- Department of Pediatrics, Division of Critical Care, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, Michigan
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Ohye RG, Schonbeck JV, Eghtesady P, Laussen PC, Pizarro C, Shrader P, Frank DU, Graham EM, Hill KD, Jacobs JP, Kanter KR, Kirsh JA, Lambert LM, Lewis AB, Ravishankar C, Tweddell JS, Williams IA, Pearson GD. Cause, timing, and location of death in the Single Ventricle Reconstruction trial. J Thorac Cardiovasc Surg 2012; 144:907-14. [PMID: 22901498 DOI: 10.1016/j.jtcvs.2012.04.028] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Revised: 03/15/2012] [Accepted: 04/13/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVES The Single Ventricle Reconstruction trial randomized 555 subjects with a single right ventricle undergoing the Norwood procedure at 15 North American centers to receive either a modified Blalock-Taussig shunt or right ventricle-to-pulmonary artery shunt. Results demonstrated a rate of death or cardiac transplantation by 12 months postrandomization of 36% for the modified Blalock-Taussig shunt and 26% for the right ventricle-to-pulmonary artery shunt, consistent with other publications. Despite this high mortality rate, little is known about the circumstances surrounding these deaths. METHODS There were 164 deaths within 12 months postrandomization. A committee adjudicated all deaths for cause and recorded the timing, location, and other factors for each event. RESULTS The most common cause of death was cardiovascular (42%), followed by unknown cause (24%) and multisystem organ failure (7%). The median age at death for subjects dying during the 12 months was 1.6 months (interquartile range, 0.6 to 3.7 months), with the highest number of deaths occurring during hospitalization related to the Norwood procedure. The most common location of death was at a Single Ventricle Reconstruction trial hospital (74%), followed by home (13%). There were 29 sudden, unexpected deaths (18%), although in retrospect, 12 were preceded by a prodrome. CONCLUSIONS In infants with a single right ventricle undergoing staged repair, the majority of deaths within 12 months of the procedure are due to cardiovascular causes, occur in a hospital, and within the first few months of life. Increased understanding of the circumstances surrounding the deaths of these single ventricle patients may reduce the high mortality rate.
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Affiliation(s)
- Richard G Ohye
- University of Michigan Medical School, Ann Arbor, MI, USA.
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