Hypoplastic left heart syndrome: consensus and controversies in 2007

Establishing a neonatology consultation program: extending care beyond the neonatal intensive care unit

Neonates can be cared for in neonatal, pediatric, or cardiac intensive care units, and general and subspecialty pediatric units. Disposition is based on phase of care, gestational and postnatal age, birth weight, specific cardiac or surgical diagnoses, and co-existing medical morbidities. In addition, neonates may transfer between the neonatal intensive care unit (NICU) and other units several times throughout their hospitalization. As such, care for high-risk infants with ongoing neonatal morbidities (often related to prematurity or congenital anomalies) is provided in units with varying neonatal expertise. In this perspective, we provide a framework for the design and implementation of a neonatology consultation service for infants cared for in clinical units outside the NICU. We describe the core principles of effective neonatology consultation and focus on understanding hospital/unit workflow, team composition, patient selection, billing and compliance, and offer suggestions for research initiatives and educational opportunities.

Milrinone for treatment of elevated lactate in the pre-operative newborn with hypoplastic left heart syndrome

BACKGROUND

There is a paucity of information reported regarding the use of milrinone in patients with hypoplastic left heart syndrome prior to the Norwood procedure. At our institution, milrinone is initiated in the pre-operative setting when over-circulation and elevated serum lactate levels develop. We aimed to review the responses associated with the administration of milrinone in the pre-operative hypoplastic left heart syndrome patient. Second, we compared patients who received high- versus low-dose milrinone prior to Norwood procedure.

METHODS

Single-centre retrospective study of patients diagnosed with hypoplastic left heart syndrome between January 2000 and December 2019 who underwent Norwood procedure. Patient characteristics and outcomes were compared.

RESULTS

During the study period, 375 patients were identified; 79 (21%) received milrinone prior to the Norwood procedure with median lactate 2.55 mmol/l, and SpO2 93%. Patients who received milrinone were older at the time of Norwood procedure (6 vs. 5 days) and were more likely to be intubated and sedated. In a subset analysis stratifying patients to low- versus high-dose milrinone, median lactate decreased from time of initiation (2.39 vs 2.75 to 1.6 vs 1.8 mmol/l) at 12 hours post-initiation, respectively. Repeated measures analysis showed a significant decrease in lactate levels by 4 hours following initiation of milrinone, that persisted over time, with no significant difference in mean arterial pressure.

CONCLUSIONS

The use of milrinone in the pre-operative over-circulated hypoplastic left heart syndrome patient is well tolerated, is associated with decreased lactate levels, and was not associated with significant hypotension or worsening of excess pulmonary blood flow.

Perioperative Care Models for Neonates With Congenital Heart Disease: Evolving Role of Neonatology Within the Cardiac Intensive Care Unit

A multidisciplinary team is needed to optimally care for infants with congenital heart disease (CHD). Different compositions of teams trained in cardiology, critical care, cardiothoracic surgery, anesthesia, and neonatology have been identified as being primarily responsible for perioperative care of this high-risk population in dedicated cardiac intensive care units (CICUs). Although the specific role of cardiac intensivists has become more well defined over the past two decades, the responsibilities of neonatologists remain highly variable in the CICU with neonatologists providing care along with a unique spectrum of primary, shared, or consultative care. The neonatologist can function as the primary physician and assume all or share responsibility with the cardiac intensivists for the management of infants with CHD. A neonatologist can provide care as a secondary consultant physician in a supportive role for the primary CICU team. Additionally, neonates with CHD can be mixed with older children in a CICU, cohorted in a dedicated space within the CICU or placed in a stand-alone infant CICU without older children. Although variations exist between centers on which model of care is deployed and the location within a CICU, characterization of current practice patterns represents the initial step required to determine optimal best practices to improve the quality of care for neonates with cardiac disease. In this manuscript, we present four models utilized in the United States in which the neonatologist provides neonatal-cardiac-focused care in a dedicated CICU. We also outline the different permutations of location where neonates can be cared for in dedicated pediatric/infant CICUs.

A dynamic Norwood mortality estimation: Characterizing individual, updated, predicted mortality trajectories after the Norwood operation

Objective

Post-Norwood mortality remains high and unpredictable. Current models for mortality do not incorporate interstage events. We sought to determine the association of time-related interstage events, along with (pre)operative characteristics, with death post-Norwood and subsequently predict individual mortality.

Methods

From the Congenital Heart Surgeons' Society Critical Left Heart Obstruction cohort, 360 neonates underwent Norwood operations from 2005 to 2016. Risk of death post-Norwood was modeled using a novel application of parametric hazard analysis, in which baseline and operative characteristics and time-related adverse events, procedures, and repeated weight and arterial oxygen saturation measurements were considered. Individual predicted mortality trajectories that dynamically update (increase or decrease) over time were derived and plotted.

Results

After the Norwood, 282 patients (78%) progressed to stage 2 palliation, 60 patients (17%) died, 5 patients (1%) underwent heart transplantation, and 13 patients (4%) were alive without transitioning to another end point. In total, 3052 postoperative events occurred and 963 measures of weight and oxygen saturation were obtained. Risk factors for death included resuscitated cardiac arrest, moderate or greater atrioventricular valve regurgitation, intracranial hemorrhage/stroke, sepsis, lower longitudinal oxygen saturation, readmission, smaller baseline aortic diameter, smaller baseline mitral valve z-score, and lower longitudinal weight. Each patient's predicted mortality trajectory varied as risk factors occurred over time. Groups with qualitatively similar mortality trajectories were noted.

Conclusions

Risk of death post-Norwood is dynamic and most frequently associated with time-related postoperative events and measures, rather than baseline characteristics. Dynamic predicted mortality trajectories for individuals and their visualization represent a paradigm shift from population-derived insights to precision medicine at the patient level.

Initial Counseling Prior to Palliation for Hypoplastic Left Heart Syndrome: 2021 vs 2011

We sought to examine current practices and changes in practice regarding initial counseling for families of patients with hypoplastic left heart syndrome (HLHS) given the evolution of options and outcomes over time. Counseling (Norwood with Blalock-Taussig-Thomas shunt (NW-BTT), NW with right ventricle to pulmonary artery conduit (NW-RVPA), hybrid palliation, heart transplantation, or non-intervention/hospice (NI)) for patients with HLHS were queried via questionnaire of pediatric care professionals in 2021 and compared to identical questionnaire from 2011. Of 322 respondents in 2021 (39% female), 299 respondents were cardiologists (92.9%), 17cardiothoracic surgeons (5.3%), and 6 were nurse practitioners (1.9%). Respondents were largely from North America (96.9%). In 2021, NW-RVPA procedure was the preferred palliation for standard risk HLHS patient (61%) and was preferred across all US regions (p < 0.001). NI was offered as an option by 71.4% of respondents for standard risk patients and was the predominant strategy for patients with end-organ dysfunction, chromosomal abnormality, and prematurity (52%, 44%, and 45%, respectively). The hybrid procedure was preferred for low birth-weight infants (51%). In comparison to the identical 2011 questionnaire (n = 200), the NW-RVPA was endorsed more in 2021 (61% vs 52%, p = 0.04). For low birth-weight infants, hybrid procedure was more recommended than in 2011 (51% vs 21%, p < 0.001). The NW-RVPA operation is the most recommended strategy throughout the US for infants with HLHS. The hybrid procedure for low birth-weight infants is increasingly recommended. NI continues to be offered even in standard risk patients with HLHS.

Impact of Home Monitoring Program and Early Gastrostomy Tube on Interstage Outcomes following Stage 1 Norwood Palliation

Nutritional management and home monitoring programs (HMPs) may be beneficial for improving interstage morbidity and mortality following stage I Norwood palliation (S1P) for hypoplastic left heart syndrome (HLHS). We recognized an increasing trend towards early feeding gastrostomy tube (GT) placement prior to discharge in our institution, and we aimed to investigate the effect of HMPs and GTs on interstage mortality and growth parameters. Single-institutional review at a tertiary referral center between 2008 and 2018. Individual patient charts were reviewed in the electronic medical record. Those listed for transplant or hybrid procedures were excluded. Baseline demographics, operative details, and interstage outcomes were analyzed in GT and non-GT patients (nGT). Our HMP was instituted in 2009, and patients were analyzed by era: I (early, 2008-2012), II (intermediate, 2013-2016), and III (recent, 2017-2018). 79 patients were included in the study: 29 nGTs and 50 GTs. GTs had higher number of preoperative risk factors more S1P complications, longer ventilation times, longer lengths of stay, and shorter times to readmission. There were no differences in interstage mortality or overall mortality between groups. There was one readmission for a GT-related issue with no periprocedural complications in the group. Weight gain doubled after GT placement in the interstage period while waiting periods for placement decreased across Eras. HMPs and early GTs, especially for patients with high-risk features, provide a dependable mode of nutritional support to optimize somatic growth following S1P.

Current Application of NIRS and CPB Initiation Times in German Cardiac Surgery Centers: A Survey

Near-infrared spectroscopy (NIRS) has been widely used in cardiac surgery to monitor cerebral oxygen supply. The initiation and perioperative management of cardiopulmonary bypass (CPB) constitute critical events in modifying the normal physiology of adequate blood and oxygen supply to the brain. First, little is known about how frequent NIRS is really used. Second, there are varying practices on how to initiate CPB. We therefore conducted a survey in Germany to get an idea of NIRS usage in cardiac surgery for the duration of initiation of CPB protocols. A web-based e-mail survey using commercial SurveyMonkey^® (SurveyMonkey, San Mateo, CA) software was conducted in August 2017 including all German cardiac surgery centers. About 75% of the perfusion departments do not use NIRS as a standard monitoring device. It is usually reserved for clinical scenarios where cerebral perfusion might be impaired such as aortic arch surgery or carotid artery stenosis. Only one-third of the departments use a standardized duration of initiation of CPB despite a common belief of potential harm with fast initiation. The usual applied time to initiate CPB ranges from 30 to 120 seconds. Our survey revealed that the NIRS technology is only used in specific types of cardiac surgery to this date. In addition, there is a clear need for scientific studies on how to initiate CPB in the best way for the patient.

Combined Hybrid Procedure and VAD insertion in 9 High-Risk Neonates and Infants with HLHS

BACKGROUND

We report nine high-risk neonates and infants with HLHS stabilized with a Hybrid Approach + VAD insertion (Hybrid+VAD) in preparation for transplantation.

METHODS

Nine patients with HLHS (7 neonates, 2 infants) presented with anatomical and/or physiological features associated with increased risk for conventional univentricular palliation with the Norwood Operation (large coronary sinusoids/fistulas, severe tricuspid regurgitation, cardiogenic shock, restrictive atrial septum). These patients underwent combined VAD insertion (Berlin EXCOR) and stage 1 hybrid palliation (application of bilateral pulmonary bands, stent placement in the PDA, and atrial septectomy if needed). During this same era, at our institution, 41 neonates underwent Norwood Operation, three neonates underwent Hybrid Approach "Stage 1" without VAD, and three HLHS patients were supported with prostaglandin while awaiting transplantation.

RESULTS

At Hybrid+VAD insertion, median age = 20 days (range = 13-143) and median weight = 3.25 kilograms (range = 2.43-4.2). Six patients survive (67%) and three patients died (33%). Five survivors are at home doing well after successful transplantation and one survivor is doing well in the ICU on VAD support awaiting transplantation. Only one of six survivors (16.7%) required intubation more than 10 days after Hybrid+VAD insertion. In eight patients no longer on VAD, median length of VAD support was 119.5 days (range = 56-196 days).

CONCLUSIONS

High-risk patients with HLHS who are suboptimal candidates for Norwood palliation can be successfully stabilized with pulsatile VAD insertion along with hybrid palliation while awaiting cardiac transplantation; these patients may be extubated and optimized for transplantation while on VAD.

Computed tomography findings of mediastinitis after cardiovascular surgery

BACKGROUND

To our knowledge, no systematic study has been conducted on computed tomography (CT) imaging of mediastinitis in children post-cardiovascular surgery. We aimed to assess the CT findings of pediatric patients diagnosed with mediastinitis after cardiovascular surgery.

METHODS

We included 28 pediatric patients with suspected mediastinitis after undergoing cardiovascular surgery and who underwent CT. Patients were divided into a group with mediastinitis requiring antibiotic therapy (n = 15) confirmed by positive bacterial culture from the mediastinum and a group without mediastinitis (n = 13). Fisher's exact test was used to compare the following CT findings between the two groups: (i) mediastinal fluid collection; (ii) free gas bubble within fluid collection; (iii) sternal destruction; and (iv) capsular ring enhancement. The enhancement extent was categorized into the following four grades: whole rim enhancement, >50% of the rim enhancement, <50% of the rim enhancement, and no rim enhancement. A receiver operating characteristic curve analysis was performed to establish a cut-off point for obtaining the maximum diagnostic accuracy.

RESULTS

A significant difference was observed between patients, with and without mediastinitis in sternal destruction (73.6% vs 0%, P = <0.0001) and capsular ring enhancement (100.0% vs 38.5%, P = 0.0004). By using a cut-off grade of the whole rim enhancement, the estimated sensitivity and specificity for mediastinitis diagnosis were 100% and 92.3%, respectively.

CONCLUSION

Computed tomography findings of sternal destruction and capsular ring enhancement were observed more in patients with mediastinitis than in those without mediastinitis, and should be assessed carefully to diagnose mediastinitis accurately in pediatric patients who have undergone cardiac surgery.

Center Variation in Chest Tube Duration and Length of Stay After Congenital Heart Surgery

BACKGROUND

Nearly every child undergoing congenital heart surgery has chest tubes placed intraoperatively. Center variation in removal practices and impact on outcomes has not been well described. This study evaluated variation in chest tube management practices and outcomes across centers.

METHODS

The study included patients undergoing any of 10 benchmark operations from June 2017 to May 2018 at participating Pediatric Acute Care Cardiology Collaborative (PAC³) and Pediatric Cardiac Critical Care Consortium (PC⁴) centers. Clinical data from PC⁴ centers were merged with chest tube data from PAC³ centers. Practices and outcomes were compared across centers in univariate and multivariable analysis.

RESULTS

The cohort included 1029 patients (N = 9 centers). Median chest tube duration varied significantly across centers for 9 of 10 benchmark operations (all P ≤ .03), with a "model" center noted to have the shortest duration for 9 of 10 operations (range, 27.9% to 87.4% shorter duration vs other centers across operations). This effect persisted in multivariable analysis (P < .0001). The model center had higher volumes of chest tube output before removal (median, 8.5 mL/kg/24 h [model] vs 2.2 mL/kg/24 h [other centers]; P < .001], but it did not have higher rates of chest tube reinsertion (model center 1.3% vs 2.1%; P = .59) or readmission for pleural effusion (model center 4.4% vs 3.0%; P = .31), and had the shortest length of stay for 7 of 10 operations.

CONCLUSIONS

This study suggests significant center variation in chest tube removal practices and associated outcomes after congenital heart surgery. Best practices used at the model center have informed the design of an ongoing collaborative learning project aimed at reducing chest tube duration and length of stay.

Content validity of the developmental care scale for neonates with CHD

PurposeNeuroprotective developmental care is paramount for neonates with CHD. Although several developmental care scales exist, either they have not been psychometrically tested or were not designed for the needs of neonates with CHD. The purpose of this study is to describe item development and content validity testing of the developmental care scale for neonates with CHD, which measures five domains of the developmental care provided by bedside nurses to neonates in the cardiac ICU: sleep, pain and stress management, activities of daily living, family-centred care, and environment.

METHODS

For this cross-sectional study, items were developed based on clinical expertise and the core measures for developmental care. In this study, seven experts provided content validity ratings of items for total scale and subscale fit and relevance. A content validity index was used to determine item retention. Item modifications and additions were based on expert feedback.

RESULTS

Expert ratings provided evidence of content validity on 24 of 53 items within the five domains of developmental care. A total of 24 items were deleted, and five items with low content validity ratings were retained, because of conceptual importance, and revised. An additional 11 items were added based on expert qualitative feedback.

CONCLUSIONS

This study provided evidence of content validity of the developmental care scale for neonates with CHD by researchers and bedside nurses caring for these neonates. Further psychometric testing is warranted to provide evidence of internal consistency reliability, construct validity, and to identify variables that influence quality of the developmental care.

Pathophysiology, adaptation, and imaging of the right ventricle in Fontan circulation

The Fontan procedure, which creates a total cavopulmonary anastomosis and represents the final stage of palliation for hypoplastic left heart syndrome, generates a unique circulation relying on a functionally single right ventricle (RV). The RV pumps blood in series around the systemic and pulmonary circulation, which requires adaptations to the abnormal volume and pressure loads. Here, we provide a complete review of RV adaptations as the RV assumes the role of the systemic ventricle, the progression of RV dysfunction to a distinct pattern of heart failure unique to this disease process, and the assessment and management strategies used to protect and rehabilitate the failing RV of Fontan circulation.

A Review of Goal-Directed Cardiopulmonary Bypass Management in Pediatric Cardiac Surgery

Cardiopulmonary bypass perfusion management significantly affects postoperative outcomes. In recent years, the principles of goal-directed therapy have been applied to the field of cardiothoracic surgery to improve patient outcomes. Goal-directed therapy involves continuous peri- and postoperative monitoring of vital clinical parameters to tailor perfusion to each patient's specific needs. Closely measured parameters include fibrinogen, platelet count, lactate, venous oxygen saturation, central venous oxygen saturation, mean arterial pressure, perfusion flow rate, and perfusion pulsatility. These parameters have been shown to influence postoperative fresh frozen plasma transfusion rate, coagulation state, end-organ perfusion, and mortality. In this review, we discuss the recent paradigm shift in pediatric perfusion management toward goal-directed perfusion.

Applying Lessons from an Inaugural Clinical Pathway to Establish a Clinical Effectiveness Program

INTRODUCTION

Clinical effectiveness (CE) programs promote standardization to reduce unnecessary variation and improve healthcare value. Best practices for successful and sustainable CE programs remain in question. We developed and implemented our inaugural clinical pathway with the aim of incorporating lessons learned in the build of a CE program at our academic children's hospital.

METHODS

The Lucile Packard Children's Hospital Stanford Heart Center and Center for Quality and Clinical Effectiveness partnered to develop and implement an inaugural clinical pathway. Project phases included team assembly, pathway development, implementation, monitoring and evaluation, and improvement. We ascertained Critical CE program elements by focus group discussion among a multidisciplinary panel of experts and key affected groups. Pre and postintervention compared outcomes included mechanical ventilation duration, cardiovascular intensive care unit, and total postoperative length of stay.

RESULTS

Twenty-seven of the 30 enrolled patients (90%) completed the pathway. There was a reduction in ventilator days (mean 1.0 + 0.5 versus 1.9 + 1.3 days; P < 0.001), cardiovascular intensive care unit (mean 2.3 + 1.1 versus 4.6 + 2.1 days; P < 0.001) and postoperative length of stay (mean 5.9 + 1.6 versus 7.9 + 2.7 days; P < 0.001) compared with the preintervention period. Elements deemed critical included (1) project prioritization for maximal return on investment; (2) multidisciplinary involvement; (3) pathway focus on best practices, critical outcomes, and rate-limiting steps; (4) active and flexible implementation; and (5) continuous data-driven and transparent pathway iteration.

CONCLUSIONS

We identified multiple elements of successful pathway implementation, that we believe to be critical foundational elements of our CE program.

Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association

Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.

Preoperative Feeding Neonates With Cardiac Disease

BACKGROUND

The potential for necrotizing enterocolitis (NEC) in neonates requiring cardiac surgery has contributed largely to wide feeding practice variations and a hesitation to initiate enteral feeding during the preoperative period, specifically those patients with hypoplastic left heart syndrome.

METHODS

A retrospective chart review of neonates undergoing cardiac surgery at a single institution between July 2011 and July 2013 was performed. The primary objective of this study was to determine if preoperative feeding was associated with NEC in neonates requiring cardiac surgery. Univariable and multivariable analyses were performed to evaluate the relationship between preoperative feeding and NEC. Secondary outcomes including growth failure, total ventilator days, total length of stay, and tube-assisted feeds at discharge were analyzed.

RESULTS

One hundred thirty consecutive neonates who required cardiac surgery were included in the analysis. Preoperative feeding occurred in 61% (n = 79). The overall prevalence of NEC was 9% (12/130), including three neonates with surgical NEC. There was no difference in the prevalence of NEC between the preoperative feeding and nil per os (NPO) groups. Preoperative NPO status was associated with longer ventilator-dependent days ( P = .01) but was not associated with worsened growth failure, longer length of stay, or increased prevalence of tube-assisted feeds at discharge.

CONCLUSION

In this study cohort, preoperative feeding was associated with a low prevalence of NEC. Larger prospective studies evaluating the safety and benefits of preoperative feeding in cardiac neonates are warranted.

Training Pathways in Pediatric Cardiac Intensive Care: Proceedings From the 10th International Conference of the Pediatric Cardiac Intensive Care Society

The increase in pediatric cardiac surgical procedures and establishment of the practice of pediatric cardiac intensive care has created the need for physicians with advanced and specialized knowledge and training. Current training pathways to become a pediatric cardiac intensivist have a great deal of variability and have unique strengths and weaknesses with influences from critical care, cardiology, neonatology, anesthesiology, and cardiac surgery. Such variability has created much confusion among trainees looking to pursue a career in our specialized field. This is a report with perspectives from the most common advanced fellowship training pathways taken to become a pediatric cardiac intensivist as well as various related topics including scholarship, qualifications, and credentialing.

Management Options and Outcomes for Neonatal Hypoplastic Left Heart Syndrome in the Early Twenty-First Century

Without surgical treatment, neonatal hypoplastic left heart syndrome (HLHS) mortality in the first year of life exceeds 90 % and, in spite of improved surgical outcomes, many families still opt for non-surgical management. The purpose of this study was to investigate trends in neonatal HLHS management and to identify characteristics of patients who did not undergo surgical palliation. Neonates with HLHS were identified from a serial cross-sectional analysis using the Healthcare Cost and Utilization Project's Kids' Inpatient Database from 2000 to 2012. The primary analysis compared children undergoing surgical palliation to those discharged alive without surgery using a binary logistic regression model. Multivariate logistic regression was conducted to determine factors associated with treatment choice. A total of 1750 patients underwent analysis. Overall hospital mortality decreased from 35.3 % in 2000 to 22.9 % in 2012. The percentage of patients undergoing comfort care discharge without surgery also decreased from 21.2 to 14.8 %. After controlling for demographics and comorbidities, older patients at presentation were less likely to undergo surgery (OR 0.93, 0.91-0.96), and patients in 2012 were more likely to undergo surgery compared to those in prior years (OR 1.5, 1.1-2.1). Discharge without surgical intervention is decreasing with a 30 % reduction between 2000 and 2012. Given the improvement in surgical outcomes, further dialogue about ethical justification of non-operative comfort or palliative care is warranted. In the meantime, clinicians should present families with surgical outcome data and recommend intervention, while supporting their option to refuse.

Development of Standardized Clinical Assessment and Management Plans (SCAMPs) in Plastic and Reconstructive Surgery

Background:

With rising cost of healthcare, there is an urgent need for developing effective and economical streamlined care. In clinical situations with limited data or conflicting evidence-based data, there is significant institutional and individual practice variation. Quality improvement with the use of Standardized Clinical Assessment and Management Plans (SCAMPs) might be beneficial in such scenarios. The SCAMPs method has never before been reported to be utilized in plastic surgery.

Methods:

The topic of immediate breast reconstruction was identified as a possible SCAMPs project. The initial stages of SCAMPs development, including planning and implementation, were entered. The SCAMP Champion, along with the SCAMPs support team, developed targeted data statements. The SCAMP was then written and a decision-tree algorithm was built. Buy-in was obtained from the Division of Plastic Surgery and a SCAMPs data form was generated to collect data.

Results:

Decisions pertaining to “immediate implant-based breast reconstruction” were approved as an acceptable topic for SCAMPs development. Nine targeted data statements were made based on the clinical decision points within the SCAMP. The SCAMP algorithm, and the SDF, required multiple revisions. Ultimately, the SCAMP was effectively implemented with multiple iterations in data collection.

Conclusions:

Full execution of the SCAMP may allow better-defined selection criteria for this complex patient population. Deviations from the SCAMP may allow for improvement of the SCAMP and facilitate consensus within the Division. Iterative and adaptive quality improvement utilizing SCAMPs creates an opportunity to reduce cost by improving knowledge about best practice.

Long-term progression and survival following Norwood Single Ventricle Reconstruction

PURPOSE OF REVIEW

Much data exist concerning Norwood discharge mortality. Less is known about late survival. Examining the available data in light of the Single Ventricle Reconstruction trial is insightful as focus shifts toward long-term survival.

RECENT FINDINGS

Data from 2000 to 2001 demonstrated approximately 40-50% 10-year survival, 30-40% or less between 10 and 15 years. The shape of the curves was characteristic; the majority of deaths within the first year, followed by a late constant phase. Publications from 2001 to 2005 suggested that various combinations of technical and perioperative modifications allowed hospital discharge survivals as high as 90-94%. As results matured (2005-2010) a consistent message was that, although the shape of the newer curves was similar (highest hazard in the first 1 year), higher hospital survival shifted the later phase to yield better long-term survival (70-85% between 5 and 10 years). Some emphasized right ventricle-based shunts as a 'cause' of improving results. Since 2010, the Single Ventricle Reconstruction trial has matured and has increasingly shifted opinion away from the right ventricle shunt as a 'cause' of improved results. The survival of the right ventricle shunt group is slightly higher at 3 years, but the 1-year statistical significance has been lost and the two groups converge. As the Single Ventricle Reconstruction study was based on the interaction between randomized shunt and survival, the secondary and other endpoint analyses must be cautiously considered.

SUMMARY

The current English-language literature suggests a 60-80% 5-10 year survival expectation. The shape of the survival curve remains; the highest hazard remains the first year before a later, stable phase is reached. Rather than a 'magic bullet' theory surrounding one technique or practice, centers have differentially adopted various combinations to optimize Norwood survival. Optimizing interstage I survival is a challenge to further increase the percentage of patients reaching the late, stable phase.

Early results of neurodevelopment following hybrid stage I for hypoplastic left heart syndrome

Motor skills and neurodevelopment in infants with hypoplastic left heart syndrome (HLHS) who have undergone Hybrid Stage I palliation is unknown. The purpose of this study is to assess early neurodevelopment in infants with HLHS after Hybrid Stage I palliation. Developmental assessment was performed in HLHS infants who underwent Hybrid Stage I palliation at 2 and 4 months of age using the Test of Infant Motor Performance, and at 6 months of age, prior to undergoing the second staged surgery, using the Bayley Scales of Infant and Toddler Development, 3rd edition (Bayley-III). Results were compared to healthy control subjects and norm-referenced data. The HLHS group scored between -1 and -2 standard deviations (SD) below the mean at 2 months of age (p = 0.002), and within -1 SD of the mean, at 4 months of age (p = 0.0019), on the TIMP. Compared to the control group, composite motor skills were significantly lower at 6 months of age on the Bayley-III in the HLHS group (p = 0.0489), however, not significant for cognitive (p = 0.29) or language (p = 0.68). Percentile rank motor scores were 17 ± 20 % in the HLHS group compared to 85 ± 12 % for the healthy age-matched control group. Infants with HLHS who undergo Hybrid Stage I palliation score lower on standardized motor skill tests compared to healthy age-matched controls and the norm-referenced population. This suggests that infants with HLHS have poorer motor skill performance than typically developing infants at 6 months of age.

Gathering and learning from relevant clinical data: a new framework

Given the rising costs of health care in today's economic environment, the need for effective, value-driven care has never been more pressing. While the U.S. health care system strives continually to improve patient outcomes, it struggles with the inadequacies due to variation in care and the inefficiencies of unnecessary resource utilization. The tools traditionally used to study care, from retrospective studies to randomized controlled trials, may be inadequate to address the complicated, interdependent questions related to defining effective care. To overcome the deficiencies of these traditional tools and better optimize our health care system, a new kind of methodology is required--one that integrates the functionality of previously existing tools in a novel way. Standardized Clinical Assessment and Management Plans (SCAMPs) were designed to accomplish this goal. A SCAMP is a care pathway, designed by clinicians, to guide medical decision making around a particular disorder. SCAMPs are unique in that they invite knowledge-based diversions from their recommendations and are accompanied by data collection and continuous improvement processes. Through these mechanisms, SCAMPs successfully reduce practice variation, optimize resource use, and create an integrated medical learning system which overcomes many of the inadequacies of traditional research tools. As such, the SCAMP paradigm may represent an important breakthrough in the effort to define and implement effective health care.

Standardized Clinical Assessment And Management Plans (SCAMPs) provide a better alternative to clinical practice guidelines

Variability in medical practice in the United States leads to higher costs without achieving better patient outcomes. Clinical practice guidelines, which are intended to reduce variation and improve care, have several drawbacks that limit the extent of buy-in by clinicians. In contrast, standardized clinical assessment and management plans (SCAMPs) offer a clinician-designed approach to promoting care standardization that accommodates patients' individual differences, respects providers' clinical acumen, and keeps pace with the rapid growth of medical knowledge. Since early 2009 more than 12,000 patients have been enrolled in forty-nine SCAMPs in nine states and Washington, D.C. In one example, a SCAMP was credited with increasing clinicians' rate of compliance with a recommended specialist referral for children from 19.6 percent to 75 percent. In another example, SCAMPs were associated with an 11-51 percent decrease in total medical expenses for six conditions when compared with a historical cohort. Innovative tools such as SCAMPs should be carefully examined by policy makers searching for methods to promote the delivery of high-quality, cost-effective care.

Does ICU structure impact patient outcomes after congenital heart surgery? A critical appraisal of "care models and associated outcomes in congenital heart surgery" by Burstein et al (Pediatrics 2011; 127: e1482-e1489)

OBJECTIVE

To review the findings and discuss the implications of different ICU care models on morbidity and mortality in pediatric patients after congenital heart surgery.

DATA SOURCES

The electronic PubMed database was used to perform the clinical query, as well as to search for additional pertinent literature.

STUDY SELECTION AND DATA EXTRACTION

The article by Burstein DS et al "Care Models and Associated Outcomes in Congenital Heart Surgery. Pediatrics 2011; 15:77-81" was selected for critical appraisal and literature review.

DATA SYNTHESIS

The authors evaluated in-hospital mortality, postoperative length of stay, and postoperative complications in pediatric patients after congenital heart surgery and compared the odds of these outcomes by model of care received (cardiac ICU or mixed ICU). The data for the study was extracted from the Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery (STS-EACTS) database. Overall, the cardiac ICU group represented hospitals with higher surgical volumes and included more patients with high-risk defects. After multivariate analysis, the adjusted in-hospital mortality was not associated with the care model (cardiac ICU vs. ICU). The only significant finding was a lower morality in the STS-EACTS risk category 3 (odds ratio, 0.47 [95% CI, 0.25-0.86]). There were no significant differences between groups for adjusted postoperative length of stay or postoperative complications.

CONCLUSIONS

This paper suggests that the composition of the ICU is not a critical factor in determining outcomes after congenital heart surgery. Other factors, such as expertise of the nurses, physicians, and surgeons, as well as technical performance, should be considered.

Attention deficit/hyperactivity disorder after neonatal surgery: review of the pathophysiology and risk factors

There are many factors that influence the long-term neurological outcomes in children following cardiac surgery. Because there is also complex interaction between these many factors, it is difficult to assess which are primary and modifiable and which can be used to make improvements in outcomes. As survival after complex neonatal heart surgery has increased, the number of children with long-term neurological deficits is becoming more evident and this affects quality of life for children and their families.

One area of long-term assessment is the incidence of attention deficit/hyperactivity disorder (ADHD). The incidence rate for ADHD following pediatric cardiac surgery is significantly higher than the normal rate for children of the same age. Because this is a measureable long-term outcome, it can be used to evaluate methods for cerebral protection during surgery as well as the timing of surgical procedures to maximize cerebral oxygen levels.

This paper will review the pathophysiological basis for ADHD in this population, based on the similarities between neonatal cardiac surgical patients and pre-term infants. Both populations have an increased risk for ADHD and the etiology and pathological changes in pre-term infants have been widely investigated over the past 25 years. The rate of ADHD in this population is a window into the effects of these pathological changes on long-term outcomes.

Reducing the incidence of ADHD in the future in this population should be a primary goal in developing and assessing new cerebral protective strategies during cardiac surgery.

Outcomes analysis and quality improvement for the treatment of patients with pediatric and congenital cardiac disease

Tremendous progress has been made in the science of assessing the outcomes of the treatments of patients with pediatric and congenital cardiac disease. Multi-institutional databases have been developed that span subspecialty, geographic, and temporal boundaries. Linking of different databases enables additional analyses not possible using the individual data sets alone and can facilitate quality improvement initiatives. Measures of quality can be developed, in the domains of structure, process, and outcome, which can facilitate quality improvement. Parents are an integral part of the health care team and are key partners with regard to quality improvement. The role of the parent in the process of health care delivery can be facilitated by enhancing the organizational culture and creating methods of transparency, empowering parents, and implementing effective strategies of communication. The professionals caring for patients with pediatric and congenital cardiac disease, in collaboration with the patients and their families, now have the opportunity to capitalize on the power of our databases and move beyond outcome assessment and benchmarking, to collaborative quality improvement.

Variation in models of care delivery for children undergoing congenital heart surgery in the United States

Limited data are available regarding contemporary models of care delivery for patients undergoing congenital heart surgery. The purpose of this survey was to evaluate current US practice patterns in this patient population. Cross-sectional evaluation of US centers caring for patients undergoing congenital heart surgery was performed using an Internet-based survey. Data regarding postoperative care were collected and described overall and were compared in centers with a pediatric intensive care unit (PICU) versus dedicated pediatric cardiac intensive care unit (CICU). A total of 94 (77%) of the estimated 122 US centers performing congenital heart surgery participated in the survey. The majority (79%) of centers were affiliated with a university. Approximately half were located in a free-standing children's hospital and half in a children's hospital in a hospital. Fifty-five percent provided care in a PICU versus a CICU. A combination of cardiologists and/or critical care physicians made up the largest proportion of physicians primarily responsible for postoperative care. Trainee involvement most often included critical care fellows (53%), pediatric residents (53%), and cardiology fellows (47%). Many centers (76%) also used physician extenders. In centers with a CICU, there was greater involvement of cardiologists and physicians with dual training (cardiology and critical care), fellows versus residents, and physician extenders. Results of this survey demonstrate variation in current models of care delivery used in patients undergoing congenital heart surgery in the United States. Further study is necessary to evaluate the implications of this variability on quality of care and patient outcomes.

Prenatal diagnosis of Potocki-Lupski syndrome in a fetus with hypoplastic left heart and aberrant right subclavian artery

Potocki-Lupski syndrome (PTLS) is a rare genetic disorder associated with neurodevelopmental delay and heart defects. We report the first case of prenatal diagnosis of PTLS in a fetus with hypoplastic left heart and aberrant right subclavian artery. Detection of a fetal heart defect should be followed by chromosomal and genetic studies in order to rule out fetal aneuploidy and/or associated genetic syndromes with significant implications for the treatment of children with PTLS.

Inferior vena cava oxygen saturation monitoring after the Norwood procedure

BACKGROUND

Superior vena cava oxygen saturation monitoring in the early postoperative period after the Norwood procedure (NP) has been associated with improved survival and decreased adverse events (AE). There is no data describing inferior vena cava saturation (Sivo2) monitoring after NP. We sought to investigate the utility of intermittent Sivo2 monitoring after NP and to assess the correlation of Sivo2 with renal near-infrared spectroscopy (rNIRS). We hypothesized failure to achieve Sivo2 greater than 45% within the first 4 hours after NP is predictive of AE, and that rNIRS correlates with Sivo2.

METHODS

A retrospective study of 26 consecutive NP patients who received postoperative management with Sivo2 monitoring according to a strict protocol was conducted. Primary outcome was AE, defined as cardiopulmonary resuscitation, extracorporeal membrane oxygenation, death before discharge, or residual surgical defects.

RESULTS

Ten (38%) patients had one or more AE; mortality was 23%. On admission to the cardiac intensive care unit, patients with AE had lower Sivo2 (45% ± 9.4% versus 62% ± 12.0%; p < 0.001) and lower rNIRS (56 ± 6.5 versus 77 ± 7.2; p < 0.001). At 4 hours, 90% of AE patients had an Sivo2 less than 45% versus 6% of non-AE patients. Both Sivo2 and rNIRS were highly predictive of AE: the area under the receiver-operating characteristic curve was greater than 0.86 and 0.95, respectively. Two hours after admission, an Sivo2 less than 45% predicted AE with a specificity of 93%, a sensitivity of 70%, and a positive predictive value of 82%. The Sivo2 was strongly correlated with rNIRS (r = 0.81).

CONCLUSIONS

Intermittent Sivo2 can be used to guide early postoperative NP management; rNIRS is an accurate continuous, noninvasive surrogate for Sivo2. An Sivo2 of less than 45% in the first 4 hours after the NP is predictive of AE.

Pulse oximetry home monitoring in infants with single-ventricle physiology and a surgical shunt as the only source of pulmonary blood flow

BACKGROUND

Shunt occlusion is a major cause of death in children with single ventricle. We evaluated whether one daily measurement of oxygen saturation at home could detect life-threatening shunt dysfunction.

METHODS

A total of 28 infants were included. Parents were instructed to measure saturation once daily and if less than or equal to 70% repeat the measurement. Home monitoring was defined as positive when a patient was admitted to Queen Silvia Children's Hospital because of saturation less than or equal to 70% on repeated measurement at home. A shunt complication was defined as arterial desaturation and a narrowing of the shunt that resulted in an intervention to relieve the obstruction or in death. Parents' attitude towards the method was investigated using a questionnaire.

RESULTS

A shunt complication occurred out of hospital eight times in eight patients. Home monitoring was positive in five out of eight patients. In two patients, home monitoring was probably life saving; in one of them, the shunt was replaced the same day and the other had an emergency balloon dilatation of the shunt. In three out of eight patients, home monitoring was negative; one had an earlier stage II and survived, but two died suddenly at home from thrombotic shunt occlusion. On seven occasions in three patients home monitoring was positive but there was no shunt complication. The method was well accepted by the parents according to the results of the questionnaire.

CONCLUSION

Home monitoring of oxygen saturation has the potential to detect some of the life-threatening shunt obstructions between stages I and II in infants with single-ventricle physiology.

Centre variation in cost and outcomes for congenital heart surgery

Although overall outcomes for children undergoing heart surgery have improved, there is a significant variation in outcomes across hospitals. This review discusses the variation in cost and outcomes across centres performing congenital heart surgery, potential underlying mechanisms, and efforts to reduce variation and improve outcome.

A developmental care framework for a cardiac intensive care unit: a paradigm shift

Within the past several decades, medical and surgical advancements have dramatically decreased mortality rates in neonates and infants with congenital heart disease. Although patients are surviving in greater numbers, little research is reported on issues related to newborn care for these at-risk infants. A developmental care model was introduced to the nursing staff at the Children's Hospital of Philadelphia, which included 5 core measures to support evidence-based developmental care practices: (1) sleep, pain, and stress assessment; (2) management of daily living; (3) positioning, feeding, and skin care; (4) family-centered care; and (5) a healing environment. The care practices were adapted to the specific issues of the late preterm and full-term infant who has experienced neonatal cardiac surgery. The purpose of this article is to review the process of implementing a development model of care in a cardiac intensive care unit.

Interstage feeding and weight gain in infants following the Norwood operation: can we change the outcome?

BACKGROUND

Poor weight gain is common in infants after Stage I Norwood operation and can negatively impact outcomes.

OBJECTIVES

The purpose of this study was to examine the impact of feeding strategy on interstage weight gain.

METHODS

In a multi-centre study, 158 infants discharged following the Norwood operation were enrolled prospectively. Weight and feeding data were obtained at 2-week intervals. Differences between feeding regimens in average daily weight gain and change in weight-for-age z-score between Stage I discharge and Stage II surgery were examined.

RESULTS

Discharge feeding regimens were oral only in 52%, oral with tube supplementation in 33%, and by nasogastric/gastrostomy tube only in 15%. There were significant differences in the average daily interstage weight gain among the feeding groups - oral only 25.0 grams per day, oral/tube 21.4 grams per day, and tube only 22.3 grams per day - p = 0.019. Tube-only-fed infants were significantly older at Stage II (p = 0.004) and had a significantly greater change in weight-for-age z-score (p = 0.007). The overall rate of weight gain was 16-32 grams per day, similar to infant norms. The rate of weight gain declined over time, with earlier decline observed for oral- and oral/tube-fed infants (less than 15 grams per day at 5.4 months) in comparison with tube-only-fed infants (less than 15 grams per day at 8.6 months).

CONCLUSION

Following Stage I Norwood, infants discharged on oral feeding had better average daily weight gain than infants with tube-assisted feeding. The overall weight gain was within the normal limits in all feeding groups, but the rate of weight gain decreased over time, with an earlier decline in infants fed orally.

Superior cavopulmonary anastomosis timing and outcomes in infants with single ventricle

OBJECTIVES

We sought to identify factors associated with the timing and surgical outcomes of the superior cavopulmonary anastomosis.

METHODS

The Pediatric Heart Network's Infant Single Ventricle trial database identified participants who underwent superior cavopulmonary anastomosis. Factors potentially associated with age at superior cavopulmonary anastomosis, length of stay and death by 14 months of age were evaluated. Factors included subject demographics, cardiac anatomy, measures from neonatal hospitalization and pre-superior cavopulmonary anastomosis visit, adverse events, echocardiographic variables, intraoperative variables, superior cavopulmonary anastomosis type, and number of concurrent cardiac surgical procedures. Age at superior cavopulmonary anastomosis was analyzed using Cox proportional hazards regression. Natural log length of stay was analyzed by multiple linear regression.

RESULTS

Superior cavopulmonary anastomosis was performed in 193 subjects at 5.2 months of age (interquartile range, 4.2, 6.2) and weight of 5.9 kg (interquartile range, 5.3, 6.6). The median length of stay was 7 days (interquartile range, 6, 10). There were 3 deaths and 1 transplant during the superior cavopulmonary anastomosis hospitalization, and 3 deaths and 3 transplants between discharge and 14 months of age. Age at superior cavopulmonary anastomosis was associated with center and interstage adverse events. A longer length of stay was associated with younger age and greater case complexity. Superior cavopulmonary anastomosis type, valve regurgitation, ventricular ejection fraction, and ventricular end-diastolic pressure were not independently associated with age at superior cavopulmonary anastomosis or the length of stay.

CONCLUSIONS

Greater case complexity and more frequent interstage adverse events are associated with an earlier age at superior cavopulmonary anastomosis. Significant variation in age at superior cavopulmonary anastomosis among centers, independent of subject factors, highlights a lack of consensus regarding the optimal timing. Factors associated with length of stay could offer insights for improving presuperior cavopulmonary anastomosis care and surgical outcome.

Contemporary Fontan operation: association between early outcome and type of cavopulmonary connection

BACKGROUND

Extracardiac conduit and lateral atrial tunnel total cavopulmonary connection are both widely used in the management of functionally univentricular hearts. The effect of the type of connection on early outcomes after Fontan operation remains unclear. We evaluated the effect of Fontan type on early outcome in a large clinical database.

METHODS

Patients in the Society of Thoracic Surgeons Congenital Heart Surgery Database undergoing the Fontan operation (2000 to 2009) were included. We used multivariable analysis to evaluate the effect of Fontan type (extracardiac conduit vs lateral tunnel) on in-hospital death, Fontan takedown/revision, Fontan failure (in-hospital death or Fontan takedown/revision), postoperative length of stay, and complications, adjusting for patient, procedural, and center factors.

RESULTS

The study included 2,747 patients (61% male) from 68 centers. A right-dominant ventricle was present in 45%. Extracardiac conduit Fontan (vs lateral atrial tunnel) was performed in 63%; in all, 65% were fenestrated. In multivariable analysis with adjustment for patient, procedural (including fenestration), and center factors (including Fontan volume), the extracardiac conduit Fontan was associated with significantly higher Fontan takedown/revision (odds ratio, 2.73; 95% confidence interval, 1.09 to 6.87) and Fontan failure (odds ratio, 2.28; 95% confidence interval, 1.13 to 4.59), and longer postoperative hospital stay (adjusted estimated difference in postoperative hospital stay: +1.4 days).

CONCLUSIONS

These multicenter data suggest that of the two prevalent forms of Fontan connection in current use, the lateral atrial tunnel Fontan may be associated with superior early outcomes.

Variation in perioperative care across centers for infants undergoing the Norwood procedure

OBJECTIVES

In the Single Ventricle Reconstruction trial, infants undergoing the Norwood procedure were randomly allocated to undergo a right ventricle-to-pulmonary artery shunt or a modified Blalock-Taussig shunt. Apart from shunt type, subjects received the local standard of care. We evaluated variation in perioperative care during the Norwood hospitalization across 14 trial sites.

METHODS

Data on preoperative, operative, and postoperative variables for 546 enrolled subjects who underwent the Norwood procedure were collected prospectively on standardized case report forms, and variation across the centers was described.

RESULTS

Gestational age, birth weight, and proportion with hypoplastic left heart syndrome were similar across sites. In contrast, all recorded variables related to preoperative care varied across centers, including fetal diagnosis (range, 55%-85%), preoperative intubation (range, 29%-91%), and enteral feeding. Perioperative and operative factors were also variable across sites, including median total support time (range, 74-189 minutes) and other perfusion variables, arch reconstruction technique, intraoperative medication use, and use of modified ultrafiltration (range, 48%-100%). Additional variation across centers was seen in variables related to postoperative care, including proportion with an open sternum (range, 35%-100%), median intensive care unit stay (range, 9-44 days), type of feeding at discharge, and enrollment in a home monitoring program (range, 1%-100%; 5 sites did not have a program). Overall, in-hospital death or transplant occurred in 18% (range across sites, 7%-39%).

CONCLUSIONS

Perioperative care during the Norwood hospitalization varies across centers. Further analysis evaluating the underlying causes and relationship of this variation to outcome is needed to inform future studies and quality improvement efforts.

Hypoplastic left heart syndrome: current considerations and expectations

In the recent era, no congenital heart defect has undergone a more dramatic change in diagnostic approach, management, and outcomes than hypoplastic left heart syndrome (HLHS). During this time, survival to the age of 5 years (including Fontan) has ranged from 50% to 69%, but current expectations are that 70% of newborns born today with HLHS may reach adulthood. Although the 3-stage treatment approach to HLHS is now well founded, there is significant variation among centers. In this white paper, we present the current state of the art in our understanding and treatment of HLHS during the stages of care: 1) pre-Stage I: fetal and neonatal assessment and management; 2) Stage I: perioperative care, interstage monitoring, and management strategies; 3) Stage II: surgeries; 4) Stage III: Fontan surgery; and 5) long-term follow-up. Issues surrounding the genetics of HLHS, developmental outcomes, and quality of life are addressed in addition to the many other considerations for caring for this group of complex patients.

Opportunities and challenges in linking information across databases in pediatric cardiovascular medicine

Multicenter databases are increasingly utilized in pediatric cardiovascular research. In this review, we discuss the rational for using these types of data sources, provide several examples of how large datasets have been utilized in clinical research, and describe different mechanisms for linking databases to enable studies not possible with individual datasets alone.

The hybrid approach--current knowns and unknowns: the perspective of cardiology

The hybrid approach to the treatment of patients with hypoplastic left heart syndrome most commonly includes transcatheter placement of a stent in the arterial duct and surgical placement of bands on the branch pulmonary arteries via median sternotomy. This manuscript will review the concept of hybrid palliation and discuss topics related to several time intervals: peri-procedural, post-procedural, interstage, and comprehensive stage 2.

Prevention for pediatric low cardiac output syndrome: results from the European survey EuLoCOS-Paed

OBJECTIVE

Characterize current hospital practices related to preventive drug therapy for low cardiac output syndrome (LCOS) in children with open heart surgery (OHS) in Europe.

METHODS

Web-based questionnaire survey of European hospitals performing OHS in children, conducted between January and August 2009.

RESULTS

Responses to the questionnaire were obtained from 90 of 125 hospitals (72.0%) from 31 different countries across the geographical European regions. The majority of hospitals (77.8%) administered preventive drug therapy and primarily targeted patients at risk (63.3%). Twenty-four different drug regimens were reported, involving 17 drugs from seven therapeutic drug classes. Milrinone, dopamine, epinephrine, dobutamine, and levosimendan made up 85.9% of the total drug use. Furthermore, milrinone was reported in 70.7% of all drug regimens and significantly more often in combination with other drugs than monotherapy (Δ20%, 95% CI 4.7-34.1%). Milrinone combination therapy reports included lower bolus but higher maintenance infusion doses than monotherapy reports. The timing of drug regimen administration varied across the full perioperative period, but drug regimens were mostly initiated during surgery and continued postoperatively.

CONCLUSION

Although current hospital practices related to preventive drug therapy for LCOS in children with OHS are characterized by a marked variability, only few drugs make up the bulk of prescribing practice with milrinone being most commonly used. Therefore, the survey provides information on which drugs to focus research and establish safe and effective drug use. A unified approach is urgently needed to ensure that children with OHS can benefit from evidence-based care.

Neonatal surgical reconstruction and peri-operative care for hypoplastic left heart syndrome: current strategies

The management of newborns with hypoplastic left heart syndrome has changed significantly over the past three decades, with an associated dramatic improvement in outcomes. The aim of this paper is to discuss current peri-operative and palliative surgical strategies. Owing to the fact that comparative outcomes for these strategies have been addressed in a limited number of prospective trials and extractions from multi-centred databases, the primary focus of this review is descriptive.

Neurodevelopment and quality of life for children with hypoplastic left heart syndrome: current knowns and unknowns

The aim of this review is to describe the current state of knowledge related to neurodevelopmental outcomes and quality of life for children with hypoplastic left heart syndrome and to explore future questions to be answered for this group of children.

Living with complex congenital heart disease

A child with complex congenital heart disease in 2008 is very likely to survive a series of surgical and medical interventions, and confront an array of medical and psychosocial stressors that are presently poorly understood. As approaches to medical problems change, careful assessment of those results is essential, and the initial work of the multicentre Pediatric Heart Network is a huge step in the right direction, setting the stage for proper controlled trials of therapies. Major complications, notably ventricular failure, rhythm problems and thromboembolism, will affect nearly one-quarter of survivors, necessitating further interventions. Appropriate educational and psychosocial support for these children and their families is the next challenge for all of us in the field of paediatrics. How ironic would it be to have invested so much in early survival, only to allow the child to fail in life itself.