Preoperative Determinants of Outcomes of Infant Heart Surgery in a Limited-Resource Setting

Neurodevelopmental outcomes after infant heart surgery for congenital heart disease: a hospital-based multicentre prospective cohort study from India

BACKGROUND

Neurodevelopmental disability is a common long-term concern following surgery for congenital heart disease (CHD). Little information is available from low-resource environments where the majority of children with CHD are born. Several challenges in the CHD care continuum exist in such environments.

METHODS

We followed 1346 infants who were operated for CHD using cardiopulmonary bypass from five paediatric cardiac programmes across India. The neurodevelopmental assessment was done using the Developmental Assessment Scale for Indian Infants (DASII) at 6 months after surgery.

RESULTS

A total of 1145 (94.8%) infants were alive at 6 months and 127 (11.1%) were lost to follow-up. The mean age of participants at baseline was 5.2 (3.6) months. The mean motor developmental quotient (DMoQ) and mental developmental quotient (DMeQ) of the remaining 1018 infants were 81.8 (69.5, 93.0) and 87.7 (77.1, 95.7), respectively. A total of 262 (25.7%) infants had motor developmental delay and 157 (15.4%) had mental developmental delay. Syndromic association, younger age at surgery, duration of mechanical ventilation and head circumference were significantly associated with DMoQ. The DMeQ was associated with syndromes, duration of hospital and intensive care unit stay and socioeconomic status. The preoperative condition did not impact mental and motor development. Motor clusters with maximum delay included body control and locomotion. Mental clusters with maximum delay included reaching and manipulation, social interaction-imitative behaviour and vocabulary comprehension.

CONCLUSIONS

Survivors of infant heart surgery experience significant motor and mental neurodevelopmental delay. This delay is associated with similar factors reported by earlier studies. As more high-risk infants undergo cardiac surgery in low-resource settings, a growing population will require significant societal resources for neurodevelopmental assessment as well as neurodevelopmental rehabilitation. These resources include trained personnel for comprehensive developmental assessment of survivors of CHD surgery, as well as infrastructural requirements for dedicated assessment rooms in centres providing surgical care for CHD patients.

Achieving excellence in paediatric cardiac care in resource limited and resource plentiful settings and building successful care networks across different countries

BACKGROUND

The delivery of paediatric cardiac care across the world occurs in settings with significant variability in available resources. Irrespective of the resources locally available, we must always strive to improve the quality of care we provide to our patients and simultaneously deliver such care in the most efficient and cost-effective manner. The development of cardiac networks is used widely to achieve these aims.

METHODS

This paper reports three talks presented during the 56th meeting of the Association for European Paediatric and Congenital Cardiology held in Dublin in April 2023.

RESULTS

The three talks describe how centres of congenital cardiac excellence can be developed in low-income countries, middle-income countries, and well-resourced environments, and also reports how centres across different countries can come together to collaborate and deliver high-quality care. It is a fact that barriers to creating effective networks may arise from competition that may exist among programmes in unregulated and especially privatised health care environments. Nevertheless, reflecting on the creation of networks has important implications because collaboration between different centres can facilitate the maintenance of sustainable programmes of paediatric and congenital cardiac care.

CONCLUSION

This article examines the delivery of paediatric and congenital cardiac care in resource limited environments, well-resourced environments, and within collaborative networks, with the hope that the lessons learned from these examples can be helpful to other institutions across the world. It is important to emphasise that irrespective of the differences in resources across different continents, the critical principles underlying provision of excellent care in different environments remain the same.

Outcomes Following Neonatal Cardiac Surgery in Cape Town, South Africa

BACKGROUND

Neonatal Cardiac Surgery has developed significantly since its advent, with improved outcomes, survival, and physiological repair. Limited programs offer neonatal cardiac surgery in emerging economies. We report our experience with neonates undergoing cardiac surgery in our cardiac surgery program.

METHODS

We performed a secondary data analysis on all neonates aged ≤ 30 days undergoing congenital cardiac surgery from April 1, 2017 to March 31, 2020, including outcomes up to 30-days post-surgery.

RESULTS

A total of 859 patients underwent cardiac surgery at our center, of these 81 (9.4%) were neonates. The proportion of neonates increased annually (8.7%, 9.6%, and 10.2%). There were 49 (60%) male patients, and 32 (40%) had surgery in the second week of life. Fourteen (17%) were premature, four (5%) had a major chromosomal abnormality, five (6%) a major medical illness, and eight (10%) a major noncardiac structural anomaly. The Risk Adjustment for Congenital Heart Surgery (RACHS) categorization of surgery was predominantly RACHS 3; n = 28 (35%) and 4; n = 23 (29%). Hours in the intensive care unit (ICU) were extensive; median 189 [interquartile range (IQR): 114-286] as were hours of ventilation; median 95 [IQR 45-163]. Almost 60% (n = 48) of procedures were complicated by sepsis, as defined in our database. The in-hospital mortality rate was 16% (n = 13); the 30-day mortality rate was 19.8% (n = 16).

CONCLUSION

The proportion of neonates in our service increased over the period. Focused strategies to shorten prolonged ICU stay and decrease rates of bacterial sepsis in neonates are needed. A multidisciplinary, collaborative heart-team approach is crucial for best outcomes.

Aortic Origin of a Branch Pulmonary Artery: Early and Mid-Term Single Center Outcomes

BACKGROUND

Anomalous origin of pulmonary artery (AOPA) is a rare congenital cardiac anomaly. It requires early surgical intervention (<6 months) to prevent irreversible pulmonary vaso-occlusive disease. This study was conducted to determine the surgical outcomes of this rare and intriguing anomaly.

METHODS

From January 2015 to 2022, we have studied, 20 patients who underwent surgical correction for this anomaly with a mean age of 6.25 ± 3.7 months. There were 12 patients of <6 months of age. Their preoperative, intraoperative, and postoperative data were collected. They were followed up at every three months for the first year, every six months for two years, and then annually.

RESULTS

Among three early mortalities, two were operated before six months of age and one was older than six months (ten months). Those patients presented after six months had longer ventilation time (P = .001). There was no difference in their pulmonary artery pressure (P = .06), right ventricle systolic pressure (RVSP) (P = .85), postoperative saturation (P = .51), inotropic score (P = .06), hospital and intensive care unit stay (P > .05), or mortality (P = .79). There was no late mortality at mean follow-up of 51.31 ± 20.27 months with Kaplan-Meier survival of 85% at 1, 5, and ten years. All patients were asymptomatic, with normal biventricular function and RVSP. One patient required balloon dilatation of the anastomotic site, with Kaplan-Meier event-free survival of 100% at one year, 92% at five and ten years.

CONCLUSION

Surgical correction of AOPA in patients beyond six months is still feasible with a higher early morbidity and comparable mortality with good clinical and echocardiographical outcomes at mid-term follow-up.

The outcome of surgery for congenital heart disease in India: A systematic review and metanalysis

Background

The mortality risks of children undergoing various cardiac surgeries for congenital heart disease (CHD) in India are not well defined. We conducted a systematic review and meta-analysis to estimate the inhospital mortality of various common CHD surgeries reported in India and compared it to representative data from established Western databases.

Methods and Results

We searched four bibliographic databases for studies published in India over the last 25 years. In total, 135 studies met the inclusion criteria and included 30,587 patients aged from 1 day to 65 years. The pooled mortality rate of 43 Indian studies reporting multiple CHD surgical outcomes is 5.63% (95% confidence interval [CI]: 4.26-7.16; I 2 = 93.9%), whereas the Western data showed a pooled mortality rate of 2.65% (P value for comparison <0.0001). The pooled mortality risk for ventricular septal defect closure and tetralogy of Fallot repair in Indian studies was 2.87% (95% CI: 0.76-5.91; I 2 = 62.4%) and 4.61% (95% CI: 2.0-8.02; I 2 = 87.4%), respectively. The estimated mortality risk was higher than the Western databases for all subcategories studied except for surgeries in the grown-ups with CHD population and coarctation repair.

Conclusions

The estimated mortality risks are higher among Indian patients undergoing cardiac surgery for CHD as compared to Western data. We need prospective multicentric data to document whether the observed excess mortality exists after adjusting for various high-risk features and comorbidities in Indian patients. We need systemic measures to improve the outcomes of CHD surgeries in India.

The Myths, Perils, and Pitfalls of Redo Pediatric Cardiac Surgery: The New Normal in Developing Countries Such as India

Pediatric patients undergoing reoperative cardiac surgery after a previous sternotomy face a higher degree of surgical complexity compared to those undergoing initial procedures. They have higher intraoperative and postoperative risks. The increased risk of surgery is due to preoperative patient factors and intraoperative technical challenges. Redo-pediatric cardiac surgery is a common event in almost every pediatric cardiac surgeon's professional life. Redo-surgery is almost inevitable in patients who have multi-stage repair of congenital heart surgeries and biological valves at a young age, and often in those having valve repair in rheumatic disease. So, being familiar with the pitfalls and precautions to be taken is of crucial importance. In general, the patients presenting for repeat procedures are sicker, older, and have more comorbid conditions. The dissection is always rendered difficult by adhesions, scarring, and previous graft placements. Hence, prolonged dissection time, intraoperative injuries to heart chambers, great vessels, and grafts, increased bleeding, and poorer cardiac function result in higher morbidity and mortality in such subsets of patients. The outcome is worse with emergency redo-cardiac surgeries.

Outcomes of neonatal critical congenital heart disease: results of a prospective registry-based study from South India

OBJECTIVES

Congenital heart disease (CHD) is now a leading contributor of infant and neonatal mortality in many low/middle-income countries including India. We established a prospective neonatal heart disease registry in Kerala to understand presentation of CHD, proportion of newborns with critical defects who receive timely intervention, outcomes at 1 month, predictors of mortality and barriers to timely management.

METHODS

The congenital heart disease registry for newborns (≤28 days) in Kerala (CHRONIK) was a prospective hospital-based registry involving 47 hospitals from 1 June 2018 to 31 May 2019. All CHDs, except small shunts with a high likelihood of spontaneous closure, were included. Data on demographics, complete diagnosis, details of antenatal and postnatal screening, mode of transport and distance travelled and need for surgical or percutaneous interventions and survival were collected.

RESULTS

Of the 1474 neonates with CHD identified, 418 (27%) had critical CHD, 22% of whom died at 1 month. Median age at diagnosis of critical CHD was 1 (0-22) day. Pulse oximeter screening identified 72% of critical CHD and 14% were diagnosed prenatally. Only 8% of neonates with duct-dependent lesions were transported on prostaglandin. Preoperative mortality accounted for 86% all deaths. On multivariable analysis, only birth weight (OR 2.7; 95% CI 2.1 to 6.5; p<0.0005) and duct-dependent systemic circulation (OR 6.43; 95% CI 5 to 21.8, p<0.0005) were predictive of mortality.

CONCLUSIONS

While systematic screening, especially pulse oximetry screening, enabled early identification and prompt management of a significant proportion of neonates with critical CHD, important health system challenges like low use of prostaglandin need to be overcome to minimise preoperative mortality.

Global leadership in paediatric and congenital cardiac care: education and empowerment to improve outcomes in low- and middle-income countries - an interview with Krishna Kumar, MD, DM FAHA

Dr Krishna Kumar is the focus of our sixth in a series of interviews in Cardiology in the Young entitled, "Global Leadership in Paediatric and Congenital Cardiac Care." Dr Kumar was born in Raurkela, India. He attended medical school at Maulana Azad Medical College in New Delhi, graduating in 1984. Dr Kumar then went on to complete internal medicine, emergency medicine, and adult cardiology training at All India Institute of Medical Sciences in 1988, 1989, and 1990, respectively. He then pursued paediatric cardiology training at Harvard Medical School in Boston, MA, USA. Dr Kumar began his clinical position as a paediatric cardiologist at Amrita Institute of Medical Sciences in Kochi, Kerala, India.During his impressive career, Dr Kumar has made significant contributions to educational advancement, research and innovation, public health advocacy, and clinical care. Dr Kumar is credited for distinguishing paediatric cardiology as a distinct subspecialty in India. He was a founding member of the Pediatric Cardiology Society of India and the original editor of the society's academic journal. Recognising the deficit of paediatric cardiology-trained physicians in low- and middle-income countries, Dr Kumar helped establish formal structured training programmes for paediatric cardiology in India. More recently, he established the Children's HeartLink Fellowships in paediatric cardiac sciences at Amrita Institute of Medical Sciences in Kochi and Institut Jantung Negara in Malaysia. Through educational programmes, Dr Kumar has taught countless caregivers and paediatricians, in India and neighbouring countries, the early identification and management of children with CHD. Dr Kumar has established a premier paediatric heart programme at Amrita Institute of Medical Sciences. As department Chief, he emphasises the importance of teamwork, advocacy, and continuous quality improvement. He has developed numerous low-cost strategies for the management of CHD. He has established large community-based studies on rheumatic heart disease and CHD in South India. Dr Kumar's focus on advocacy and policy change in India has made a substantial impact on early identification and treatment of CHD in the subcontinent. He has made a global impact on the care of paediatric cardiology patients through his educational programmes, research and innovation, large-scale research registries, and advocacy for public health policy changes. He is an incredibly humble and generous leader, and his patients and community are the source of his unending motivation.

Perioperative Risk Assessment in Humanitarian Settings: A Scoping Review

BACKGROUND

No validated perioperative risk assessment models currently exist for use in humanitarian settings. To inform the development of a perioperative mortality risk assessment model applicable to humanitarian settings, we conducted a scoping review of the literature to identify reports that described perioperative risk assessment in surgical care in humanitarian settings and LMICs.

METHODS

We conducted a scoping review of the literature to identify records that described perioperative risk assessment in low-resource or humanitarian settings. Searches were conducted in databases including: PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Web of Science, World Health Organization Catalog, and Google Scholar.

RESULTS

Our search identified 1582 records. After title/abstract and full text screening, 50 reports remained eligible for analysis in quantitative and qualitative synthesis. These reports presented data from over 37 countries from public, NGO, and military facilities. Data reporting was highly inconsistent: fewer than half of reports presented the indication for surgery; less than 25% of reports presented data on injury severity or prehospital data. Most elements of perioperative risk models designed for high-resource settings (e.g., vital signs, laboratory data, and medical comorbidities) were unavailable.

CONCLUSION

At present, no perioperative mortality risk assessment model exists for use in humanitarian settings. Limitations in consistency and quality of data reporting are a primary barrier, however, can be addressed through data-driven identification of several key variables encompassed by a minimum dataset. The development of such a score is a critical step toward improving the quality of care provided to populations affected by conflict and protracted humanitarian crises.

The influence of age and weight on the outcomes of complete atrioventricular septal defect repair

Background

The appropriate age and weight for surgical repair of atrioventricular septal defect (AVSD) is an area of controversy. We aimed to study the effect of weight and age at the time of surgical repair for complete AVSD in children less than 2 years of age on postoperative outcomes. A retrospective data review was performed for patients who underwent the AVSD repair from 2012 to 2019 at our institutions. Our primary outcome was the postoperative in-hospital length of stay (LOS). Secondary outcomes included total positive pressure ventilation (PPV), ventilation time, maximum vasoactive–inotropic score (max VIS), and other postoperative complications.

Results

The study included fifty patients. The median age was 191 days, and the median weight was 4.38 kg at the time of surgery. Weight < 4 kg was associated with longer PPV time and postoperative in-hospital LOS (p value of 0.033 and 0.015, respectively). Additionally, they had higher max VIS at 24 h and 48 h than the other groups with bodyweight 4–5.9 kg or ≥ 6 kg (p value of 0.05 and 0.027, respectively). Patients with older age or lower weight at operation had a longer in-hospital LOS and total length of PPV after surgery. There were no postoperative in-hospital deaths.

Conclusions

Older age and lower weight at the time of surgical repair of atrioventricular septal defect could be independent predictors of prolonged postoperative in-hospital length of stay and total length of positive pressure ventilation.

Growth assessment in down syndrome after cardiac surgery

Objective

To assess the effect of cardiac surgery on growth catch-up of Down syndrome (DS) children with failure to thrive (FTT) and congenital heart disease (CHD) and investigate other causes of FTT in DS children.

Method

We conducted a retrospective observational study in tertiary cardiac center from 2015 to 2018. We included all cases of DS diagnosed with CHD and FTT who completed a 1-year follow-up after cardiac surgery. We divided the cases into two groups; “normalize group” includes children who normalized their growth parameters and “underweight group” includes those who remained in FTT category during the follow-up period. We compared both groups for multiple risk factors.

Result

Most of DS had FTT upon surgery. Fifty percent of cases completed 1-year follow-up including 29 (60%) in the normalized group and 19 (40%) in underweight group. Within 6 months post-surgery, the normalized group though did not reach yet normalization of growth parameters, demonstrated statically significant improvement in weight for age, weight Z-score in compared to underweight group.

Within 12 months post-surgery, the normalized group achieved normalization of growth parameters and continue to show more statistically significant differences in growth parameters.

Both groups had comparable post-operation course. Univariate analysis of possible peri-operative risk factors showed no difference between both groups except for presence of untreated subclinical hypothyroidism in 58% of the underweight group versus 17% in control group (p = 0.005).

Conclusion

FTT in DS patient is multifactorial which needs thorough investigation and work up by multidisciplinary team. Cardiac surgery may not guarantee the improvement of growth parameters.

Total Anomalous Pulmonary Venous Connection Repair: Single-Center Outcomes in a Lower-Middle Income Region

BACKGROUND

The management of total anomalous pulmonary venous connection (TAPVC) in neonates and infants is resource-intensive. We describe early and follow-up outcomes after surgical repair of isolated TAPVC at a single institution in a resource-limited setting.

METHODS

The data of 316 consecutive patients with isolated TAPVC undergoing repair (January 2010-September 2020) were reviewed. The study setting was a tertiary hospital in southern India that provides subsidized or charitable care. Standard surgical technique was used for repair, circulatory arrest was avoided, and suture-less anastomosis was reserved for small or stenotic pulmonary veins. Surgical and postoperative strategies were directed toward minimizing intensive care unit (ICU) stay.

RESULTS

302 (95.6%) patients were infants and 128 patients (40.5%) were neonates; median weight was 3.3 kg (IQR 2.8-4.0 kg). Obstruction of the TAPVC was seen in 176 patients (56%) and pulmonary hypertension in 278 patients (88%). Seventeen (5.4%) underwent delayed sternal closure. The median postoperative ICU stay was 120 h (IQR 96-192 h), mechanical ventilation was 45 h (IQR 24-82 h), and hospital stay was 13 days (IQR 9-17 days). There were three in-hospital deaths (0.9%). Over a median follow-up period of 53.3 months (IQR 22.9-90.4), pulmonary vein restenosis was seen in 32 patients (10.1%) after a mean of 2.2 months (1-6 months). No perioperative risk factors for restenosis were identified.

CONCLUSIONS

Using specific perioperative strategies, it is possible to correct TAPVC with excellent surgical outcomes in low-resource environments. Late pulmonary vein restenosis remains an important complication.

Association Between Preoperative Factors and In-hospital Mortality in Neonates After Cardiac Surgery in China

Background: Little is known about preoperative factors affecting cardiac surgery outcomes of neonates in China. We sought to examine the association between characteristics of neonates with congenital heart disease (CHD) and early postoperative outcomes after cardiac repair in a tertiary care paediatric hospital. Methods: A single-centre retrospective cohort study of neonates who underwent cardiac surgery between January 2006 and December 2019 was performed. Demographic, institutional, and surgical characteristics of neonates were examined and their association with in-hospital mortality was analysed using multivariable logistic regression models. Results: During the study period, we analysed the outcomes of 1,078 neonates. In-hospital mortality decreased to 13.8% in the era 2017-2019. The overall in-hospital mortality rate was 16.3%. Normal weight at surgery [odds ratio (OR), 0.63; 95% confidence interval (CI), 0.47-0.85; P = 0.003] was associated with lower mortality risk. Poor health status (emergent: OR, 3.11; 95% CI, 1.96-4.94; P < 0.001; elective: OR, 1.63; 95% CI, 1.11-2.40; P = 0.013), higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) categories (STAT 5 category: OR, 2.58; 95% CI, 1.04-6.43; P = 0.042), and limited individual surgeon experience (surgeon with 5-10 operations per year: OR, 1.43; 95% CI, 1.06-1.95; P = 0.021) were associated with higher odds of early death. Conclusion: In-hospital mortality after neonatal cardiac surgery remained high in our centre over the past 10 years. Some preoperative aspects, including low-weight at surgery, poor health status, increased surgical complexity, and limited surgeon experience were significantly associated with higher mortality. Based on the observed associations, the necessary practises to be modified, especially in preoperative care, should be identified and assessed in future research.

Neonatal cardiac surgery in low resource settings: implications of birth weight

OBJECTIVE

We sought to evaluate the association between low birth weight (LBW) and outcomes following neonatal cardiac surgery in a low-income and middle-income country setting where LBW prevalence is high and its impact on surgical outcomes is undefined.

DESIGN

Single-centre retrospective cohort study.

SETTING

Referral paediatric hospital in Southern India PATIENTS: All neonatal cardiac surgical cases between January 2011 and December 2018. LBW was defined as <2.5 kg.

MAIN OUTCOME MEASURES

Patient demographics, corrective versus palliative surgery and postoperative outcomes were collected from the institutional database which undergoes regular audit as part of International Quality Improvement Collaborative for Congenital Heart Disease. In-hospital mortality was the primary outcome measure.

RESULTS

Of 569 neonatal cardiac operations, 123 (21.6%) had LBW (mean: 2.2±0.3 kg); 18.7% <2 kg and 21.1% were preterm (<37 weeks). Surgery type (corrective vs palliative) or non-cardiac anomalies were not associated with birth weight. Birth weight did not correlate with ICU length of stay (LOS) and mechanical ventilation but was lower in those with postoperative sepsis. Overall in-hospital mortality was 7.0%; LBW neonates had higher mortality (OR 2.16, 95% CI 1.09 to 4.29, p=0.025). Multivariable analyses revealed birth weight (OR per 100 g decrease in weight: 1.12; 95% CI 1.03 to 1.22), age at surgery (OR per day increase in age of 0.93; 95% CI 0.87 to 0.99) and palliative intervention (OR 4.46 (95% CI 1.91 to 10.44) as independent predictors of in-hospital mortality.

CONCLUSION

LBW adversely impacts in-hospital mortality outcomes following neonatal cardiac surgery in a resource-limited setting without increase in ICU or hospital LOS.

Impact of transport on arrival status and outcomes in newborns with heart disease: a low-middle-income country perspective

OBJECTIVES

We sought to systematically study determinants of "clinical status at arrival after transport" of neonates with CHD and its impact on clinical outcomes in a low- and middle-income country environment.

METHODS AND RESULTS

Consecutive neonates with CHD (n = 138) transported (median distance 138 km; 5-425 km) to a paediatric cardiac programme in Southern India were studied prospectively. Among 138 neonatal transports, 134 were in ambulances. Four neonates were transported by family in private vehicles; 60% with duct-dependent circulation (n = 57) were transported without prostaglandin E1. Clinical status at arrival after transport was assessed using California modification of TRIPS Score (Ca-TRIPS), evidence of end-organ injury and metabolic insult.Upon arrival, 42% had end-organ injury, 24% had metabolic insult and 36% had Ca-TRIPS Score >25. Prior to surgery or catheter intervention, prolonged ICU stay (>48 hours), prolonged ventilation (>48 hours), blood stream sepsis, and death occurred in 48, 15, 19, and 3.6%, respectively. Ca-TRIPS Score >25 was significantly associated with mortality (p = 0.005), sepsis (p = 0.035), and prolonged ventilation (p < 0.001); end-organ injury with prolonged ICU stay (p = 0.031) and ventilation (p = 0.045); metabolic insult with mortality (p = 0.012) and sepsis (p = 0.015).Fifteen babies needed only medical management, 10 received comfort care (due to severe end-organ injury in 3), 107 underwent cardiac surgery (n = 83) or catheter intervention (n = 24), with a mortality of 6.5%. Clinical status at arrival after transport did not impact post-procedure outcomes.

CONCLUSION

Neonates with CHD often arrive in suboptimal status after transport in low- and middle-income countries resulting in adverse clinical outcomes. Robust transport systems need to be integrated in plans to develop newborn heart surgery in low- and middle-income countries.

Early weight trends after congenital heart surgery and their determinants

BACKGROUND

Early weight trends after cardiac surgery in infants from low- and middle-income countries where the majority are undernourished have not been defined. We studied the early post-operative weight trends to identify specific factors associated with early weight loss and poor weight gain after discharge following congenital heart surgery in consecutive infants undergoing cardiac surgery at a referral hospital in Southern India.

METHODS

This was a prospective observational study. Weights of the babies were recorded at different time points during the hospital stay and at 1-month post-discharge. A comprehensive database of pre-operative, operative, and post-operative variables was created and entered into a multivariate logistic regression analysis model to identify factors associated with excessive early weight loss after cardiac surgery, and poor weight gain following hospital discharge.

RESULTS

The study enrolled 192 infants (mean age 110.7 ± 99.9 days; weight z scores - 2.5 ± 1.5). There was a small but significant (p < 0.001) decline in weight in the hospital following surgery (1.6% decline (interquartile range -5.3 to +1.7)); however, there was substantial growth following discharge (26.7% increase (interquartile range 15.3-41.8)). The variables associated with post-operative weight loss were cumulative nil-per-oral duration and cardiopulmonary bypass time, while weight gain following discharge was only associated with age.

CONCLUSION

Weight loss is almost universal early after congenital heart surgery and is associated with complex surgery and cumulative nil-per-oral duration. After discharge, weight gain is almost universal and not associated with any of the perioperative variables.

Cardiovascular, respiratory, and related disorders: key messages from Disease Control Priorities, 3rd edition

Cardiovascular, respiratory, and related disorders (CVRDs) are the leading causes of adult death worldwide, and substantial inequalities in care of patients with CVRDs exist between countries of high income and countries of low and middle income. Based on current trends, the UN Sustainable Development Goal to reduce premature mortality due to CVRDs by a third by 2030 will be challenging for many countries of low and middle income. We did systematic literature reviews of effectiveness and cost-effectiveness to identify priority interventions. We summarise the key findings and present a costed essential package of interventions to reduce risk of and manage CVRDs. On a population level, we recommend tobacco taxation, bans on trans fats, and compulsory reduction of salt in manufactured food products. We suggest primary health services be strengthened through the establishment of locally endorsed guidelines and ensured availability of essential medications. The policy interventions and health service delivery package we suggest could serve as the cornerstone for the management of CVRDs, and afford substantial financial risk protection for vulnerable households. We estimate that full implementation of the essential package would cost an additional US$21 per person in the average low-income country and $24 in the average lower-middle-income country. The essential package we describe could be a starting place for low-income and middle-income countries developing universal health coverage packages. Interventions could be rolled out as disease burden demands and budgets allow. Our outlined interventions provide a pathway for countries attempting to convert the UN Sustainable Development Goal commitments into tangible action.

Management of undernutrition and failure to thrive in children with congenital heart disease in low- and middle-income countries

Poor growth with underweight for age, decreased length/height for age, and underweight-for-height are all relatively common in children with CHD. The underlying causes of this failure to thrive may be multifactorial, including innate growth potential, severity of cardiac disease, increased energy requirements, decreased nutritional intake, malabsorption, and poor utilisation of absorbed nutrition. These factors are particularly common and severe in low- and middle-income countries. Although nutrition should be carefully assessed in all patients, failure of growth is not a contraindication to surgical repair, and patients should receive surgical repair where indicated as soon as possible. Close attention should be paid to nutritional support - primarily enteral feeding, with particular use of breast milk in infancy - in the perioperative period and in the paediatric ICU. This nutritional support requires specific attention and allocation of resources, including appropriately skilled personnel. Thereafter, it is essential to monitor growth and development and to identify causes for failure to catch-up or grow appropriately.

Management of late presentation congenital heart disease

In many parts of the world, mostly low- and middle-income countries, timely diagnosis and repair of congenital heart diseases (CHDs) is not feasible for a variety of reasons. In these regions, economic growth has enabled the development of cardiac units that manage patients with CHD presenting later than would be ideal, often after the window for early stabilisation - transposition of the great arteries, coarctation of the aorta - or for lower-risk surgery in infancy - left-to-right shunts or cyanotic conditions. As a result, patients may have suffered organ dysfunction, manifest signs of pulmonary vascular disease, or the sequelae of profound cyanosis and polycythaemia. Late presentation poses unique clinical and ethical challenges in decision making regarding operability or surgical candidacy, surgical strategy, and perioperative intensive care management.

The global burden of paediatric heart disease

An estimated 15 million children die or are crippled annually by treatable or preventable heart disease in low- and middle-income countries. Global efforts to reduce under-5 mortality have focused on reducing death from communicable diseases in low- and middle-income countries with little to no attention focusing on paediatric CHD and acquired heart disease. Lack of awareness of CHD and acquired heart disease, access to care, poor healthcare infrastructure, competing health priorities, and a critical shortage of specialists are important reasons why paediatric heart disease has not been addressed in low resourced settings. Non-governmental organisations have taken the lead to address these challenges. This review describes the global burden of paediatric heart disease and strategies to improve the quality of care for paediatric heart disease. These strategies would improve outcomes for children with heart disease.

Health-related quality of life in congenital heart disease surgery patients in Pakistan: protocol for a mixed-methods study

INTRODUCTION

Reduced health-related quality of life (HRQOL) has been reported in postoperative patients with congenital heart disease (CHD). However, there is a paucity of data from low-income and middle-income countries (LMIC). Differences in sociodemographics and sociocultural contexts may influence HRQOL. This protocol paper describes a study exploring HRQOL in surgical patients with CHD from a tertiary hospital in Pakistan. The study findings will assist development of strategies to improve HRQOL in a resource-constrained context.

METHODS AND ANALYSIS

This prospective, concurrent triangulation, mixed-methods study aims to compare HRQOL of postsurgery patients with CHD with age-matched healthy siblings and to identify HRQOL predictors. A qualitative component aims to further understand HRQOL data by exploring the experiences related to CHD surgery for patients and parents. Participants include patients with CHD (a minimum of n~95) with at least 1-year postsurgery follow-up and no chromosomal abnormality, their parents and age-matched, healthy siblings. PedsQL 4.0 Generic Core Scales, PedsQL Cognitive Functioning Scale and PedsQL 3.0 Cardiac Module will measure HRQOL. Clinical/surgical data will be retrieved from patients' medical files. Student's t-test will be used to compare the difference in the means of HRQOL between CHD and siblings. Multiple regression will identify HRQOL predictors. A subsample of enrolled patients (n~20) and parents (n~20) from the quantitative arm will be engaged in semistructured qualitative interviews, which will be analysed using directed content analysis. Anticipated challenges include patient recruitment due to irregular follow-up compliance. Translation of data collection tools to the Urdu language and back-translation of interviews increases the study complexity.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from The Aga Khan University, Pakistan (3737-Ped-ERC-15). Study findings will be published in peer-reviewed journals and presented at national and international conferences.