Outcomes of truncus arteriosus repair and predictors of mortality

Cardiogenic Necrotizing Enterocolitis in Infants with Congenital Heart Disease: A Systematic Review and Meta-analysis

Necrotizing enterocolitis (NEC) is a known cause of morbidity and mortality in infants with congenital heart disease (CHD), but reports about the burden of cardiogenic NEC frequently conflict. To synthesize the extant literature on the incidence, risk factors, and prognosis of NEC in patients with CHD. Medline, Cochrane, and EMBASE were searched from 1946 through 2023 for studies of NEC in infants 0-12 months of age with CHD. Risk of bias was assessed with validated tools for incidence and risk factors. Pooled estimates were meta-analyzed by risk of bias or synthesized without meta-analysis. Eighty-six studies with a total of 67,924 participants were included. The incidence of cardiogenic NEC was 7.1% (95% CI 4.7-10.5%) in term infants and 13.0% (10.2-16.5%) in low birthweight preterm infants. NEC required surgery in 0.8% (0.5-1.1%) of term and 2.7% (2.0-3.7%) of premature infants, respectively. Only gestational age and birth weight were consistently associated with risk of NEC. Restricting pooled estimates to studies of moderate or low risk of bias significantly reduced the number of studies included. Necrotizing enterocolitis is a common cause of morbidity in infants with CHD, but additional research is needed to determine which infants are at highest risk of developing NEC and would benefit most from a change in management. This systematic review and meta-analysis was conducted according to a prespecified protocol registered at the Prospective Register of Systematic Reviews (CRD42021282114).

Outcomes of Gastrostomy and Tracheostomy in Infants Undergoing Truncus Arteriosus Repair: Database Study Using the Pediatric Health Information System

OBJECTIVES

We sought to determine the prevalence of and factors associated with gastrostomy tube placement and tracheostomy in infants undergoing truncus arteriosus repair, and associations between these procedures and outcome.

DESIGN

Retrospective cohort study.

SETTING

Pediatric Health Information System database.

PATIENTS

Infants less than 90 days old who underwent truncus arteriosus repair from 2004 to 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Multivariable logistic regression models were used to identify factors associated with gastrostomy tube and tracheostomy placement and to identify associations between these procedures and hospital mortality and prolonged postoperative length of stay (LOS; > 30 d). Of 1,645 subjects, gastrostomy tube was performed in 196 (11.9%) and tracheostomy in 56 (3.4%). Factors independently associated with gastrostomy tube placement were DiGeorge syndrome, congenital airway anomaly, admission age less than or equal to 2 days, vocal cord paralysis, cardiac catheterization, infection, and failure to thrive. Factors independently associated with tracheostomy congenital airway anomaly, truncal valve surgery, and cardiac catheterization. Gastrostomy tube was independently associated with prolonged postoperative LOS (odds ratio [OR], 12.10; 95% CI, 7.37-19.86). Hospital mortality occurred in 17 of 56 patients (30.4%) who underwent tracheostomy versus 147 of 1,589 patients (9.3%) who did not ( p < 0.001), and median postoperative LOS was 148 days in patients who underwent tracheostomy versus 18 days in those who did not ( p < 0.001). Tracheostomy was independently associated with mortality (OR, 3.11; 95% CI, 1.43-6.77) and prolonged postoperative LOS (OR, 9.85; 95% CI, 2.16-44.80).

CONCLUSIONS

In infants undergoing truncus arteriosus repair, tracheostomy is associated with greater odds of mortality; while gastrostomy and tracheostomy are strongly associated with greater odds of prolonged postoperative LOS.

Updated clinical practice recommendations for managing children with 22q11.2 deletion syndrome

This review aimed to update the clinical practice guidelines for managing children and adolescents with 22q11.2 deletion syndrome (22q11.2DS). The 22q11.2 Society, the international scientific organization studying chromosome 22q11.2 differences and related conditions, recruited expert clinicians worldwide to revise the original 2011 pediatric clinical practice guidelines in a stepwise process: (1) a systematic literature search (1992-2021), (2) study selection and data extraction by clinical experts from 9 different countries, covering 24 subspecialties, and (3) creation of a draft consensus document based on the literature and expert opinion, which was further shaped by survey results from family support organizations regarding perceived needs. Of 2441 22q11.2DS-relevant publications initially identified, 2344 received full-text reviews, including 1545 meeting criteria for potential relevance to clinical care of children and adolescents. Informed by the available literature, recommendations were formulated. Given evidence base limitations, multidisciplinary recommendations represent consensus statements of good practice for this evolving field. These recommendations provide contemporary guidance for evaluation, surveillance, and management of the many 22q11.2DS-associated physical, cognitive, behavioral, and psychiatric morbidities while addressing important genetic counseling and psychosocial issues.

Association Between Birth Weight Z-Scores and Early Outcomes Following Truncus Arteriosus Repair

In infants undergoing truncus arteriosus (TA) repair, we sought to determine associations between fetal growth restrictions as measured by birth weight Z-score and early outcomes. We utilized the Pediatric Health Information System (PHIS) database to identify infants < 90 days old who underwent TA repair from 2004 to 2019. The primary exposure variable was birth weight Z-score, calculated based on gestational age at birth, gender, and birth weight. The primary outcome was postoperative hospital mortality. Secondary outcomes included major complications, prolonged postoperative length of hospital stay (LOS; > 30 days), and hospital readmission within 1 year. Generalized estimating equation (GEE) models were used to identify adjusted associations between birth weight Z-score, small for gestational age (SGA) status, and mortality and included were 1039 subjects. Median birth weight was 2960 g, gestational age at birth was 38 weeks, and birth weight Z-score was - 0.47. SGA was present in 21% of subjects. Hospital mortality occurred in 104 patients (10%). By multivariable analysis, lower birth weight Z-score was associated with higher hospital mortality [for each unit decrease in birth weight Z-score below - 1.0, adjusted OR 1.71 (95% CI 1.10-4.25)]. SGA status was associated with increased hospital mortality (adjusted OR 2.17; 95% CI 1.39-3.40). Birth weight Z-scores and SGA status were not significantly associated with occurrence of cardiac arrest, ECMO use, gastrostomy tube placement, tracheostomy, seizures, infection, prolonged postoperative LOS, or hospital readmission. In infants undergoing TA repair, lower birth weight Z-scores and SGA status were strongly associated with increased hospital mortality.

Surgical Repair of Truncus Arteriosus: A Long-Term Hemodynamic Assessment

Background: Unrepaired truncus arteriosus (TA) carries poor prognosis due to complications of unrestricted pulmonary flow, truncal valve insufficiency, and pulmonary vascular disease. Currently, the hemodynamic profile of adults late after TA repair is unknown. We reviewed the hemodynamics, prevalence, and pathophysiology of pulmonary hypertension (PH) in this population. Methods: Eighteen adult patients with repaired TA who underwent cardiac catheterization at Mayo Clinic, MN, between 1997 and 2021 were identified. PH was defined as either precapillary (mean pulmonary artery pressure [mPAP] ≥25 mm Hg, pulmonary artery wedge pressure [PAWP] ≤15 mm Hg, and pulmonary vascular resistance [PVR] >3 Wood units), isolated postcapillary (mPAP ≥25, PAWP >15, PVR ≤3), or combined (mPAP ≥25, PAWP >15, and PVR >3). Diastolic pressure and transpulmonary gradients were used as ancillary data for classification. Results: Mean age at catheterization was 34 ± 10 years. Mean right ventricular (RV) systolic pressure was 82 ± 22.6 mm Hg, mean right and left mPAPs 28.1 ± 16.2 and 27.9 ± 11.9 mm Hg, respectively. Seven patients (41.2%) had PAWP >15 mm Hg and, among those undergoing arterial catheterization, 7 (53.8%) had a left ventricular (LV) end-diastolic pressure >15 mm Hg. PH was diagnosed in 13 patients (72.2%): 6 (33.3%) precapillary, 4 (22.2%) isolated postcapillary, and 3 (16.7%) combined. PAWP >15 mm Hg was associated with male sex ( P = .049), <moderate RV dysfunction ( P = .049), and lesser RV conduit mean systolic gradient ( P = .02). Patients with PH with precapillary component were older at catheterization ( P = .046). Conclusions: In adults with repaired TA, precapillary PH was only present in one-third of patients with mPAPs not significantly increased in most, whereas elevated PAWP and left-heart disease were common.

22q11.2 Deletion Syndrome: Impact of Genetics in the Treatment of Conotruncal Heart Defects

Congenital heart diseases represent one of the hallmarks of 22q11.2 deletion syndrome. In particular, conotruncal heart defects are the most frequent cardiac malformations and are often associated with other specific additional cardiovascular anomalies. These findings, together with extracardiac manifestations, may affect perioperative management and influence clinical and surgical outcome. Over the past decades, advances in genetic and clinical diagnosis and surgical treatment have led to increased survival of these patients and to progressive improvements in postoperative outcome. Several studies have investigated long-term follow-up and results of cardiac surgery in this syndrome. The aim of our review is to examine the current literature data regarding cardiac outcome and surgical prognosis of patients with 22q11.2 deletion syndrome. We thoroughly evaluate the most frequent conotruncal heart defects associated with this syndrome, such as tetralogy of Fallot, pulmonary atresia with major aortopulmonary collateral arteries, aortic arch interruption, and truncus arteriosus, highlighting the impact of genetic aspects, comorbidities, and anatomical features on cardiac surgical treatment.

Hospital Outcomes Among Infants With Interrupted Aortic Arch With Simple and Complex Associated Heart Defects

There is a lack of current, multi-institutional data regarding hospital outcomes of infants with interrupted aortic arch (IAA). We analyzed the Pediatric Health Information System database to identify infants with IAA who underwent repair during 2004 to 2019. We classified patients as simple or complex based on associated heart defects. We evaluated factors associated with hospital mortality and complications related to 22q11.2 deletion syndrome (22q11.2del) using mixed logistic regression, accounting for hospital clustering. In 1,283 infants included (904 simple, 379 complex), mortality was higher in the complex group (11.7% vs 4.4%, p <0.001). Factors associated with mortality in the simple group were low birth weight (adjusted risk ratio [aRR] 3.77, 95% confidence interval [95% CI] 1.83 to 7.77), non-22q11.2del genetic conditions (aRR 6.44, 95% CI 1.73 to 23.96), and gastrointestinal anomalies (aRR 8.47, 95% CI 3.12 to 22.95), whereas surgery between 2012 and 2015 (aRR 0.36, 95% CI 0.13 to 0.99) was protective. In the complex group, factors associated with mortality were male (aRR 2.32, 95% CI 1.10 to 4.24) and central nervous system anomalies (aRR 3.73, 95% CI 1.62 to 8.59). Compared with their nonsyndromic counterparts, infants with simple IAA and 22q11.2del were at higher risk of sepsis (aRR 1.63, 95% CI 1.02 to 2.39) and gastrostomy tube placement (aRR 3.18, 95% CI 2.13 to 4.74), and infants with complex IAA and 22q11.2del were at higher risk of gastrostomy tube placement (aRR 2.42, 95% CI 1.20 to 4.88). In conclusion, presence of complex cardiac lesions is associated with increased mortality after IAA repair. The co-occurrence of extracardiac congenital anomalies and non-22q11.2del genetic conditions elevates mortality risk. Presence of 22q11.2del is associated with hospital complications.