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Kolwaite AR, Edwards JA, Higgins M, Kandaswamy S, Orenstein E, Boughton D, Zinyandu T, Brasher S, Shashidharan S, Thompson LM, Chanani NK. Associations between Child Opportunity Index and Pediatric Cardiac Surgical Outcomes. J Pediatr 2024; 270:114000. [PMID: 38432295 DOI: 10.1016/j.jpeds.2024.114000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 02/25/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE To assess the relationship between the Child Opportunity Index (COI), a comprehensive measurement of social determinants of health, and specific COI domains on patient-specific outcomes following congenital cardiac surgery in the metropolitan region of Atlanta, Georgia. STUDY DESIGN In this retrospective chart review, we included patients who underwent an index operation for congenital heart disease between 2010 and 2020 in a single pediatric health care system. Patients' addresses were geocoded and mapped to census tracts. Descriptive statistics, univariable analysis, and multivariable regression models were employed to assess associations between variables and outcomes. RESULTS Of the 7460 index surgeries, 3798 (51%) met eligibility criteria. Presence of an adverse outcome, defined as either mortality or 1 of several other major postoperative morbidities, was significantly associated with COI in the univariable model (P = .008), but not the multivariable regression model (P = .39). Postoperative hospital length of stay was significantly associated with COI (P < .001) in univariable and multivariable regression models. There was no significant association between COI and readmission within 30 days of hospital discharge in univariable (P < .094) and multivariable (P = .49) models. CONCLUSION COI is associated with postoperative hospital length of stay but not all outcomes in patients after congenital heart surgery. By understanding the role of COI in outcomes related to cardiac surgery, targeted interventions can be developed to improve health equity.
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Affiliation(s)
- Amy R Kolwaite
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA.
| | - Johnathan A Edwards
- Rollins School of Public Health, Emory University, Atlanta, GA; University of Lincoln, School of Health and Social Care, Lincolnshire, UK
| | - Melinda Higgins
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
| | | | - Evan Orenstein
- Rollins School of Public Health, Emory University, Atlanta, GA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Division of Hospital Medicine, Children's Healthcare of Atlanta, Atlanta, GA; Information Services and Technology, Children's Healthcare of Atlanta, Atlanta, GA
| | - Dawn Boughton
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Tawanda Zinyandu
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Susan Brasher
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
| | | | - Lisa M Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA; Rollins School of Public Health, Emory University, Atlanta, GA
| | - Nikhil K Chanani
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
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2
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Stephens EH, Feins EN, Karamlou T, Anderson BR, Alsoufi B, Bleiweis MS, d'Udekem Y, Nelson JS, Ashfaq A, Marino BS, St Louis JD, Najm HK, Turek JW, Ahmad D, Dearani JA, Jacobs JP. The Society of Thoracic Surgeons Clinical Practice Guidelines on the Management of Neonates and Infants with Coarctation. Ann Thorac Surg 2024:S0003-4975(24)00337-0. [PMID: 38904587 DOI: 10.1016/j.athoracsur.2024.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/06/2024] [Accepted: 04/22/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Although coarctation of the aorta without concomitant intracardiac pathology is relatively common, there is lack of guidance regarding aspects of its management in neonates and infants. METHODS A panel of experienced congenital cardiac surgeons, cardiologists, and intensivists was created, and key questions related to the management of isolated coarctation in neonates and infants were formed using the PICO (Patients/Population, Intervention, Comparison/Control, Outcome) Framework. A literature search was then performed for each question. Practice guidelines were developed with classification of recommendation and level of evidence using a modified Delphi method. RESULTS For neonates and infants with isolated coarctation, surgery is indicated in the absence of obvious surgical contraindications. For patients with risk factors for surgery, medical management before intervention is reasonable. For those stable off prostaglandin E1, the threshold for intervention remains unclear. Thoracotomy is indicated when arch hypoplasia is not present. Sternotomy is preferable when arch hypoplasia is present that cannot be adequately addressed through a thoracotomy. Sternotomy may also be considered in the presence of a bovine aortic arch. Antegrade cerebral perfusion may be reasonable when the repair is performed through a sternotomy. Extended end-to-end, arch advancement, and patch augmentation are all reasonable techniques. CONCLUSIONS Surgery remains the standard of care for the management of isolated coarctation in neonates and infants. Depending on degree and location, arch hypoplasia may require a sternotomy approach as opposed to a thoracotomy approach. Significant opportunities remain to better delineate management in these patients.
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Affiliation(s)
| | - Eric N Feins
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brett R Anderson
- Division of Pediatric Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
| | - Bahaaldin Alsoufi
- Cardiovascular Surgery, Norton Children's Hospital, University of Louisville, Louisville, Kentucky
| | - Mark S Bleiweis
- Congenital Heart Center, Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida; Congenital Heart Center, Division of Cardiovascular Surgery, Department of Pediatrics, University of Florida, Gainesville, Florida
| | - Yves d'Udekem
- Children's National Heart Institute, Children's National Hospital, Washington, DC
| | - Jennifer S Nelson
- Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida
| | - Awais Ashfaq
- Division of Cardiovascular Surgery, Department of Surgery, Cincinnati Children's Hospital, Cincinnati, Ohio
| | | | - James D St Louis
- Departent of Surgery, Children's Hospital of Georgia, Augusta, Georgia; Departent of Surgery, Inova L.J. Murphy Children's Hospital, Falls Church, Virginia
| | - Hani K Najm
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph W Turek
- Duke Pediatric and Congenital Heart Center, Duke University Medical Center, Durham, North Carolina
| | - Danial Ahmad
- Cardiac Surgery Research Laboratory, Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jeffrey P Jacobs
- Congenital Heart Center, Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida; Congenital Heart Center, Division of Cardiovascular Surgery, Department of Pediatrics, University of Florida, Gainesville, Florida.
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3
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Heino A, Morris JK, Garne E, Baldacci S, Barisic I, Cavero-Carbonell C, García-Villodre L, Given J, Jordan S, Loane M, Lutke LR, Neville AJ, Santoro M, Scanlon I, Tan J, de Walle HEK, Kiuru-Kuhlefelt S, Gissler M. The Association of Prenatal Diagnoses with Mortality and Long-Term Morbidity in Children with Specific Isolated Congenital Anomalies: A European Register-Based Cohort Study. Matern Child Health J 2024; 28:1020-1030. [PMID: 38438690 PMCID: PMC11059158 DOI: 10.1007/s10995-024-03911-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 03/06/2024]
Abstract
OBJECTIVES To compare 5-year survival rate and morbidity in children with spina bifida, transposition of great arteries (TGA), congenital diaphragmatic hernia (CDH) or gastroschisis diagnosed prenatally with those diagnosed postnatally. METHODS Population-based registers' data were linked to hospital and mortality databases. RESULTS Children whose anomaly was diagnosed prenatally (n = 1088) had a lower mean gestational age than those diagnosed postnatally (n = 1698) ranging from 8 days for CDH to 4 days for TGA. Children with CDH had the highest infant mortality rate with a significant difference (p < 0.001) between those prenatally (359/1,000 births) and postnatally (116/1,000) diagnosed. For all four anomalies, the median length of hospital stay was significantly greater in children with a prenatal diagnosis than those postnatally diagnosed. Children with prenatally diagnosed spina bifida (79% vs 60%; p = 0.002) were more likely to have surgery in the first week of life, with an indication that this also occurred in children with CDH (79% vs 69%; p = 0.06). CONCLUSIONS Our findings do not show improved outcomes for prenatally diagnosed infants. For conditions where prenatal diagnoses were associated with greater mortality and morbidity, the findings might be attributed to increased detection of more severe anomalies. The increased mortality and morbidity in those diagnosed prenatally may be related to the lower mean gestational age (GA) at birth, leading to insufficient surfactant for respiratory effort. This is especially important for these four groups of children as they have to undergo anaesthesia and surgery shortly after birth. Appropriate prenatal counselling about the time and mode of delivery is needed.
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Affiliation(s)
- Anna Heino
- Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Mannerheimintie 166, 00270, Helsinki, Finland.
| | - Joan K Morris
- Population Health Research Institute, St George's, University of London, London, UK
| | - Ester Garne
- Department of Pediatrics and Adolescent Medicine, Lillebaelt Hospital, University Hospital of Southern Denmark, Kolding, Denmark
| | - Silvia Baldacci
- Unit of Epidemiology of Rare Diseases and Congenital Anomalies, Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Ingeborg Barisic
- Centre of Excellence for Reproductive and Regenerative Medicine, Children's Hospital Zagreb, Medical School University of Zagreb, Klaiceva 16, 10000, Zagreb, Croatia
| | - Clara Cavero-Carbonell
- Rare Diseases Research Unit, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region, Valencia, Spain
| | - Laura García-Villodre
- Rare Diseases Research Unit, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region, Valencia, Spain
| | - Joanne Given
- Institute of Nursing and Health Research, Ulster University, Coleraine, UK
| | - Sue Jordan
- Faculty Health and Life Sciences, Swansea, Wales
| | - Maria Loane
- Institute of Nursing and Health Research, Ulster University, Coleraine, UK
| | - L Renée Lutke
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Amanda J Neville
- IMER Registry (Emilia Romagna Registry of Birth Defects), Center for Clinical and Epidemiological Research, University of Ferrara, 44121, Ferrara, Italy
| | - Michele Santoro
- Unit of Epidemiology of Rare Diseases and Congenital Anomalies, Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | | | - Joachim Tan
- Population Health Research Institute, St George's, University of London, London, UK
| | - Hermien E K de Walle
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Sonja Kiuru-Kuhlefelt
- Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Mannerheimintie 166, 00270, Helsinki, Finland
| | - Mika Gissler
- Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Mannerheimintie 166, 00270, Helsinki, Finland
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Opotowsky AR, Khairy P, Diller G, Kasparian NA, Brophy J, Jenkins K, Lopez KN, McCoy A, Moons P, Ollberding NJ, Rathod RH, Rychik J, Thanassoulis G, Vasan RS, Marelli A. Clinical Risk Assessment and Prediction in Congenital Heart Disease Across the Lifespan: JACC Scientific Statement. J Am Coll Cardiol 2024; 83:2092-2111. [PMID: 38777512 DOI: 10.1016/j.jacc.2024.02.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/12/2024] [Accepted: 02/22/2024] [Indexed: 05/25/2024]
Abstract
Congenital heart disease (CHD) comprises a range of structural anomalies, each with a unique natural history, evolving treatment strategies, and distinct long-term consequences. Current prediction models are challenged by generalizability, limited validation, and questionable application to extended follow-up periods. In this JACC Scientific Statement, we tackle the difficulty of risk measurement across the lifespan. We appraise current and future risk measurement frameworks and describe domains of risk specific to CHD. Risk of adverse outcomes varies with age, sex, genetics, era, socioeconomic status, behavior, and comorbidities as they evolve through the lifespan and across care settings. Emerging technologies and approaches promise to improve risk assessment, but there is also need for large, longitudinal, representative, prospective CHD cohorts with multidimensional data and consensus-driven methodologies to provide insight into time-varying risk. Communication of risk, particularly with patients and their families, poses a separate and equally important challenge, and best practices are reviewed.
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Affiliation(s)
- Alexander R Opotowsky
- Adult Congenital Heart Disease Program, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
| | - Paul Khairy
- Adult Congenital Heart Centre, Montreal Heart Institute, Montréal, Quebec, Canada
| | - Gerhard Diller
- Department of Cardiology III, University Hospital Münster, Münster, Germany
| | - Nadine A Kasparian
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Heart and Mind Wellbeing Center, Cincinnati, Ohio, USA; Heart Institute and Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - James Brophy
- Department of Medicine, Faculty of Medicine and Health Sciences, McGill University, Montréal, Quebec, Canada
| | - Kathy Jenkins
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Keila N Lopez
- Department of Pediatrics, Section of Cardiology, Texas Children's Hospital & Baylor College of Medicine, Houston, Texas, USA
| | - Alison McCoy
- Vanderbilt Clinical Informatics Core, Department of Biomedical Informatics, Vanderbilt University Medical Center and Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Philip Moons
- KU Leuven Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium; Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden; Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Nicholas J Ollberding
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rahul H Rathod
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jack Rychik
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - George Thanassoulis
- Department of Medicine, Faculty of Medicine and Health Sciences, McGill University, Montréal, Quebec, Canada
| | - Ramachandran S Vasan
- School of Public Health, University of Texas, San Antonio, Texas, USA; Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Ariane Marelli
- McGill Adult Unit for Congenital Heart Disease Excellence, McGill University, Montreal, Quebec, Canada.
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Patel SR, Michelfelder E. Prenatal Diagnosis of Congenital Heart Disease: The Crucial Role of Perinatal and Delivery Planning. J Cardiovasc Dev Dis 2024; 11:108. [PMID: 38667726 PMCID: PMC11050606 DOI: 10.3390/jcdd11040108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 03/29/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024] Open
Abstract
Although most congenital heart defects (CHDs) are asymptomatic at birth, certain CHD lesions are at significant risk of severe hemodynamic instability and death if emergent cardiac interventions are not performed in a timely fashion. Therefore, accurate identification of at-risk fetuses and appropriate delivery resource planning according to the degree of anticipated hemodynamic instability is crucial. Fetal echocardiography has increased prenatal CHD detection in recent years due to advancements in ultrasound techniques and improved obstetrical cardiac screening protocols, enabling the prediction of newborns' hemodynamic status. This assessment can guide multidisciplinary resource planning for postnatal care, including selection of delivery site, delivery room management, and transport to a cardiac center based on CHD risk severity. This review will discuss fetal cardiovascular physiology and the circulatory changes that occur at the time of and immediately following birth, outline fetal echocardiographic findings used to risk-stratify newborns with CHDs, and outline principles for neonatal resuscitation and initial transitional care in neonates with these complex CHD lesions.
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Affiliation(s)
- Sheetal R. Patel
- Ann & Robert H Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Erik Michelfelder
- Children’s Healthcare of Atlanta, Emory School of Medicine, Emory University, Atlanta, GA 30265, USA
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6
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Morrison TM, Forget A, Keyes M, Sullivan A, Kelley J, Katz J, Morton S, Sayeed S, Levy PT. Establishing a neonatology consultation program: extending care beyond the neonatal intensive care unit. J Perinatol 2024; 44:458-463. [PMID: 38001156 DOI: 10.1038/s41372-023-01827-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 10/19/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023]
Abstract
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.
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Affiliation(s)
- Tierney M Morrison
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Avery Forget
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Madeline Keyes
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Anne Sullivan
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Jenna Kelley
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Jenna Katz
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Sarah Morton
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | - Sadath Sayeed
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Philip T Levy
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
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7
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Ihle E, Thompson J, Butt W, Namachivayam SP. High risk of necrotising enterocolitis in term-born neonates with CHD delivered by caesarean section: a case-control study. Cardiol Young 2024; 34:576-580. [PMID: 37608758 DOI: 10.1017/s1047951123003128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
OBJECTIVE Necrotising enterocolitis is linked with altered intestinal microbiota, and caesarean birth is associated with imbalance of newborn intestinal microbiome. We aimed to investigate the role of delivery mode (vaginal or caesarean) and gestational age in the development of necrotising enterocolitis among term-born neonates (≥ 37 weeks) with CHD. METHODS Case-control study. We studied all newborns with CHD who underwent cardiac surgery during the neonatal (≤ 28 days of age) period, between 2007 and 2017. Totally, 60 cases of necrotising enterocolitis were matched (by year of birth and type of congenital heart lesion) with 180 controls (1:3 ratio). Multivariable conditional logistic regression was used to assess the study question. RESULTS The overall prevalence of necrotising enterocolitis was 6.3% in term-born newborns with CHD. Neonates with a left-ventricular outflow tract lesion or single ventricle lesion accounted for 55% (n = 33) of cases. 62% (n = 37) cases were in the modified Bell's stage 2 or more for necrotising enterocolitis classification. In multivariable modelling, gestational age at birth was not associated with the development of necrotising enterocolitis [adjusted odds ratio per week increase, 95% confidence interval: 1.20 (0.90-1.60)]. Birth by caesarean delivery (compared to vaginal) was strongly associated with development of necrotising enterocolitis [adjusted odds ratio (95% confidence interval): 2.64 (1.31-5.29)]. We failed to identify an association between preoperative enteral nutrition and necrotising enterocolitis. CONCLUSION This study showed a high risk of necrotising enterocolitis in newborns with critical CHD born via caesarean. This information is important given the high prevalence of planned birth by caesarean in newborns with CHD.
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Affiliation(s)
- Eloise Ihle
- Cardiac Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
| | - Jenny Thompson
- Cardiac Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
| | - Warwick Butt
- Cardiac Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Siva P Namachivayam
- Cardiac Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
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8
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Duhaney L, Steurer MA, Baer R, Chambers C, Rajagopal S, Mercer-Rosa LM, Reddy VM, Jelliffe-Pawlowski LL, Peyvandi S. The Association of Gestational Age and Size with Management Strategies and Outcomes in Symptomatic Neonatal Tetralogy of Fallot. Pediatr Cardiol 2024; 45:300-308. [PMID: 38167967 PMCID: PMC10821998 DOI: 10.1007/s00246-023-03365-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 11/27/2023] [Indexed: 01/05/2024]
Abstract
In neonatal, symptomatic tetralogy of Fallot (sTOF), data are lacking on whether high-risk groups would benefit from staged (SR) or complete repair (CR). We studied the association of gestational age (GA) at birth and z-score for birth weight (BWz), with management strategy and outcomes in sTOF. California population-based cohort study (2011-2017) of infants with sTOF (defined as catheter or surgical intervention prior to 44 weeks corrected GA) was performed, comparing management strategy and timing by GA and BWz categories. Multivariable models evaluated composite outcomes and days alive and out of hospital (DAOOH) in the first year of life. Among 345 patients (SR = 194; CR = 151), management strategy did not differ by GA or BWz with complete repair defined as prior to 44 weeks corrected gestational age; however, did differ by GA with regard to complete/timely repair (defined as complete repair within first 30 days of life). Full-term and early-term neonates underwent CR 20 (95%CI: - 27.1, - 14.1; p < 0.001) and 15 days (95%CI: - 22.1, - 8.2; p < 0.001) sooner than preterm neonates. Prematurity and major anomaly were associated with mortality or non-cardiac morbidity, while only major anomaly was associated with mortality or cardiac morbidity (OR = 3.5, 95%CI: 1.8,6.7, p < .0001). Full-term infants had greater DAOOH compared to preterm infants (35.2 days, 95%CI: 4.0, 66.5, p = 0.03). LGA infants and those with major anomaly had significantly lower DAOOH. In sTOF, patient specific risk factors such as prematurity and major anomaly were more associated with outcomes than management strategy.
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Affiliation(s)
| | - Martina A Steurer
- University of California San Francisco, 550 16th Street, San Francisco, CA, 94158, USA
| | - Rebecca Baer
- University of California San Francisco, 550 16th Street, San Francisco, CA, 94158, USA
| | | | - Satish Rajagopal
- University of California San Francisco, 550 16th Street, San Francisco, CA, 94158, USA
| | | | - V Mohan Reddy
- University of California San Francisco, 550 16th Street, San Francisco, CA, 94158, USA
| | | | - Shabnam Peyvandi
- University of California San Francisco, 550 16th Street, San Francisco, CA, 94158, USA.
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9
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Mangla M, Anne RP. Perinatal Management of Pregnancies with Fetal Congenital Anomalies: A Guide to Obstetricians and Pediatricians. Curr Pediatr Rev 2024; 20:150-165. [PMID: 36200158 DOI: 10.2174/1573396318666221005142001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 08/14/2022] [Accepted: 08/29/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Congenital anomalies are responsible for approximately 20% of all neonatal deaths worldwide. Improvements in antenatal screening and diagnosis have significantly improved the prenatal detection of birth defects; however, these improvements have not translated into the improved neonatal prognosis of babies born with congenital anomalies. OBJECTIVES An attempt has been made to summarise the prenatal interventions, if available, the optimal route, mode and time of delivery and discuss the minimum delivery room preparations that should be made if expecting to deliver a fetus with a congenital anomaly. METHODS The recent literature related to the perinatal management of the fetus with prenatally detected common congenital anomalies was searched in English peer-reviewed journals from the PubMed database to work out an evidence-based approach for their management. RESULTS Fetuses with prenatally detected congenital anomalies should be delivered at a tertiary care centre with facilities for neonatal surgery and paediatric intensive care if needed. There is no indication for preterm delivery in the majority of cases. Only a few congenital malformations, like highrisk sacrococcygeal teratoma, congenital lung masses with significant fetal compromise, fetal cerebral lesions or neural tube defects with Head circumference >40 cm or the biparietal diameter is ≥12 cm, gastroschisis with extracorporeal liver, or giant omphaloceles in the fetus warrant caesarean section as the primary mode of delivery. CONCLUSION The prognosis of a fetus with congenital anomalies can be significantly improved if planning for delivery, including the place and time of delivery, is done optimally. A multidisciplinary team should be available for the fetus to optimize conditions right from when it is born.
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Affiliation(s)
- Mishu Mangla
- Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, Bibinagar, Hyderabad, India
| | - Rajendra Prasad Anne
- Department of Pediatrics, All India Institute of Medical Sciences, Bibinagar, Hyderabad, India
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10
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Jowett V. How do we use the opportunity of prenatal diagnosis of congenital heart disease to optimise outcome? Arch Dis Child 2023; 109:1-2. [PMID: 37945323 DOI: 10.1136/archdischild-2023-326302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Affiliation(s)
- Victoria Jowett
- Cardiology, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK
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11
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Namachivayam SP, Butt W, Brizard C, Millar J, Thompson J, Walker SP, Cheung MMH. Potential benefits of prenatal diagnosis of TGA in Australia may be outweighed by the adverse effects of earlier delivery: likely causation and potential solutions. Arch Dis Child 2023; 109:16-22. [PMID: 37751944 DOI: 10.1136/archdischild-2022-324861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 09/10/2023] [Indexed: 09/28/2023]
Abstract
OBJECTIVE Prenatal diagnosis of transposition of great arteries (TGA) is expected to improve postoperative outcomes after neonatal arterial switch operation (ASO); however, published reports give conflicting results. We aimed to determine the association between prenatal diagnosis and early postoperative outcomes after neonatal ASO. METHODS Cohort study involving 243 newborns who underwent ASO (70% prenatally diagnosed) between 2010 and 2019. Multivariable regression was used to determine the association between prenatal diagnosis and (a) birth characteristics and (b) postoperative outcomes. RESULTS Gestational age and birthweight centile were lower and small-for-gestational-age more common (11.8% vs 1.4%) in those diagnosed prenatally. Among births which followed labour induction or prelabour caesarean, prenatal diagnosis was associated with earlier gestation at birth (mean (SD), 38.5 (1.6) vs 39.2 (1.4), p=0.01). Among births which followed spontaneous labour, prenatal diagnosis was associated with earlier gestation at labour onset (38.2 (1.8) vs 39.2 (1.4), p=0.01). Prenatal diagnosis was associated with longer postoperative mechanical ventilation (incidence rate ratio 1.74, 95% CI 1.37 to 2.21), intensive care (1.70, 1.31 to 2.21) and hospital length of stay (1.37, 1.14 to 1.66) after ASO. Gestational age mediated up to 60% of the effect of prenatal diagnosis on postoperative outcomes. CONCLUSION Among newborns undergoing ASO for TGA, prenatal diagnosis is associated with poorer early postoperative outcomes. In addition to minimising iatrogenic factors (such as planned births) resulting in earlier births, evaluation of other dynamics following a prenatal diagnosis which may result in poor fetal growth and earlier onset of spontaneous labour is important.
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Affiliation(s)
- Siva P Namachivayam
- Cardiac Intensive Care Unit, Royal Children's Hospital, Parkville, Victoria, Australia
- Department of Critical Care, The University of Melbourne-Parkville Campus, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne-Parkville Campus, Melbourne, Victoria, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Warwick Butt
- Cardiac Intensive Care Unit, Royal Children's Hospital, Parkville, Victoria, Australia
- Department of Critical Care, The University of Melbourne-Parkville Campus, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne-Parkville Campus, Melbourne, Victoria, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Christian Brizard
- Department of Paediatrics, The University of Melbourne-Parkville Campus, Melbourne, Victoria, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Cardiac Surgery, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Johnny Millar
- Cardiac Intensive Care Unit, Royal Children's Hospital, Parkville, Victoria, Australia
- Department of Critical Care, The University of Melbourne-Parkville Campus, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne-Parkville Campus, Melbourne, Victoria, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Jenny Thompson
- Cardiac Intensive Care Unit, Royal Children's Hospital, Parkville, Victoria, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Susan P Walker
- Department of Obstetrics and Gynaecology, The University of Melbourne-Parkville Campus, Melbourne, Victoria, Australia
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Michael M H Cheung
- Department of Paediatrics, The University of Melbourne-Parkville Campus, Melbourne, Victoria, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Cardiology, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
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12
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Abboud F, Easson K, Majnemer A, Rohlicek CV, Brossard-Racine M. Psychological Well-Being, Everyday Functioning, and Autonomy In Emerging Adults with a Congenital Heart Defect. J Pediatr 2023; 262:113621. [PMID: 37473990 DOI: 10.1016/j.jpeds.2023.113621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/10/2023] [Accepted: 07/12/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE To characterize the psychological well-being, everyday functioning, and autonomy of emerging adults with congenital heart disease (CHD) and explore how they relate to the executive function (EF) deficits commonly observed in this population. STUDY DESIGN Questionnaires assessing psychological well-being (encompassing psychosocial functioning and resilience), EF, and age-appropriate indicators of everyday function and autonomy (eg, housing, education, employment, relationship status) were completed by participants with CHD (16-26 years) who underwent open-heart surgery during infancy and age- and sex-matched controls. RESULTS A total of 58 emerging adults with CHD and 57 controls participated in this study. Mean scores on the resilience and psychosocial functioning questionnaires were not significantly different between CHD and control participants. Emerging adults with CHD also did not differ from controls in terms of holding a driver's license, involvement in a romantic relationship, or current employment status. Multiple linear regression identified that better EF was associated with better psychological well-being. CONCLUSIONS This study supports the need for systematic screening for EF deficits during adolescence and early adulthood to promote optimal well-being in this population. Further research is required to continue to document the everyday experiences of adolescents and young adults with CHD to identify protective factors associated with a successful and satisfying transition to adult life.
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Affiliation(s)
- Fatme Abboud
- Advances in Brain and Child Health Development Research Laboratory, Research Institute of the McGill University Health Center, Montreal, Canada; Department of Neurology and Neurosurgery, McGill University, Montreal, Canada
| | - Kaitlyn Easson
- Advances in Brain and Child Health Development Research Laboratory, Research Institute of the McGill University Health Center, Montreal, Canada; Department of Neurology and Neurosurgery, McGill University, Montreal, Canada
| | - Annette Majnemer
- Department of Neurology and Neurosurgery, McGill University, Montreal, Canada; School of Physical and Occupational Therapy, McGill University, Montreal, Canada; Division of Neurology, Department of Pediatrics, McGill University Health Center, Montreal, Canada
| | - Charles V Rohlicek
- Division of Cardiology, Department of Pediatrics, McGill University Health Center, Montreal, Canada
| | - Marie Brossard-Racine
- Advances in Brain and Child Health Development Research Laboratory, Research Institute of the McGill University Health Center, Montreal, Canada; Department of Neurology and Neurosurgery, McGill University, Montreal, Canada; School of Physical and Occupational Therapy, McGill University, Montreal, Canada; Division of Cardiology, Department of Pediatrics, McGill University Health Center, Montreal, Canada; Division of Neonatology, Department of Pediatrics, McGill University Health Center, Montreal, Canada.
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13
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Butler V, Belhadjer Z, Gaudin R, Raisky O, Houyel L, Bonnet D. Outcomes after aortic coarctation repair in neonates weighing less than 2000 g. Arch Pediatr 2023; 30:567-572. [PMID: 37709606 DOI: 10.1016/j.arcped.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/06/2023] [Accepted: 08/21/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Preterm birth is common in children with congenital heart disease. However, data on how to manage low-birth-weight infants with aortic coarctation are scarce and outcomes are poorly reported. Surgery is often delayed in these infants because gaining weight is supposed to improve mortality and to reduce the risk for recoarctation. METHODS All infants weighing less than 2000 g who underwent repair for aortic coarctation at our institution between January 2017 and December 2020 were included in a retrospective study. Baseline characteristics, medical and surgical management, and outcomes, including recoarctation, death, and complications of preterm birth, were analyzed. RESULTS A total of 15 patients had coarctation repair at a median age of 15 days and at a median weight of 1585 g. Infants with a birth weight <1200 g were operated on later and did not have higher recoarctation rates compared to those with a birth weight >1200 g. The recoarctation rate was 26.6% and one infant died of an extracardiac cause. Concerning prematurity-related complications, we observed 40% of bronchopulmonary dysplasia, 40% of intraventricular hemorrhage, and 27% of retinopathy of prematurity. These complications were more prevalent in children with a birth weight of <1200 g. CONCLUSION Delaying surgery beyond 15 days to gain weight does not appear to decrease the risk of recoarctation and may be deleterious in low-birth-weight infants who are exposed for a longer period to risk factors of prematurity-related complications.
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Affiliation(s)
- Victoria Butler
- Assistance Publique-Hôpitaux de Paris, Port-Royal Maternity, Neonatal Intensive Care Unit, 123 Boulevard de Port-Royal, 75014 Paris, France; Paris Cité University, Paris, France.
| | - Zahra Belhadjer
- Paris Cité University, Paris, France; Assistance Publique-Hôpitaux de Paris, Necker-Enfants malades Hospital, M3C, 149 Rue de Sèvres, 75015 Paris, France
| | - Régis Gaudin
- Assistance Publique-Hôpitaux de Paris, Necker-Enfants malades Hospital, M3C, 149 Rue de Sèvres, 75015 Paris, France
| | - Olivier Raisky
- Paris Cité University, Paris, France; Assistance Publique-Hôpitaux de Paris, Necker-Enfants malades Hospital, M3C, 149 Rue de Sèvres, 75015 Paris, France
| | - Lucile Houyel
- Paris Cité University, Paris, France; Assistance Publique-Hôpitaux de Paris, Necker-Enfants malades Hospital, M3C, 149 Rue de Sèvres, 75015 Paris, France
| | - Damien Bonnet
- Paris Cité University, Paris, France; Assistance Publique-Hôpitaux de Paris, Necker-Enfants malades Hospital, M3C, 149 Rue de Sèvres, 75015 Paris, France
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14
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Schwartz BN, Pearson GD, Burns KM. Multicenter Clinical Research in Congenital Heart Disease: Leveraging Research Networks to Investigate Important Unanswered Questions. Neoreviews 2023; 24:e504-e510. [PMID: 37525311 PMCID: PMC10615178 DOI: 10.1542/neo.24-8-e504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
Congenital heart disease (CHD) is the most common birth defect in the United States. Neonates with CHD are often cared for by neonatologists in addition to cardiologists. However, there is a paucity of rigorous evidence and limited clinical trials regarding the management of neonates with CHD. In this review, we will describe some of the challenges of research in this field. The Pediatric Heart Network serves as an example of how a research network can effectively overcome barriers to conduct and execute well-designed multicenter studies.
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Affiliation(s)
- Bryanna N Schwartz
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
- Division of Cardiology, Children's National Hospital, Washington, DC
| | - Gail D Pearson
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Kristin M Burns
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
- Division of Cardiology, Children's National Hospital, Washington, DC
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15
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Steurer MA, McCulloch C, Santana S, Collins JW, Branche T, Costello JM, Peyvandi S. Disparities in 1-Year-Mortality in Infants With Cyanotic Congenital Heart Disease: Insights From Contemporary National Data. Circ Cardiovasc Qual Outcomes 2023; 16:e009981. [PMID: 37463254 DOI: 10.1161/circoutcomes.122.009981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 05/16/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Racial inequities in congenital heart disease (CHD) outcomes are well documented, but contributing factors warrant further investigation. We examined the interplay between race, socioeconomic position, and neonatal variables (prematurity and small for gestational age) on 1-year death in infants with CHD. We hypothesize that socioeconomic position mediates a significant part of observed racial disparities in CHD outcomes. METHODS Linked birth/death files from the Natality database for all liveborn neonates in the United States were examined from 2014 to 2018. Infants with cyanotic CHD were identified. Non-Hispanic Black (NHB) and Hispanic infants were compared with non-Hispanic White (NHW) infants. The primary outcome was 1-year death. Socioeconomic position was defined as maternal education and insurance status. Variables included as mediators were prematurity, small for gestational age, and socioeconomic position. Structural equation modeling was used to calculate the contribution of each mediator to the disparity in 1-year death. RESULTS We identified 7167 NHW, 1393 NHB, and 1920 Hispanic infants with cyanotic CHD. NHB race and Hispanic ethnicity were associated with increased 1-year death compared to NHW (OR, 1.43 [95% CI, 1.25-1.64] and 1.17 [95% CI, 1.03-1.33], respectively). The effect of socioeconomic position explained 28.2% (CI, 15.1-54.8) of the death disparity between NHB and NHW race and 100% (CI, 42.0-368) of the disparity between Hispanic and NHW. This was mainly driven by maternal education (21.3% [CI, 12.1-43.3] and 82.8% [CI, 33.1-317.8], respectively) while insurance status alone did not explain a significant percentage. The direct effect of race or ethnicity became nonsignificant: NHB versus NHW 43.1% (CI, -0.3 to 63.6) and Hispanic versus NHW -19.0% (CI, -329.4 to 45.3). CONCLUSIONS Less privileged socioeconomic position, especially lower maternal education, explains a large portion of the 1-year death disparity in Black and Hispanic infants with CHD. These findings identify targets for social interventions to decrease racial disparities.
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Affiliation(s)
- Martina A Steurer
- Department of Pediatrics (M.A.S., S.P.), University of California San Francisco
- Department of Epidemiology and Biostatistics (M.A.S., C.M., S.P.), University of California San Francisco
| | - Charles McCulloch
- Department of Epidemiology and Biostatistics (M.A.S., C.M., S.P.), University of California San Francisco
| | - Stephanie Santana
- Department of Pediatrics, Shawn Jenkins Children's Hospital, Medical University of South Carolina, Charleston (S.S., J.M.C.)
| | - James W Collins
- Department of Pediatrics, Division of Neonatology, Ann & Robert H. Lurie Children's Hospital of Chicago at Northwestern University Feinberg School of Medicine, IL (J.W.C., T.B.)
| | - Tonia Branche
- Department of Pediatrics, Division of Neonatology, Ann & Robert H. Lurie Children's Hospital of Chicago at Northwestern University Feinberg School of Medicine, IL (J.W.C., T.B.)
| | - John M Costello
- Department of Pediatrics, Shawn Jenkins Children's Hospital, Medical University of South Carolina, Charleston (S.S., J.M.C.)
| | - Shabnam Peyvandi
- Department of Pediatrics (M.A.S., S.P.), University of California San Francisco
- Department of Epidemiology and Biostatistics (M.A.S., C.M., S.P.), University of California San Francisco
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16
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Chaudhry PM, Sen S, Steurer M, Levy VY, Gowda S, Ball MK, Ashrafi A, Emani SM, Bacha EA, Checchia PA, Levy PT, Krishnamurthy G. Perioperative Care Models for Neonates With Congenital Heart Disease: Evolving Role of Neonatology Within the Cardiac Intensive Care Unit. World J Pediatr Congenit Heart Surg 2023; 14:481-489. [PMID: 37309123 DOI: 10.1177/21501351231170772] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
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.
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Affiliation(s)
- Paulomi M Chaudhry
- Division of Neonatology, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Shawn Sen
- Division of Neonatology and Pediatric Cardiology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Martina Steurer
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, USA
| | - Victor Y Levy
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Sharada Gowda
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Molly K Ball
- Division of Neonatology, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Amir Ashrafi
- Department of Pediatrics, CHOC Children's Hospital, Orange, CA, USA
- University of California Irvine, Orange, CA, USA
| | - Sitaram M Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Department of Surgery, Harvard Medical School Boston, Boston, MA, USA
| | - Emile A Bacha
- Division of Cardiac, Thoracic and Vascular Surgery, New York-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, Pediatric and Congenital Cardiac Surgery, New York, NY, USA
| | - Paul A Checchia
- Division of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Philip T Levy
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ganga Krishnamurthy
- Division of Neonatology, Department of Pediatrics, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY, USA
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17
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Gimeno L, Brown K, Harron K, Peppa M, Gilbert R, Blackburn R. Trends in survival of children with severe congenital heart defects by gestational age at birth: A population-based study using administrative hospital data for England. Paediatr Perinat Epidemiol 2023; 37:390-400. [PMID: 36744612 PMCID: PMC10946523 DOI: 10.1111/ppe.12959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 01/09/2023] [Accepted: 01/22/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND Children with congenital heart defects (CHD) are twice as likely as their peers to be born preterm (<37 weeks' gestation), yet descriptions of recent trends in long-term survival by gestational age at birth (GA) are lacking. OBJECTIVES To quantify changes in survival to age 5 years of children in England with severe CHD by GA. METHODS We estimated changes in survival to age five of children with severe CHD and all other children born in England between April 2004 and March 2016, overall and by GA-group using linked hospital and mortality records. RESULTS Of 5,953,598 livebirths, 5.7% (339,080 of 5,953,598) were born preterm, 0.35% (20,648 of 5,953,598) died before age five and 3.6 per 1000 (21,291 of 5,953,598) had severe CHD. Adjusting for GA, under-five mortality rates fell at a similar rate between 2004-2008 and 2012-2016 for children with severe CHD (adjusted hazard ratio [HR] 0.79, 95% CI 0.71, 0.88) and all other children (HR 0.78, 95% CI 0.76, 0.81). For children with severe CHD, overall survival to age five increased from 87.5% (95% CI 86.6, 88.4) in 2004-2008 to 89.6% (95% CI 88.9, 90.3) in 2012-2016. There was strong evidence for better survival in the ≥39-week group (90.2%, 95% CI 89.1, 91.2 to 93%, 95% CI 92.4, 93.9), weaker evidence at 24-31 and 37-38 weeks and no evidence at 32-36 weeks. We estimate that 51 deaths (95% CI 24, 77) per year in children with severe CHD were averted in 2012-2016 compared to what would have been the case had 2004-2008 mortality rates persisted. CONCLUSIONS Nine out of 10 children with severe CHD in 2012-2016 survived to age five. The small improvement in survival over the study period was driven by increased survival in term children. Most children with severe CHD are reaching school age and may require additional support by schools and healthcare services.
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Affiliation(s)
- Laura Gimeno
- UCL Great Ormond Street Institute of Child HealthLondonUK
- UCL Centre for Longitudinal StudiesLondonUK
| | - Katherine Brown
- Great Ormond Street Hospital for Children NHS Foundation TrustLondonUK
| | - Katie Harron
- UCL Great Ormond Street Institute of Child HealthLondonUK
| | - Maria Peppa
- UCL Great Ormond Street Institute of Child HealthLondonUK
| | - Ruth Gilbert
- UCL Great Ormond Street Institute of Child HealthLondonUK
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18
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Jepson BM, Metz TD, Miller TA, Son SL, Ou Z, Presson AP, Nance A, Pinto NM. Pregnancy loss in major fetal congenital heart disease: incidence, risk factors and timing. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:75-87. [PMID: 37099500 DOI: 10.1002/uog.26231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/09/2023] [Accepted: 04/14/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE Fetuses with congenital heart disease (CHD) are at increased risk of pregnancy loss compared with the general population. We aimed to assess the incidence, timing and risk factors of pregnancy loss in cases with major fetal CHD, overall and according to cardiac diagnosis. METHODS This was a retrospective, population-level cohort study of fetuses and infants diagnosed with major CHD between 1997 and 2018 identified by the Utah Birth Defect Network (UBDN), excluding cases with termination of pregnancy and minor cardiovascular diagnoses (e.g. isolated aortic/pulmonary pathology and isolated septal defects). The incidence and timing of pregnancy loss were recorded, overall and according to CHD diagnosis, with further stratification based on presence of isolated CHD vs additional fetal diagnosis (genetic diagnosis and/or extracardiac malformation). Adjusted risk of pregnancy loss was calculated and risk factors were assessed using multivariable models for the overall cohort and prenatal diagnosis subgroup. RESULTS Of 9351 UBDN cases with a cardiovascular code, 3251 cases with major CHD were identified, resulting in a study cohort of 3120 following exclusion of cases with pregnancy termination (n = 131). There were 2956 (94.7%) live births and 164 (5.3%) cases of pregnancy loss, which occurred at a median gestational age of 27.3 weeks. Of study cases, 1848 (59.2%) had isolated CHD and 1272 (40.8%) had an additional fetal diagnosis, including 736 (57.9%) with a genetic diagnosis and 536 (42.1%) with an extracardiac malformation. The observed incidence of pregnancy loss was highest in the presence of mitral stenosis (< 13.5%), hypoplastic left heart syndrome (HLHS) (10.7%), double-outlet right ventricle with normally related great vessels or not otherwise specified (10.5%) and Ebstein's anomaly (9.9%). The adjusted risk of pregnancy loss was 5.3% (95% CI, 3.7-7.6%) in the overall CHD population and 1.4% (95% CI, 0.9-2.3%) in cases with isolated CHD (adjusted risk ratio, 9.0 (95% CI, 6.0-13.0) and 2.0 (95% CI, 1.0-6.0), respectively, based on the general population risk of 0.6%). On multivariable analysis, variables associated with pregnancy loss in the overall CHD population included female fetal sex (adjusted odds ratio (aOR), 1.6 (95% CI, 1.1-2.3)), Hispanic ethnicity (aOR, 1.6 (95% CI, 1.0-2.5)), hydrops (aOR, 6.7 (95% CI, 4.3-10.5)) and additional fetal diagnosis (aOR, 6.3 (95% CI, 4.1-10)). On multivariable analysis of the prenatal diagnosis subgroup, years of maternal education (aOR, 1.2 (95% CI, 1.0-1.4)), presence of an additional fetal diagnosis (aOR, 2.7 (95% CI, 1.4-5.6)), atrioventricular valve regurgitation ≥ moderate (aOR, 3.6 (95% CI, 1.3-8.8)) and ventricular dysfunction (aOR, 3.8 (95% CI, 1.2-11.1)) were associated with pregnancy loss. Diagnostic groups associated with pregnancy loss were HLHS and variants (aOR, 3.0 (95% CI, 1.7-5.3)), other single ventricles (aOR, 2.4 (95% CI, 1.1-4.9)) and other (aOR, 0.1 (95% CI, 0-0.97)). Time-to-pregnancy-loss analysis demonstrated a steeper survival curve for cases with an additional fetal diagnosis, indicating a higher rate of pregnancy loss compared to cases with isolated CHD (P < 0.0001). CONCLUSIONS The risk of pregnancy loss is higher in cases with major fetal CHD compared with the general population and varies according to CHD type and presence of additional fetal diagnoses. Improved understanding of the incidence, risk factors and timing of pregnancy loss in CHD cases should inform patient counseling, antenatal surveillance and delivery planning. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- B M Jepson
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - T D Metz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - T A Miller
- Division of Pediatric Cardiology, Maine Medical Center, Portland, ME, USA
| | - S L Son
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado, Aurora, CO, USA
| | - Z Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - A P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - A Nance
- Utah Birth Defect Network, Office of Children with Special Healthcare Needs, Division of Family Health, Utah Department of Health and Human Services, Salt Lake City, UT, USA
| | - N M Pinto
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
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19
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Miles KG, Liu J, Tseng SY, DeFranco EA, Divanovic AA, Jones HN, Ollberding NJ, Cnota JF. Neonatal Depression Is Associated With 1-Year Mortality in Critical Congenital Heart Disease. J Am Heart Assoc 2023; 12:e028774. [PMID: 37260029 PMCID: PMC10381992 DOI: 10.1161/jaha.122.028774] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 05/03/2023] [Indexed: 06/02/2023]
Abstract
Background Low 5-minute Apgar scores (AS) are predictive of term and preterm neonatal mortality but have not been well studied in the critical congenital heart disease (CCHD) population. We analyzed US national vital statistics data to evaluate the association between neonatal depression (AS 0-3) and 1-year mortality in CCHD. Methods and Results We performed a retrospective cohort study using 2014 to 2018 Centers for Disease Control and Prevention cohort-linked birth certificate and infant death records. Five-minute AS were categorized as ≤3, 4 to 6, or ≥7. We calculated birth rates and associated mortality rates by AS group in infants with and without CCHD. Multivariable logistic regression analyzed neonatal, maternal, and pregnancy-related risk factors for neonatal depression and 1-year mortality. Of 11 642 neonates with CCHD (0.06% of all births), the 5.8% with AS 0 to 3 accounted for 23.3% of all 1-year CCHD mortality, with 69.9% of deaths occurring within 1 month of life. Gestational age at birth, growth restriction, extracardiac defects, race, and low maternal education were associated with an increased odds of AS 0 to 3 in neonates with CCHD relative to those with AS 7 to 10 on multivariable analysis. AS 0 to 3 was associated with 1-year CCHD mortality after adjusting for these factors, prenatal care, and delivery location (adjusted odds ratio, 14.57 [95% CI, 11.73-18.10]). Conclusions The AS is a routine clinical measure providing important prognostic information in CCHD. These findings suggest that prenatal and perinatal factors, beyond those included in current risk stratification tools, are important for CCHD outcomes. Multidisciplinary collaboration to understand the pathophysiology underlying neonatal depression may help identify interventions to improve CCHD mortality rates.
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Affiliation(s)
| | - James Liu
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyUniversity of CincinnatiCincinnatiOH
| | | | - Emily A. DeFranco
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyUniversity of CincinnatiCincinnatiOH
| | | | - Helen N. Jones
- Department of Physiology and AgingUniversity of FloridaGainesvilleFL
| | - Nicholas J. Ollberding
- Division of Biostatistics and EpidemiologyCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - James F. Cnota
- The Heart InstituteCincinnati Children’s HospitalCincinnatiOH
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20
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Ramonfaur D, Zhang X, Garza AP, García-Pons JF, Britton-Robles SC. Hypoplastic Left Heart Syndrome: A Review. Cardiol Rev 2023; 31:149-154. [PMID: 35349498 DOI: 10.1097/crd.0000000000000435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Hypoplastic left heart syndrome is a rare and poorly understood congenital disorder featuring a univentricular myocardium, invariably resulting in early childhood death if left untreated. The process to palliate this congenital cardiomyopathy is of high complexity and may include invasive interventions in the first week of life. The preferred treatment strategy involves a staged correction with 3 surgical procedures at different points in time. The Norwood procedure is usually performed within the first weeks of life and aims to increase systemic circulation and relieve pulmonary vascular pressure. This procedure is followed by the bidirectional Glenn and the Fontan procedures in later life, which offer to decrease stress in the ventricular chamber. The prognosis of children with this disease has greatly improved in the past decades; however, it is still largely driven by multiple modifiable and nonmodifiable variables. Novel and clever alternatives have been proposed to improve the survival and neurodevelopment of these patients, although they are not used as standard of care in all centers. The neurodevelopmental outcomes among these patients have received particular attention in the last decade in light to improve this very limiting associated comorbidity that compromises quality of life.
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Affiliation(s)
- Diego Ramonfaur
- From the Division of Postgraduate Medical Education, Harvard Medical School, Boston, MA
| | - Xiaoya Zhang
- From the Division of Postgraduate Medical Education, Harvard Medical School, Boston, MA
| | - Abraham P Garza
- Departamento de Medicina, Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, México
| | - José Fernando García-Pons
- División de Ciencias de la Salud, Departamento de Medicina y Nutrición, Universidad de Guanajuato, Guanajuato, México
| | - Sylvia C Britton-Robles
- Departamento de Medicina, Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, México
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21
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Linnane N, Kenny DP, Hijazi ZM. Congenital heart disease: addressing the need for novel lower-risk percutaneous interventional strategies. Expert Rev Cardiovasc Ther 2023; 21:329-336. [PMID: 37114439 DOI: 10.1080/14779072.2023.2208862] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
INTRODUCTION With the advent of improved neonatal care, increasingly vulnerable higher-risk patients with complex congenital heart anomalies are presenting for intervention. This group of patients will always have a higher risk of an adverse event during a procedure but by recognising this risk and with the introduction risk scoring systems and thus the development of novel lower risk procedures, the rate of adverse events can be reduced. AREA COVERED This article reviews risk scoring systems for congenital catheterization and demonstrates how they can be used to reduce the rate of adverse events. Then novel low risk strategies are discussed for low weight infants e.g. patent ductus arteriosus (PDA) stent insertion; premature infants e.g. PDA device closure; and transcatheter pulmonary valve replacement. Finally, how risk is assessed and managed within the inherent bias of an institution is discussed. EXPERT OPINION There has been a remarkable improvement in the rate of adverse events in congenital cardiac interventions but now, as the benchmark of mortality rate is switched to morbidity and quality of life, continued innovation into lower risk strategies and understanding inherent bias when assessing risk will be key to continuing this improvement.
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Affiliation(s)
- N Linnane
- Department of Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - D P Kenny
- Department of Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
- Royal College of Surgeons, Dublin, Ireland
| | - Z M Hijazi
- Department of Cardiovascular Diseases, Sidra Medicine, Doha, Qatar
- Weill Cornell Medicine, New York, NY, USA
- Jordan University, Amman, Jordan
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22
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Age at surgery and outcomes following neonatal cardiac surgery: An analysis from the Pediatric Cardiac Critical Care Consortium. J Thorac Cardiovasc Surg 2023; 165:1528-1538.e7. [PMID: 35760618 DOI: 10.1016/j.jtcvs.2022.05.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 04/22/2022] [Accepted: 05/10/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The optimal timing for neonatal cardiac surgery is a potentially modifiable factor that may affect outcomes. We studied the relationship between age at surgery (AAS) and outcomes across multiple hospitals, focusing on neonatal operations where timing appears is not emergency. METHODS We studied neonates ≥37 weeks' gestation and ≥2.5 kg admitted to a treating hospital on or before day of life 2 undergoing selected index cardiac operations. The impact of AAS on outcomes was evaluated across the entire cohort and a standard risk subgroup (ie, free of preoperative mechanical ventilation, mechanical circulatory support, or other organ failure). Outcomes included mortality, major morbidity (ie, cardiac arrest, mechanical circulatory support, unplanned cardiac reintervention, or neurologic complication), and postoperative cardiac intensive care unit and hospital length of stay. Post hoc analyses focused on operations undertaken between day of life 2 and 7. RESULTS We studied 2536 neonates from 47 hospitals. AAS from day of life 2 through 7 was not associated with risk adjusted mortality or major morbidity among the entire cohort and the standard risk subgroup. Older AAS, although associated with modest increases in postoperative cardiac intensive care unit and hospital length of stay in the entire cohort, was not associated with hospital length of stay in the standard risk subgroup. CONCLUSIONS Among select nonemergency neonatal cardiac operations, AAS between day of life 2 and 7 was not found to be associated with risk adjusted mortality or major morbidity. Although delays in surgical timing may modestly increase preoperative resource use, studies of AAS and outcomes not evident at the time of discharge are needed.
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23
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Navaratnam M, Mendoza JM, Zhang S, Boothroyd D, Maeda K, Kamra K, Williams GD. Activated 4-Factor Prothrombin Complex Concentrate as a Hemostatic Adjunct for Neonatal Cardiac Surgery: A Propensity Score-Matched Cohort Study. Anesth Analg 2023; 136:473-482. [PMID: 36729967 DOI: 10.1213/ane.0000000000006294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Prothrombin complex concentrates are an emerging "off-label" therapy to augment hemostasis after cardiopulmonary bypass (CPB), but data supporting their use for neonatal cardiac surgery are limited. METHODS We retrospectively reviewed neonates undergoing open heart surgery with first-time sternotomy between May 2014 and December 2018 from a hospital electronic health record database. Neonates who received activated 4-factor prothrombin complex concentrate (a4FPCC) after CPB were propensity score matched (PSM) to neonates who did not receive a4FPCC (control group). The primary efficacy outcome was total volume (mL/kg) of blood products transfused after CPB, including the first 24 hours on the cardiovascular intensive care unit (CVICU). The primary safety outcome was the incidence of 7- and 30-day postoperative thromboembolism. Secondary outcomes included 24 hours postoperative chest tube output, time to extubation, duration of CVICU stay, duration of hospital stay, 30-day mortality, and incidence of acute kidney injury on postoperative day 3. We used linear regression modeling on PSM data for the primary efficacy outcome. For the primary safety outcome, we tested for differences using McNemar test on PSM data. For secondary outcomes, we used linear regression, Fisher exact test, or survival analyses as appropriate, with false discovery rate-adjusted P values. RESULTS A total of 165 neonates were included in the final data analysis: 86 in the control group and 79 in the a4FPCC group. After PSM, there were 43 patients in the control group and 43 in the a4FPCC group. We found a statistically significant difference in mean total blood products transfused for the a4FPCC group (47.5 mL/kg) compared with the control group (63.7 mL/kg) for PSM patients (adjusted difference, 15.3; 95% CI, 29.4-1.3; P = .032). We did not find a statistically significant difference in 7- or 30-day thromboembolic rate, postoperative chest tube output, time to extubation, incidence of postoperative acute kidney injury (AKI), or 30-day mortality between the groups. The a4FPCC group had a significantly longer length of intensive care unit stay (32.9 vs 13.3 days; adjusted P = .049) and hospital stay (44.6 vs 24.1 days; adjusted P = .049) compared with the control group. CONCLUSIONS We found that the use of a4FPCC as a hemostatic adjunct for post-CPB bleeding in neonatal cardiac surgery was associated with a decrease in mean total blood products transfused after CPB without an increased rate of 7- or 30-day postoperative thromboembolism. Our findings suggest that a4FPCCs can be considered as part of a hemostasis pathway for refractory bleeding in neonatal cardiac surgery.
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Affiliation(s)
- Manchula Navaratnam
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Julianne M Mendoza
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Shiqi Zhang
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Derek Boothroyd
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Katsuhide Maeda
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Komal Kamra
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Glyn D Williams
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
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24
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Alsoufi B. Hybrid First-stage Palliation and Other Strategies to Achieve Biventricular Repair in High-Risk Neonates With Complex Heart Anomalies and Aortic Arch Obstruction. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2023; 26:40-49. [PMID: 36842797 DOI: 10.1053/j.pcsu.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/18/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022]
Abstract
Medical and surgical advances have allowed single-stage total repair in neonates born with complex congenital heart anomalies and aortic arch obstruction. Nonetheless, total repair might be too complex or high risk in certain neonates with demographic, clinical or morphologic risk factors. Alternative management strategies might offer these neonates better outcomes with superior anatomic repair, shorter hospitalization, reduced morbidity, and improved survival. Alternative initial surgical strategies might include aortic arch repair and pulmonary artery band with or without cardiopulmonary bypass, extracardiac repair only and pulmonary artery band, Norwood operation, and hybrid first-stage palliation; all deferring complex biventricular intra-cardiac repair to later stage. The strategy choice should be personalized to each patient, taking into consideration the morphologic and clinical state, and the existent goals of care.
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Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky.
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25
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Santana S, Peyvandi S, Costello JM, Baer RJ, Collins JW, Branche T, Jelliffe-Pawlowski LL, Steurer MA. Adverse Maternal Fetal Environment Partially Mediates Disparate Outcomes in Non-White Neonates with Major Congenital Heart Disease. J Pediatr 2022; 251:82-88.e1. [PMID: 35803301 PMCID: PMC11267490 DOI: 10.1016/j.jpeds.2022.06.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/05/2022] [Accepted: 06/30/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To determine whether differential exposure to an adverse maternal fetal environment partially explains disparate outcomes in infants with major congenital heart disease (CHD). STUDY DESIGN Retrospective cohort study utilizing a population-based administrative California database (2011-2017). Primary exposure: Race/ethnicity. Primary mediator: Adverse maternal fetal environment (evidence of maternal metabolic syndrome and/or maternal placental syndrome). OUTCOMES Composite of 1-year mortality or severe morbidity and days alive out of hospital in the first year of life (DAOOH). Mediation analyses determined the percent contributions of mediators on pathways between race/ethnicity and outcomes after adjusting for CHD severity. RESULTS Included were 2747 non-Hispanic White infants (reference group), 5244 Hispanic, and 625 non-Hispanic Black infants. Hispanic and non-Hispanic Black infants had a higher risk for composite outcome (crude OR: 1.18; crude OR: 1.25, respectively) and fewer DAOOH (-6 & -12 days, respectively). Compared with the reference group, Hispanic infants had higher maternal metabolic syndrome exposure (43% vs 28%, OR: 1.89), and non-Hispanic Black infants had higher maternal metabolic syndrome (44% vs 28%; OR: 1.97) and maternal placental syndrome exposure (18% vs 12%; OR, 1.66). Both maternal metabolic syndrome exposure (OR: 1.21) and maternal placental syndrome exposure (OR: 1.56) were related to composite outcome and fewer DAOOH (-25 & -16 days, respectively). Adverse maternal fetal environment explained 25% of the disparate relationship between non-Hispanic Black race and composite outcome and 18% of the disparate relationship between Hispanic ethnicity and composite outcome. Adverse maternal fetal environment explained 16% (non-Hispanic Black race) and 21% (Hispanic ethnicity) of the association with DAOOH. CONCLUSIONS Increased exposure to adverse maternal fetal environment contributes to racial and ethnic disparities in major CHD outcomes.
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Affiliation(s)
- Stephanie Santana
- Department of Pediatrics, Division of Cardiology, Shawn Jenkins Children's Hospital, Medical University of South Carolina, Charleston, SC.
| | - Shabnam Peyvandi
- Department of Pediatrics, Division of Critical Care, University of California San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
| | - John M Costello
- Department of Pediatrics, Division of Cardiology, Shawn Jenkins Children's Hospital, Medical University of South Carolina, Charleston, SC
| | - Rebecca J Baer
- Department of Pediatrics, University of California San Diego, La Jolla, CA
| | - James W Collins
- Department of Pediatrics, Division of Neonatology, Ann & Robert H. Lurie Children's Hospital of Chicago at Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Tonia Branche
- Department of Pediatrics, Division of Neonatology, Ann & Robert H. Lurie Children's Hospital of Chicago at Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Martina A Steurer
- Department of Pediatrics, Division of Critical Care, University of California San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
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26
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Kwiatkowski DM, Ball MK, Savorgnan FJ, Allan CK, Dearani JA, Roth MD, Roth RZ, Sexson KS, Tweddell JS, Williams PK, Zender JE, Levy VY. Neonatal Congenital Heart Disease Surgical Readiness and Timing. Pediatrics 2022; 150:189888. [PMID: 36317977 DOI: 10.1542/peds.2022-056415d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- David M Kwiatkowski
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Molly K Ball
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Fabio J Savorgnan
- Department of Pediatrics, UT Southwestern, Children's Health, Dallas, Texas
| | - Catherine K Allan
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo College of Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | - Kristen S Sexson
- Department of Pediatrics, UT Southwestern, Children's Health, Dallas, Texas
| | - James S Tweddell
- Department of Surgery, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Patricia K Williams
- Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Jill E Zender
- Department of Pediatrics, UT Southwestern, Children's Health, Dallas, Texas
| | - Victor Y Levy
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas
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27
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Bronicki RA, Benitz WE, Buckley JR, Yarlagadda VV, Porta NFM, Agana DO, Kim M, Costello JM. Respiratory Care for Neonates With Congenital Heart Disease. Pediatrics 2022; 150:189881. [PMID: 36317970 DOI: 10.1542/peds.2022-056415h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
Affiliation(s)
- Ronald A Bronicki
- Baylor College of Medicine, Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, Texas
| | - William E Benitz
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, California
| | - Jason R Buckley
- Medical University of South Carolina, Divison of Pediatric Cardiology, Shawn Jenkins Children's Hospital, Charleston, South Carolina
| | - Vamsi V Yarlagadda
- Stanford School of Medicine, Division of Cardiology, Lucile Packard Children's Hospital, Palo Alto, California
| | - Nicolas F M Porta
- Northwestern University Feinberg School of Medicine, Division of Neonatology, Pediatric Pulmonary Hypertension Program, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Devon O Agana
- Mayo Clinic College of Medicine and Science, Department of Anesthesiology and Pediatric Critical Care Medicine, Mayo Eugenio Litta Children's Hospital, Rochester, Minnesota
| | - Minso Kim
- University of California San Francisco School of Medicine, Division of Critical Care, University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | - John M Costello
- Medical University of South Carolina, Divison of Pediatric Cardiology, Shawn Jenkins Children's Hospital, Charleston, South Carolina
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28
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Vergales J, Figueroa M, Frommelt M, Putschoegl A, Singh Y, Murray P, Wood G, Allen K, Villafane J. Transitioning Neonates With CHD to Outpatient Care: A State-of-the-Art Review. Pediatrics 2022; 150:189880. [PMID: 36317969 DOI: 10.1542/peds.2022-056415m] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
Affiliation(s)
- Jeffrey Vergales
- Division of Pediatric Cardiology, University of Virginia, Charlottesville, Virginia
| | - Mayte Figueroa
- Divisions of Pediatric Cardiology and Pediatric Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Michele Frommelt
- Children's Wisconsin, Division of Pediatric Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Adam Putschoegl
- Division of Pediatric Cardiology, Children's Hospital and Medical Center, Omaha, Nebraska
| | - Yogen Singh
- Division of Pediatric Cardiology and Neonatology, Cambridge University Hospitals, University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
| | - Peter Murray
- Division of Neonatology, University of Virginia, Charlottesville, Virginia
| | - Garrison Wood
- Division of Pediatric Cardiology, University of Virginia, Charlottesville, Virginia
| | - Kiona Allen
- Division of Pediatric Cardiology and Division of Pediatric Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Juan Villafane
- Cincinnati Children's Hospital, Division of Pediatric Cardiology, University of Cincinnati, Cincinnati, Ohio
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29
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Chowdhury D, Toms R, Brumbaugh JE, Bindom S, Ather M, Jaquiss R, Johnson JN. Evaluation and Management of Noncardiac Comorbidities in Children With Congenital Heart Disease. Pediatrics 2022; 150:189884. [PMID: 36317973 DOI: 10.1542/peds.2022-056415e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 02/25/2023] Open
Abstract
Outcomes for patients with neonatal heart disease are affected by numerous noncardiac and genetic factors. These can include neonatal concerns, such as prematurity and low birth weight, and congenital anomalies, such as airway, pulmonary, gastrointestinal, and genitourinary anomalies, and genetic syndromes. This section will serve as a summary of these issues and how they may affect the evaluation and management of a neonate with heart disease. These noncardiac factors are heavily influenced by conditions common to neonatologists, making a strong argument for multidisciplinary care with neonatologists, cardiologists, surgeons, anesthesiologists, and cardiovascular intensivists. Through this section and this project, we aim to facilitate a comprehensive approach to the care of neonates with congenital heart disease.
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Affiliation(s)
- Devyani Chowdhury
- Cardiology Care for Children, Lancaster, Pennsylvania Nemours Cardiac Center.,These two co-first authors contributed equally to this manuscript
| | - Rune Toms
- Division of Neonatal-Perinatal Medicine, Joe DiMaggio Children's Hospital, Hollywood, Florida.,These two co-first authors contributed equally to this manuscript
| | | | - Sharell Bindom
- Division of Neonatal-Perinatal Medicine, Joe DiMaggio Children's Hospital, Hollywood, Florida
| | - Mishaal Ather
- Cardiology Care for Children, Lancaster, Pennsylvania Nemours Cardiac Center
| | - Robert Jaquiss
- Division of Pediatric and Congenital Cardiothoracic Surgery, Children's Medical Center, Dallas, Texas
| | - Jonathan N Johnson
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic Children's Center, Rochester, Minnesota
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30
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Haxel CS, Johnson JN, Hintz S, Renno MS, Ruano R, Zyblewski SC, Glickstein J, Donofrio MT. Care of the Fetus With Congenital Cardiovascular Disease: From Diagnosis to Delivery. Pediatrics 2022; 150:189887. [PMID: 36317976 DOI: 10.1542/peds.2022-056415c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The majority of congenital cardiovascular disease including structural cardiac defects, abnormalities in cardiac function, and rhythm disturbances can be identified prenatally using screening obstetrical ultrasound with referral for fetal echocardiogram when indicated. METHODS Diagnosis of congenital heart disease in the fetus should prompt assessment for extracardiac abnormalities and associated genetic abnormalities once maternal consent is obtained. Pediatric cardiologists, in conjunction with maternal-fetal medicine, neonatology, and cardiothoracic surgery subspecialists, should counsel families about the details of the congenital heart defect as well as prenatal and postnatal management. RESULTS Prenatal diagnosis often leads to increased maternal depression and anxiety; however, it decreases morbidity and mortality for many congenital heart defects by allowing clinicians the opportunity to optimize prenatal care and plan delivery based on the specific lesion. Changes in prenatal care can include more frequent assessments through the remainder of the pregnancy, maternal medication administration, or, in selected cases, in utero cardiac catheter intervention or surgical procedures to optimize postnatal outcomes. Delivery planning may include changing the location, timing or mode of delivery to ensure that the neonate is delivered in the most appropriate hospital setting with the required level of hospital staff for immediate postnatal stabilization. CONCLUSIONS Based on the specific congenital heart defect, prenatal echocardiogram assessment in late gestation can often aid in predicting the severity of postnatal instability and guide the medical or interventional level of care needed for immediate postnatal intervention to optimize the transition to postnatal circulation.
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Affiliation(s)
- Caitlin S Haxel
- The University of Vermont Children's Hospital, Burlington, Vermont
| | | | - Susan Hintz
- Stanford University, Lucille Salter Packard Children's Hospital, Palo Alto, California
| | - Markus S Renno
- University Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | | | - Julie Glickstein
- Columbia University Vagelos School of Medicine, Morgan Stanley Children's Hospital, New York, New York
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31
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Haid B, Tack LJW, Spinoit AF, Weigl C, Steinkellner L, Gernhold C, Banuelos B, Sforza S, O'Kelly F, Oswald J. Being born small for gestational age (SGA) might be associated with a higher reoperation rate in proximal hypospadias. J Pediatr Urol 2022; 18:609.e1-609.e11. [PMID: 36075827 DOI: 10.1016/j.jpurol.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 07/16/2022] [Accepted: 08/16/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE Being born small for gestational age (SGA) is associated with a higher frequency and more severe forms of hypospadias as well as with potential developmental differences. This study aims to characterize operative outcomes in SGA boys compared to boys born with normal weight and length for gestational age (appropriate/large for gestational age, AGA/LGA). METHODS Demographic data, hypospadias characteristics, associated pathologies and operative outcomes of boys who underwent hypospadias repair at a single center (10/2012-10/2019) were evaluated. Boys were categorized into SGA and non-SGA, which were then compared using unpaired t-tests and chi square tests. To examine the effect of SGA on reoperative risk, a logistic regression model was applied integrating surgical technique, meatal localization and complex hypospadias (narrow glans/plate, curvature, micropenis, bilateral cryptorchidism). RESULTS SGA boys accounted for 13.7% (n = 80) of the total cohort (n = 584) and 33% of all proximal hypospadias (n = 99, SGA vs. non-SGA 41.3% vs. 13%, p < 0.001). After a mean follow-up of 18.6 months the reoperation rate for all hypospadias was 17.9% (n = 105). In distal hypospadias there was no difference in reoperation rate between SGA and AGA/LGA boys (p = 0.548, multivariate regression model). For each meatal localization in proximal hypospadias SGA was a significant, independent factor predicting higher reoperation rates (p = 0.019, OR 3.21) in a logistic regression model (Figure ROC). DISCUSSION Hypospadias surgery carries a substantial risk for unplanned reinterventions. Apart from meatal localization, there are only a few factors (urethral plate quality, glandular diameter, curvature) reported in literature to be associated with reoperative risk. Intrauterine growth retardation associated with SGA might lead to not only a higher probability of proximal hypospadias but also contribute to a higher risk for complications mediated by developmental differences. Whether these findings could help to tailor surgical strategies or adjuvant measures, as for example the application of preoperative hormonal stimulation remains to be determined in future studies. This study is limited by being a single-center series with limited follow-up resulting in some complications probably not yet detected - however, in the same extent in both groups. CONCLUSION Based on this study, 33% of all proximal hypospadias cases occur in boys born SGA. While the reoperation rate in boys with distal hypospadias was not influenced by SGA status, SGA proved to be an independent predictor of a higher risk of reoperation in those with proximal hypospadias. After validation of these findings in other centers, this could be integrated into counseling and risk-stratification.
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Affiliation(s)
- Bernhard Haid
- Department of Paediatric Urology, Ordensklinikum Linz Hospital of the Sisters of Charity, Linz, Austria.
| | - Lloyd J W Tack
- Department of Internal Medicine and Paediatrics, Division of Paediatric Endocrinology, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Anne-Françoise Spinoit
- Division of Paediatric Urology, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Chiara Weigl
- Department of Paediatric Urology, Ordensklinikum Linz Hospital of the Sisters of Charity, Linz, Austria
| | - Lukas Steinkellner
- Department of Paediatric Urology, Ordensklinikum Linz Hospital of the Sisters of Charity, Linz, Austria
| | - Christa Gernhold
- Department of Paediatric Urology, Ordensklinikum Linz Hospital of the Sisters of Charity, Linz, Austria
| | - Beatriz Banuelos
- Department of Urology, Charite Universitätsmedizin, Berlin, Germany
| | - Simone Sforza
- Department of Pediatric Urology, University of Florence, Meyer Children Hospital, Florence, Italy
| | - Fardod O'Kelly
- Departments of Urology and Pediatric Surgery, Beacon Hospital, Dublin, Ireland; University College Dublin, School of Medicine and Medical Science, Dublin, Ireland
| | - Josef Oswald
- Department of Paediatric Urology, Ordensklinikum Linz Hospital of the Sisters of Charity, Linz, Austria
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Practice variations for fetal and neonatal congenital heart disease within the Children's Hospitals Neonatal Consortium. Pediatr Res 2022; 93:1728-1735. [PMID: 36167818 DOI: 10.1038/s41390-022-02314-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/09/2022] [Accepted: 09/03/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Many aspects of care for fetuses and neonates with congenital heart disease (CHD) fall outside standard practice guidelines, leading to the potential for significant variation in clinical care for this vulnerable population. METHODS We conducted a cross-sectional survey of site sponsors of the Children's Hospitals Neonatal Consortium, a multicenter collaborative of 41 Level IV neonatal intensive care units to assess key areas of clinical practice variability for patients with fetal and neonatal CHD. RESULTS We received responses from 31 centers. Fetal consult services are shared by neonatology and pediatric cardiology at 70% of centers. Three centers (10%) routinely perform fetal magnetic resonance imaging (MRI) for women with pregnancies complicated by fetal CHD. Genetic testing for CHD patients is routine at 76% of centers. Preoperative brain MRI is standard practice at 5 centers (17%), while cerebral NIRS monitoring is regularly used at 14 centers (48%). Use of electroencephalogram (EEG) after major cardiac surgery is routine in 5 centers (17%). Neurodevelopmental follow-up programs are offered at 30 centers (97%). CONCLUSIONS Many aspects of fetal and neonatal CHD care are highly variable with evolving shared multidisciplinary models. IMPACT Many aspects of fetal and neonatal CHD care are highly variable. Genetic testing, placental examination, preoperative neuroimaging, and postoperative EEG monitoring carry a high yield of finding abnormalities in patients with CHD and these tests may contribute to more precise prognostication and improve care. Evidence-based standards for prenatal and postnatal CHD care may decrease inter-center variability.
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Olugbuyi O, Smith C, Kaul P, Dover DC, Mackie AS, Islam S, Eckersley L, Hornberger LK. Impact of Socioeconomic Status and Residence Distance on Infant Heart Disease Outcomes in Canada. J Am Heart Assoc 2022; 11:e026627. [PMID: 36073651 DOI: 10.1161/jaha.122.026627] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Socioeconomic status (SES) impacts clinical outcomes associated with severe congenital heart disease (sCHD). We examined the impact of SES and remoteness of residence (RoR) on congenital heart disease (CHD) outcomes in Canada, a jurisdiction with universal health insurance. Methods and Results All infants born in Canada (excluding Quebec) from 2008 to 2018 and hospitalized with CHD requiring intervention in the first year were identified. Neighborhood level SES income quintiles were calculated, and RoR was categorized as residing <100 km, 100 to 299 km, or >300 km from the closest of 7 cardiac surgical programs. In-hospital mortality at <1 year was the primary outcome, adjusted for preterm birth, low birth weight, and extracardiac pathology. Among 7711 infants, 4485 (58.2%) had moderate CHD (mCHD) and 3226 (41.8%) had sCHD. Overall mortality rate was 10.5%, with higher rates in sCHD than mCHD (13.3% versus 8.5%, respectively). More CHD infants were in the lowest compared with the highest SES category (27.1% versus 15.0%, respectively). The distribution of CHD across RoR categories was 52.3%, 21.3%, and 26.4% for <100 km, 100 to 299 km, and >300 km, respectively. Although SES and RoR had no impact on sCHD mortality, infants with mCHD living >300 km had a higher risk of mortality relative to those living <100 km (adjusted odds ratio [aOR], 1.43 [95% CI, 1.11-1.84]). Infants with mCHD within the lowest SES quintile and living farthest away had the highest risk for mortality (aOR, 1.74 [95% CI, 1.08-2.81]). Conclusions In Canada, neither RoR nor SES had an impact on outcomes of infants with sCHD. Greater RoR, however, may contribute to higher risk of mortality among infants with mCHD.
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Affiliation(s)
- Oluwayomi Olugbuyi
- Division of Cardiology Department of Pediatrics, University of Alberta Edmonton Alberta Canada
| | - Christopher Smith
- School of Public Health University of Alberta Edmonton Alberta Canada.,Canadian VIGOUR Centre University of Alberta Edmonton Alberta Canada
| | - Padma Kaul
- School of Public Health University of Alberta Edmonton Alberta Canada.,Canadian VIGOUR Centre University of Alberta Edmonton Alberta Canada.,Department of Medicine University of Alberta Edmonton Alberta Canada
| | - Douglas C Dover
- Canadian VIGOUR Centre University of Alberta Edmonton Alberta Canada
| | - Andrew S Mackie
- Division of Cardiology Department of Pediatrics, University of Alberta Edmonton Alberta Canada
| | - Sunjidatul Islam
- Canadian VIGOUR Centre University of Alberta Edmonton Alberta Canada
| | - Luke Eckersley
- Division of Cardiology Department of Pediatrics, University of Alberta Edmonton Alberta Canada
| | - Lisa K Hornberger
- Division of Cardiology Department of Pediatrics, University of Alberta Edmonton Alberta Canada.,Department of Obstetrics & Gynecology Women & Children's Health Research Institute, University of Alberta Edmonton Alberta Canada
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Venous waveform analysis detects acute right ventricular failure in a rat respiratory arrest model. Pediatr Res 2022; 93:1539-1545. [PMID: 36042330 PMCID: PMC9971354 DOI: 10.1038/s41390-022-02278-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 07/12/2022] [Accepted: 08/09/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Peripheral intravenous analysis (PIVA) has been shown to be more sensitive than central venous pressure (CVP) for detecting hemorrhage and volume overload. We hypothesized that PIVA is superior to CVP for detecting right ventricular (RV) failure in a rat model of respiratory arrest. METHODS Eight Wistar rats were studied in accordance with the ARRIVE guidelines. CVP, mean arterial pressure (MAP), and PIVA were recorded. Respiratory arrest was achieved with IV Rocuronium. PIVA utilizes Fourier transform to quantify the amplitude of the peripheral venous waveform, expressed as the "f1 amplitude". RV diameter was measured with transthoracic echocardiography. RESULTS RV diameter increased from 0.34 to 0.54 cm during arrest, p = 0.001, and returned to 0.33 cm post arrest, p = 0.97. There was an increase in f1 amplitude from 0.07 to 0.38 mmHg, p = 0.01 and returned to 0.08 mmHg, p = 1.0. MAP decreased from 119 to 67 mmHg, p = 0.004 and returned to 136 mmHg, p = 0.50. There was no significant increase in CVP from 9.3 mmHg at baseline to 10.5 mmHg during respiratory arrest, p = 0.91, and recovery to 8.6 mmHg, p = 0.81. CONCLUSIONS This study highlights the utility of PIVA to detect RV failure in small-caliber vessels, comparable to peripheral veins in the human pediatric population. IMPACT Right ventricular failure remains a diagnostic challenge, particularly in pediatric patients with small vessel sizes limiting invasive intravascular monitor use. Intravenous analysis has shown promise in detecting hypovolemia and volume overload. Intravenous analysis successfully detects right ventricular failure in a rat respiratory arrest model. Intravenous analysis showed utility despite utilizing small peripheral venous access and therefore may be applicable to a pediatric population. Intravenous analysis may be helpful in differentiating various types of shock.
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Heibel J, Graham EM, Mahle WT, Roux A, Graham D, Manlhiot C, Everett AD. Perioperative Metabolites Are Associated With Adverse Neonatal Congenital Heart Disease Surgical Outcomes. J Am Heart Assoc 2022; 11:e024996. [PMID: 35946448 PMCID: PMC9496308 DOI: 10.1161/jaha.121.024996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Clinical risk factors in neonatal cardiac surgery do not fully capture discrepancies in outcomes. Targeted metabolomic analysis of plasma from neonates undergoing heart surgery with cardiopulmonary bypass was performed to determine associations with clinical outcomes. Methods and Result Samples and clinical variables from 149 neonates enrolled in the Corticosteroid Therapy in Neonates Undergoing Cardiopulmonary Bypass trial with surgical treatment for congenital heart disease between 2012 and 2016 were included. Blood samples were collected before skin incision, immediately after cardiopulmonary bypass, and 12 hours after surgery. Outcomes include composite morbidity/mortality (death, extracorporeal membrane oxygenation, cardiac arrest, acute kidney injury, and/or hepatic injury) and a cardiac composite (extracorporeal membrane oxygenation, cardiac arrest, or increase in lactate level), hepatic injury, and acute kidney injury. Targeted metabolite levels were determined by high-resolution tandem liquid chromatography and mass spectrometry. Principal component and regression analyses were used to assess associations between metabolic profiles and outcomes, with 2 models created: a base clinical model and a base model+metabolites. Of the 193 metabolites examined, 40 were detected and quantified. The first principal component, principal component 1, was composed mostly of preoperative metabolites and was significantly associated with the composite morbidity/mortality, cardiac composite, and hepatic injury outcomes. In regression models, individual metabolites also improved model performance for the composite morbidity/mortality, cardiac composite, and hepatic injury outcomes. Significant disease pathways included myocardial injury (false discovery rate, 0.00091) and heart failure (false discovery rate, 0.041). Conclusions In neonatal cardiac surgery, perioperative metabolites were associated with postoperative outcomes and improved clinical model outcome associations. Preoperative metabolite levels alone may improve risk models and provide a basis for optimizing perioperative care.
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Affiliation(s)
- Jessica Heibel
- Department of Pediatrics, Blalock-Taussig-Thomas Congenital Heart Center Johns Hopkins University Baltimore MD
| | - Eric M Graham
- Division of Pediatric Cardiology, Department of Pediatrics Medical University of South Carolina Charleston SC
| | | | - Aurelie Roux
- Molecular Determinants Core Johns Hopkins All Children's Hospital St Petersburg FL
| | - David Graham
- Molecular Determinants Core Johns Hopkins All Children's Hospital St Petersburg FL
| | - Cedric Manlhiot
- Department of Pediatrics, Blalock-Taussig-Thomas Congenital Heart Center Johns Hopkins University Baltimore MD
| | - Allen D Everett
- Department of Pediatrics, Blalock-Taussig-Thomas Congenital Heart Center Johns Hopkins University Baltimore MD
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Cameron JE, Badran S, Cleveland J, Patel ND. Transjugular ductus venosus stent placement in an extremely premature, low birth weight neonate with infradiaphragmatic total anomalous pulmonary venous connection. PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2022.101571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Backer CL. Commentary: Neonatal Cardiac Care Units: The Next Step in Specialization and Regionalization. J Thorac Cardiovasc Surg 2022; 165:2212-2213. [PMID: 35995605 DOI: 10.1016/j.jtcvs.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 11/30/2022]
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Reddy RK, McVadon DH, Zyblewski SC, Rajab TK, Diego E, Southgate WM, Fogg KL, Costello JM. Prematurity and Congenital Heart Disease: A Contemporary Review. Neoreviews 2022; 23:e472-e485. [PMID: 35773510 DOI: 10.1542/neo.23-7-e472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Congenital heart disease (CHD) is the most commonly reported birth defect in newborns. Neonates with CHD are more likely to be born prematurely, and a higher proportion of preterm neonates have CHD than their term counterparts. The implications of preterm birth on the cardiac and noncardiac organ systems are vast and require special management considerations. The feasibility of surgical interventions in preterm neonates is frequently limited by patient size and delicacy of immature cardiac tissues. Thus, special care must be taken when considering the appropriate timing and type of cardiac intervention. Despite improvements in neonatal cardiac surgical outcomes, preterm and early term gestational ages and low birthweight remain important risk factors for in-hospital mortality. Understanding the risks of early delivery of neonates with prenatally diagnosed CHD may help guide perioperative management in neonates who are born preterm. In this review, we will describe the risks and benefits of early delivery, postnatal cardiac and noncardiac evaluation and management, surgical considerations, overall outcomes, and future directions regarding optimization of perinatal evaluation and management of fetuses and preterm and early term neonates with CHD.
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Affiliation(s)
- Reshma K Reddy
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Deani H McVadon
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Sinai C Zyblewski
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Taufiek K Rajab
- Division of Pediatric Cardiothoracic Surgery, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Ellen Diego
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - W Michael Southgate
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Kristi L Fogg
- Department of Food and Nutrition, Sodexo, Medical University of South Carolina, Charleston, SC
| | - John M Costello
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
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Bhombal S, Chock VY, Shashidharan S. The impact of prematurity and associated comorbidities on clinical outcomes in neonates with congenital heart disease. Semin Perinatol 2022; 46:151586. [PMID: 35525603 DOI: 10.1016/j.semperi.2022.151586] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Prematurity is a common risk factor in children, affecting approximately 10% of live births, globally. It is more common in children with critical congenital heart disease (CCHD) and carries important implications in this group of patients. While outcomes have been improving over the years, even late preterm birth is associated with worse outcomes in children born with critical congenital heart disease compared to those without. Infants with both prematurity and CCHD are at particularly high risk for important comorbidities, including: necrotizing enterocolitis, intraventricular hemorrhage, white matter injury, neurodevelopmental anomalies and retinopathy of prematurity. Lesion-specific intensive care management of these infants, interventional and peri-operative management specifically tailored to their needs, and multidisciplinary care all have the potential to improve outcomes in this challenging group.
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Affiliation(s)
- Shazia Bhombal
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, USA.
| | - Valerie Y Chock
- Department of Surgery, Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory School of Medicine, USA
| | - Subhadra Shashidharan
- Department of Surgery, Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory School of Medicine, USA
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40
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Levy PT, Thomas AR, Wethall A, Perez D, Steurer M, Ball MK. Rethinking Congenital Heart Disease in Preterm Neonates. Neoreviews 2022; 23:e373-e387. [PMID: 35641458 DOI: 10.1542/neo.23-6-e373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Congenital heart disease (CHD) and prematurity are the leading causes of infant mortality in the United States. Importantly, the combination of prematurity and CHD results in a further increased risk of mortality and significant morbidity. The key factors in these adverse outcomes are not well understood, but likely include maternal-fetal environment, perinatal and neonatal elements, and challenging postnatal care. Preterm neonates with CHD are born with "double jeopardy": not only do they experience challenges related to immaturity of the lungs, brain, and other organs, but they also must undergo treatment for cardiac disease. The role of the neonatologist caring for preterm infants with CHD has changed with the evolution of the field of pediatric cardiac critical care. Increasingly, neonatologists invested in the cardiovascular care of the newborn with CHD engage at multiple stages in their course, including fetal consultation, delivery room management, preoperative care, and postoperative treatment. A more comprehensive understanding of prematurity and CHD may inform clinical practice and ultimately improve outcomes in preterm infants with CHD. In this review, we discuss the current evidence surrounding neonatal and cardiac outcomes in preterm infants with CHD; examine the prenatal, perinatal, and postnatal factors recognized to influence these outcomes; identify knowledge gaps; consider research and clinical opportunities; and highlight the ways in which a neonatologist can contribute to the care of preterm infants with CHD.
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Affiliation(s)
- Philip T Levy
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Alyssa R Thomas
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Ashley Wethall
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Danielle Perez
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Martina Steurer
- Department of Pediatrics, University of California San Francisco, San Francisco, CA.,Department of Epidemiology and Biostatistics, California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA
| | - Molly K Ball
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH.,Division of Neonatology, The Ohio State University Wexner Medical Center, Columbus, OH
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Sethi N, Carpenter JL, Donofrio MT. Impact of perinatal management on neurodevelopmental outcomes in congenital heart disease. Semin Perinatol 2022; 46:151582. [PMID: 35418321 DOI: 10.1016/j.semperi.2022.151582] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
With advancements in cardiopulmonary bypass technique and perioperative care, there has been a progressive decline in mortality associated with neonatal surgical correction of congenital heart disease (CHD). Thus, there is now increased focus on improving neurodevelopmental outcomes in CHD survivors. While the cause of these neurodevelopmental impairments is multifactorial, there is increasing evidence that structural and functional cerebral abnormalities are present before cardiac corrective repair. This suggests that in addition to patient specific risk factors, underlying cardiac physiology and clinical hemodynamics are critical to brain health and development. Prenatal diagnosis of CHD and subsequent optimization of perinatal care may therefore be important modifiable factors for long-term neurodevelopmental outcome. This article reviews the impact that prenatal diagnosis of CHD has on perinatal care and the preoperative clinical status of a neonate, as well as the potential influence this may have on lessening the degree of cerebral injury and long-term neurodevelopmental impairments.
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Affiliation(s)
- Neeta Sethi
- Duke Children's Pediatric and Congenital Heart Center, Duke University Medical Center, Durham, NC, USA
| | - Jessica L Carpenter
- Division of Pediatric Neurology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Mary T Donofrio
- Division of Cardiology, Children's National Hospital, Washington, DC, USA.
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Goldshtrom N, Vasquez AM, Chaves DV, Bateman DA, Kalfa D, Levasseur S, Torres AJ, Bacha E, Krishnamurthy G. Outcomes after neonatal cardiac surgery: The impact of a dedicated neonatal cardiac program. J Thorac Cardiovasc Surg 2022; 165:2204-2211.e4. [PMID: 35927084 DOI: 10.1016/j.jtcvs.2022.06.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/26/2022] [Accepted: 06/20/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Prematurity is a risk factor for in-hospital mortality after cardiac surgery. The structure of intensive care unit models designed to deliver optimal care to neonates including those born preterm with critical congenital heart disease is unknown. The objective of this study was to evaluate in-hospital outcomes after cardiac surgery across gestational ages in an institution with a dedicated neonatal cardiac program. METHODS This study is a single-center, retrospective review of infants who underwent cardiac surgical interventions from our dedicated neonatal cardiac intensive care program between 2006 and 2017. We evaluated in-hospital mortality and morbidity rates across all gestational ages. RESULTS A total of 1238 subjects met inclusion criteria over a 11-year period. Overall in-hospital mortality after cardiac surgery was 6.1%. The mortality rate in very preterm infants (n = 68; <34 weeks' gestation at birth) was 17.6% (odds ratio, 3.52 [1.4-8.53]), versus 4.3% in full-term (n = 563; 39-40 weeks) referent/control infants. Very preterm infants with isolated congenital heart disease (without evidence of other affected organ systems) experienced a mortality rate of 10.5% after cardiac surgery. Neither the late preterm (34-36 6/7 weeks) nor the early term (37-38 6/7) groups had significantly increased odds of mortality compared with full-term infants. Seventy-eight percent of very preterm infants incurred a preoperative or postoperative complication (odds ratio, 4.78 [2.61-8.97]) compared with 35% of full-term infants. CONCLUSIONS In this study of a single center with a dedicated neonatal cardiac program, we report some of the lowest mortality and morbidity rates after cardiac surgery in preterm infants in the recent era. The potential survival advantage of this model is most striking for very preterm infants born with isolated congenital heart disease.
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Pruthi V, Thakur V, Jaeggi E, Rowbottom L, Naguleswaran K, Ryan G, Van Mieghem T. Impact of planned delivery on the perinatal outcome of term fetuses with isolated heart defects. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:901-907. [DOI: 10.1016/j.jogc.2022.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
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Steurer MA, Schuhmacher K, Savla JJ, Banerjee M, Chanani NK, Eckhauser A, Elhoff J, Jacobs JP, Mikesell K, Peyvandi S, Romano J, Zhang W, Gaynor JW, Tabbutt S. Fetal growth and gestational age improve outcome predictions in neonatal heart surgery. J Thorac Cardiovasc Surg 2022; 164:2003-2012.e1. [DOI: 10.1016/j.jtcvs.2022.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 04/29/2022] [Accepted: 05/05/2022] [Indexed: 10/18/2022]
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Freud LR, Seed M. Prenatal Diagnosis and Management of Single Ventricle Heart Disease. Can J Cardiol 2022; 38:897-908. [DOI: 10.1016/j.cjca.2022.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 03/27/2022] [Accepted: 04/04/2022] [Indexed: 12/18/2022] Open
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Puente BN, d'Udekem Y, Krishnan A. Very preterm and very low birthweight infant with pulmonary atresia intact ventricular septum, right ventricle-dependent coronary circulation, and discontinuous pulmonary arteries. Cardiol Young 2022; 32:1-3. [PMID: 35105393 DOI: 10.1017/s1047951122000038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Prematurity and low birthweight are associated with increased mortality in infants undergoing cardiac surgery. Pulmonary atresia with intact ventricular septum and right ventricle-dependent coronary circulation carries one of the highest risks of mortality. We present a patient who was born at 28 weeks of gestation at 1.2 kg, with pulmonary atresia intact ventricular septum, right ventricle-dependent coronary circulation, coronary artery atresia, and discontinuous pulmonary arteries, who successfully underwent palliation with a modified Blalock-Taussig shunt, pulmonary arterioplasty, and subsequently a bidirectional Glenn.
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Affiliation(s)
- Bao N Puente
- Children's National Heart Institute, Children's National Healthy System, Washington, DC, USA
| | - Yves d'Udekem
- Children's National Heart Institute, Children's National Healthy System, Washington, DC, USA
| | - Anita Krishnan
- Children's National Heart Institute, Children's National Healthy System, Washington, DC, USA
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Birth Location in Infants with Prenatally Diagnosed Hypoplastic Left Heart Syndrome. Pediatr Cardiol 2022; 43:301-307. [PMID: 34668072 DOI: 10.1007/s00246-021-02721-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
There are conflicting data on how delivery location impacts outcomes in neonates with ductal-dependent heart disease. Our goal was to evaluate the impact of delivery location on hospital length of stay and survival in infants with prenatally diagnosed hypoplastic left heart syndrome (HLHS) after stage 1 palliation (S1P). A multicenter cohort study was performed utilizing the National Pediatric Cardiology Quality Improvement Collaborative dataset for infants with prenatally diagnosed HLHS who underwent S1P from August 2016 to December 2018. Univariate comparisons of demographics, clinical, and outcome data were made and multivariable logistic regression was performed between groups stratified by distance from surgical center. A total of 790 patients from 33 centers were analyzed: 85% were born < 5 miles from the surgical center with 72% of those (486/673) born at the surgical center. Infants born < 5 miles from the surgical center were significantly (p < 0.05) more likely to be male, white, full term, have no non-cardiac anomaly, and have commercial health insurance; they were significantly more likely to breastfeed pre-operatively, and less likely to have pre-operative cardiac catheterizations, pre-operative mechanical ventilation, or delayed surgery. There was no significant difference between groups in hospital length of stay, 30-day survival, or survival to hospital discharge. In this multicenter dataset, hospital length of stay and survival after S1P did not differ based on distance from birth location to surgical center. However, neonates born < 5 miles from the surgical center had lower rates of potentially modifiable pre-operative risk factors including mechanical ventilation and delays to surgery.
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Savla JJ, Putt ME, Huang J, Parry S, Moldenhauer JS, Reilly S, Youman O, Rychik J, Mercer‐Rosa L, Gaynor JW, Kawut SM. Impact of Maternal-Fetal Environment on Mortality in Children With Single Ventricle Heart Disease. J Am Heart Assoc 2022; 11:e020299. [PMID: 35014861 PMCID: PMC9238520 DOI: 10.1161/jaha.120.020299] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Children with single ventricle heart disease have significant morbidity and mortality. The maternal–fetal environment (MFE) may adversely impact outcomes after neonatal cardiac surgery. We hypothesized that impaired MFE would be associated with an increased risk of death after stage 1 Norwood reconstruction. METHODS AND RESULTS We performed a retrospective cohort study of children with hypoplastic left heart syndrome (and anatomic variants) who underwent stage 1 Norwood reconstruction between 2008 and 2018. Impaired MFE was defined as maternal gestational hypertension, preeclampsia, gestational diabetes, and/or smoking during pregnancy. Cox proportional hazards regression models were used to investigate the association between impaired MFE and death while adjusting for confounders. Hospital length of stay was assessed with the competing risk of in‐hospital death. In 273 children, the median age at stage 1 Norwood reconstruction was 4 days (interquartile range [IQR], 3–6 days). A total of 72 children (26%) were exposed to an impaired MFE; they had more preterm births (18% versus 7%) and a greater percentage with low birth weights <2.5 kg (18% versus 4%) than those without impaired MFE. Impaired MFE was associated with a higher risk of death (hazard ratio [HR], 6.05; 95% CI, 3.59–10.21; P<0.001) after adjusting for age at surgery, Hispanic ethnicity, genetic syndrome, cardiac diagnosis, surgeon, and birth era. Children with impaired MFE had almost double the risk of prolonged hospital stay (HR, 1.95; 95% CI, 1.41–2.70; P<0.001). CONCLUSIONS Children exposed to an impaired MFE had a higher risk of death following stage 1 Norwood reconstruction. Prenatal exposures are potentially modifiable factors that can be targeted to improve outcomes after pediatric cardiac surgery.
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Affiliation(s)
- Jill J. Savla
- Division of CardiologyDepartment of Pediatrics, Children’s Hospital of Philadelphia and Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Mary E. Putt
- Department of Biostatistics, Epidemiology, and InformaticsPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Jing Huang
- Department of Biostatistics, Epidemiology, and InformaticsPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Samuel Parry
- Department of Obstetrics and GynecologyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Julie S. Moldenhauer
- Center for Fetal Diagnosis and TreatmentChildren’s Hospital of Philadelphia and Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Samantha Reilly
- Division of CardiologyDepartment of Pediatrics, Children’s Hospital of Philadelphia and Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Olivia Youman
- Division of CardiologyDepartment of Pediatrics, Children’s Hospital of Philadelphia and Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Jack Rychik
- Division of CardiologyDepartment of Pediatrics, Children’s Hospital of Philadelphia and Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Laura Mercer‐Rosa
- Division of CardiologyDepartment of Pediatrics, Children’s Hospital of Philadelphia and Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - J. William Gaynor
- Division of Cardiothoracic SurgeryDepartment of Surgery, Children’s Hospital of Philadelphia and Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Steven M. Kawut
- Department of MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
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Wang GX, Ma K, Pang KJ, Wang X, Qi L, Yang Y, Mao FQ, Li SJ. Two approaches for newborns with critical congenital heart disease: a comparative study. World J Pediatr 2022; 18:59-66. [PMID: 34822129 DOI: 10.1007/s12519-021-00482-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 10/31/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Prenatal diagnosis and planned peripartum care is an unexplored concept in China. This study aimed to evaluate the effects of the "prenatal diagnosis and postnatal treatment integrated model" for newborns with critical congenital heart disease. METHODS The medical records of neonates (≤ 28 days) admitted to Fuwai Hospital were reviewed retrospectively from January 2019 to December 2020. The patients were divided into "prenatal diagnosis and postnatal treatment integrated group" (n = 47) and "non-integrated group" (n = 69). RESULTS The age of admission to the hospital and the age at surgery were earlier in the integrated group than in the non-integrated group (5.2 ± 7.2 days vs. 11.8 ± 8.0 days, P < 0.001; 11.9 ± 7.0 days vs. 16.5 ± 7.7 days, P = 0.001, respectively). The weight at surgery also was lower in the integrated group than in the non-integrated group (3.3 ± 0.4 kg vs. 3.6 ± 0.6 kg, P = 0.010). Longer postoperative recovery time was needed in the integrated group, with a median mechanical ventilation time of 97 h (interquartile range 51-259 h) vs. 69 h (29-168 h) (P = 0.030) and with intensive care unit time of 13.0 days (8.0-21.0 days) vs. 9.0 days (4.5-16.0 days) (P = 0.048). No significant difference was observed in the all-cause mortality (2.1 vs. 8.7%, P = 0.238), but it was significantly lower in the integrated group for transposition of the great arteries (0 vs. 18.8%, log rank P = 0.032). CONCLUSIONS The prenatal diagnosis and postnatal treatment integrated model could significantly shorten the diagnosis and hospitalization interval of newborns, and surgical intervention could be performed with a lower risk of death, especially for transposition of the great arteries.
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Affiliation(s)
- Guan-Xi Wang
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Street, Xicheng District, Beijing, 100037, China
| | - Kai Ma
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Street, Xicheng District, Beijing, 100037, China
| | - Kun-Jing Pang
- Department of Echocardiography, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Street, Xicheng District, Beijing, 100037, China
| | - Xu Wang
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Street, Xicheng District, Beijing, 100037, China
| | - Lei Qi
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Street, Xicheng District, Beijing, 100037, China
| | - Yang Yang
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Street, Xicheng District, Beijing, 100037, China
| | - Feng-Qun Mao
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Street, Xicheng District, Beijing, 100037, China
| | - Shou-Jun Li
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Street, Xicheng District, Beijing, 100037, China.
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Costello JM, Kim F, Polin R, Krishnamurthy G. Double Jeopardy: Prematurity and Congenital Heart Disease-What's Known and Why It's Important. World J Pediatr Congenit Heart Surg 2021; 13:65-71. [PMID: 34919482 DOI: 10.1177/21501351211062606] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
This article is based on a composite of talks presented during the Double Jeopardy: Prematurity and Congenital Heart Disease Plenary Session at NeoHeart 2020, a global virtual conference.Prematurity and low weight remain significant risk factors for mortality after neonatal cardiac surgery despite a steady increase in survival. Newer and lower weight thresholds for operability are constantly generated as surgeons gather proficiency, technical mastery, and experience in performing complex procedures on extremely small infants. The relationship between birth weight and survival after cardiac surgery is nonlinear with 2 kilograms (kg) being an inflection point below which marked decline in survival occurs.The prevalence of congenital heart disease (CHD) in premature infants is more than twice that in term born infants. Increased risk of preterm birth in infants with CHD is most commonly due to spontaneous preterm birth and remains poorly understood.Advances in Neonatal-Perinatal medicine have led to a marked improvement in survival of neonates born prematurely over the last several decades. However, the risk of severe morbidities including retinopathy of prematurity, intraventricular hemorrhage, bronchopulmonary dysplasia and necrotizing enterocolitis remains significant in extremely low birth weight infants. Premature infants with CHD are at a greater risk of prematurity related morbidities than premature infants without CHD. Interventions that have been successful in decreasing the risk of these morbidities are addressed.
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Affiliation(s)
- John M Costello
- Department of Pediatrics, 158155Medical University of South Carolina, Charleston, SC, USA
| | - Faith Kim
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | - Richard Polin
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | - Ganga Krishnamurthy
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
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