Effectiveness of pulmonary valve-sparing strategy for transatrial-transpulmonary repair of tetralogy of Fallot: a single institution experience

OBJECTIVE

We report the midterm results of our strategy utilizing transatrial-transpulmonary repair for tetralogy of Fallot at a single institution in a low-middle income country.

METHODS

Medical records were retrospectively reviewed for 532 consecutive patients who underwent definitive repair of tetralogy of Fallot at our institution from 2010 to 2020.

RESULTS

The median age and weight of patients in the study patients were 11.6 months (interquartile range, 8.6-17.2 months) and 7.5 kg (interquartile range, 6.8-8.8 kg). The pulmonary valve annulus was preserved (no transannular patch) in 398 patients (75%) and a mini-transannular patch was utilized for 134 patients (25%). The overall survival was 98% at 1 year, and 97% at 10-years follow-up, respectively. Longer postoperative ventilation time was the only risk factor correlated to early death (p = 0.004; Odds Risk, 1.04; 95% confidence intervals, 1.01-1.07). Fourteen patients required pulmonary valve replacement (2.6%, 14/532), four required surgical resection to relieve right ventricular outflow tract obstruction (0.8%, 4/532), and freedom from reoperation of the right ventricular outflow tract was 87% at 10 years. The only risk factor for right ventricular outflow tract reoperation was a postoperative systolic pressure gradient through the right ventricular outflow tract of greater than 50 mmHg (p < 0.001; HR, 47; 95% confidence intervals, 9.1-244). In total, 94.6% (471/489) of the patients were asymptomatic at the latest follow-up without significant arrhythmia.

CONCLUSION

At our institution in an low-middle income country, the transatrial-transpulmonary repair for tetralogy of Fallot has excellent midterm results with few reoperations required. Close long-term follow-up is essential for patients who undergo repair with a mini-transannular patch and may eventually require pulmonary valve replacement.

Primary or Delayed Repair for Complete Atrioventricular Septal Defect, Tetralogy of Fallot, and Ventricular Septal Defect: Relationship to Country Economic Status

OBJECTIVE

Primary repair in the first six months of life is routine for tetralogy of Fallot, complete atrioventricular septal defect, and ventricular septal defect in high-income countries. The objective of this analysis was to understand the utilization and outcomes of palliative and reparative procedures in high versus middle-income countries.

METHODS

The World Database of Pediatric and Congenital Heart Surgery identified patients who underwent surgery for: tetralogy of Fallot, complete atrioventricular septal defect, and ventricular septal defect. Patients were categorized as undergoing primary repair, repair after prior palliation, or palliation only. Country economic status was categorized as lower middle, upper middle, and high, defined by the World Bank. Multiple logistic regression models were utilized to identify independent predictors of hospital mortality.

RESULTS

Economic categories included high (n = 571, 5.3%), upper middle (n = 5,342, 50%), and lower middle (n = 4,793, 49.7%). The proportion of patients and median age with primary repair were: tetralogy of Fallot, 88.6%, 17.7 months; complete atrioventricular septal defect, 83.4%, 7.7 months; and ventricular septal defect, 97.1%, ten months. Age at repair was younger in high income countries (P < .0001). Overall mortality after repair was lowest in high income countries. Risk factors for hospital mortality included prematurity, genetic syndromes, and urgent or emergent operations (all P < .05).

CONCLUSIONS

Primary repair was selected in >90% of patients, but definitive repair was delayed in lower and upper middle income countries compared with high-income countries. Repair after prior palliation versus primary repair was not a risk factor for hospital mortality. Initial palliation continues to have a small but important role in the management of these three specific congenital heart defects.

Survival After Single-Stage Repair of Truncus Arteriosus and Associated Defects

BACKGROUND

The goal of this study was to describe in-hospital and long-term mortality after single-stage repair of truncus arteriosus communis (TAC) and explore factors associated with these outcomes.

METHODS

This was a cohort study of consecutive patients undergoing single-stage TAC repair between 1982 and 2011 reported to the Pediatric Cardiac Care Consortium registry. In-hospital mortality was obtained for the entire cohort from registry records. Long-term mortality was obtained for patients with available identifiers by matching with the National Death Index through 2020. Kaplan-Meier survival estimates were created for up to 30 years after discharge. Cox regression models estimated hazard ratios for the associations with potential risk factors.

RESULTS

A total of 647 patients (51% male) underwent single-stage TAC repair at a median age of 18 days; 53% had type I TAC, 13% had interrupted aortic arch, and 10% underwent concomitant truncal valve surgery. Of these, 486 (75%) patients survived to hospital discharge. After discharge, 215 patients had identifiers for tracking long-term outcomes; 30-year survival was 78%. Concomitant truncal valve surgery at the index procedure was associated with increased in-hospital and 30-year mortality. Concomitant interrupted aortic arch repair was not associated with increased in-hospital or 30-year mortality.

CONCLUSIONS

Concomitant truncal valve surgery but not interrupted aortic arch was associated with higher in-hospital and long-term mortality. Careful consideration of the need and timing for truncal valve intervention may improve TAC outcomes.

Hospital Mortality and Adverse Events Following Repair of Congenital Heart Defects in Developing Countries

BACKGROUND

Mortality associated with the correction of congenital heart disease has decreased to approximately 2% in developed countries and major adverse events are uncommon. Outcomes in developing countries are less well defined. The World Database for Pediatric and Congenital Heart Surgery was utilized to compare mortality and adverse events in developed and developing countries.

METHODS

A total of 16,040 primary procedures were identified over a two-year period. Centers that submitted procedures were dichotomized to low/middle income (LMI) and high income (HI) by the Gross National Income per capita categorization. Mortality was defined as any death following the primary procedure to discharge or 90 days inpatient. Multiple logistic regression models were utilized to identify independent predictors of mortality.

RESULTS

Of the total number of procedures analyzed, 83% (n  =  13,294) were from LMI centers. Among all centers, the mean age at operation was 2.2 years, with 36% (n  =  5,743) less than six months; 85% (n  =  11,307) of procedures were STAT I/II for LMI centers compared with 77% (n = 2127) for HI centers (P < .0001). Overall mortality across the cohort was 2.27%. There was a statistical difference in mortality between HI centers (0.55%) versus LMI centers (2.64%) (P < .0001). After adjustment for other risk factors, the risk of death remained significantly higher in LMI centers (odds ratio: 2.36, 95% confidence interval: 1.707-3.27).

CONCLUSION

Although surgical expertise has increased across the globe, there remains a disparity with some outcomes associated with the correction of congenital heart disease between developing and developed countries. Further studies are needed to identify specific opportunities for improvement.

Procedure-Specific Center Volume and Mortality After Infantile Congenital Heart Surgery

BACKGROUND

Regionalization of congenital heart surgery (CHS) has been proposed to improve postsurgical outcomes by increasing experience in the care of high-risk patients. We sought to determine whether procedure-specific center volume was associated with mortality after infantile CHS up to 3 years post-procedure.

METHODS

We analyzed data from 12,263 infants in the Pediatric Cardiac Care Consortium undergoing CHS between 1982 and 2003 at 46 centers within the United States. We used logistic regression to assess the association between procedure-specific center volume and mortality from discharge to 3 years post-procedure, accounting for clustering at the center level and adjusting for patient age and weight at surgery, chromosomal abnormality, and surgical era.

RESULTS

We found decreased odds for in-hospital mortality for Norwood procedures (odds ratio [OR] 0.955, 95% CI 0.935-0.976), arterial switch operations (OR 0.924, 95% CI 0.889-0.961), tetralogy of Fallot repairs (OR 0.975, 95% CI 0.956-0.995), Glenn shunts (OR 0.971, 95% CI 0.943-1.000), and ventricular septal defect closures (OR 0.974, 95% CI 0.964-0.985). The association persisted up to 3 years post-surgery for Norwood procedures (OR 0.971, 95% CI 0.955-0.988), arterial switches (OR 0.929, 95% CI 0.890-0.970), and ventricular septal defect closures (OR 0.986, 95% CI 0.977-0.995); however, after excluding deaths that occurred within the first 90 days of following surgery, we observed no association between center volume and mortality for any of the procedures studied.

CONCLUSIONS

These findings suggest that procedure-specific center volume is inversely associated with early postoperative mortality for infantile CHS across the complexity spectrum but has no measurable effect on later mortality.

Building resilient heart center teams

PURPOSE OF REVIEW

The purpose of this review is to move beyond measures to improve individual resilience but to focus on measures to achieve better team resilience.

RECENT FINDINGS

The COVID pandemic, shortages of heath care workers, and subsequent viral resurgence in 2022 placed tremendous stress on pediatric healthcare systems. Much has been written about individual wellness, mindfulness, and strategies to be a more resilient individual. However, little has been written on the importance of team resilience. Resilient teams work together to overcome daily stressors and challenges. Although leaders must create and foster a collaborative culture to establish cohesive and resilient teams; it also requires tremendous institutional support. Four key factors have emerged with regards to successful team resilience: candor, humility, resourcefulness, and compassion and empathy. This article discusses the key elements required for resilient teams to not only survive but also to thrive.

SUMMARY

Effective heart centers, like the symphony, are a collection of individuals all coming together to care for a child or create a singular piece of music. Heart centers without effective leaders will most certainly fail, but even with the most accomplished and passionate leaders, there must be administrative institutional support and a shared vision.

Multicentre comparative analysis of long-term outcomes after aortic valve replacement in children

OBJECTIVE

The ideal valve substitute for surgical intervention of congenital aortic valve disease in children remains unclear. Data on outcomes beyond 10-15 years after valve replacement are limited but important for evaluating substitute longevity. We aimed to describe up to 25-year death/cardiac transplant by type of valve substitute and assess the potential impact of treatment centre. Our hypothesis was that patients with pulmonic valve autograft would have better survival than mechanical prosthetic.

METHODS

This is a retrospective cohort study from the Pediatric Cardiac Care Consortium, a multi-institutional US-based registry of paediatric cardiac interventions, linked with the National Death Index and United Network for Organ Sharing through 2019. Children (0-20 years old) receiving aortic valve replacement (AVR) from 1982 to 2003 were identified. Kaplan-Meier transplant-free survival was calculated, and Cox proportional hazard models estimated hazard ratios for mechanical AVR (M-AVR) versus pulmonic valve autograft.

RESULTS

Among 911 children, the median age at AVR was 13.4 years (IQR=8.4-16.5) and 73% were male. There were 10 cardiac transplants and 153 deaths, 5 after transplant. The 25-year transplant-free survival post AVR was 87.1% for autograft vs 76.2% for M-AVR and 72.0% for tissue (bioprosthetic or homograft). After adjustment, M-AVR remained related to increased mortality/transplant versus autograft (HR=1.9, 95% CI=1.1 to 3.4). Surprisingly, survival for patients with M-AVR, but not autograft, was lower for those treated in centres with higher in-hospital mortality.

CONCLUSION

Pulmonic valve autograft provides the best long-term outcomes for children with aortic valve disease, but AVR results may depend on a centre's experience or patient selection.

Clinical impact of pharmacist-led antibiotic stewardship programs in outpatient settings in the United States: A scoping review

Disclaimer

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Purpose

To provide an overview of the impact of pharmacist interventions on antibiotic prescribing and the resultant clinical outcomes in an outpatient antibiotic stewardship program (ASP) in the United States.

Methods

Reports on studies of pharmacist-led ASP interventions implemented in US outpatient settings published from January 2000 to November 2020 and indexed in PubMed or Google Scholar were included. Additionally, studies documented at the ClinicalTrials.gov website were evaluated. Study selection was based on predetermined inclusion criteria; only randomized controlled trials, observational studies, nonrandomized controlled trials, and case-control studies conducted in outpatient settings in the United States were included. The primary outcome was the observed differences in antibiotic prescribing or clinical benefits between pharmacist-led ASP interventions and usual care.

Results

Of the 196 studies retrieved for full-text review, a cumulative total of 15 studies were included for final evaluation. Upon analysis, we observed that there was no consistent methodology in the implementation of ASPs and, in most cases, the outcome of interest varied. Nonetheless, there was a trend toward improvement in antibiotic prescribing with pharmacist interventions in ASPs compared with that under usual care (P < 0.05). However, the results of these studies are not easily generalizable.

Conclusion

Our findings suggest a need for a consistent approach for the practical application of outpatient pharmacist-led ASPs. Managed care organizations could play a significant role in ensuring the successful implementation of pharmacist-led ASPs in outpatient settings.

Design and evaluation of an abbreviated pixelwise dynamic contrast enhancement analysis protocol for early extracellular volume fraction estimation

INTRODUCTION

T1-based method is considered as the gold standard for extracellular volume fraction (ECV) mapping. This technique requires at least a 10 min delay after injection to acquire the post injection T1 map. Quantitative analysis of Dynamic Contrast Enhancement (DCE) images could lead to an earlier estimation of an ECV like parameter (2 min). The purpose of this study was to design a quantitative pixel-wise DCE analysis workflow to assess the feasibility of an early estimation of ECV.

METHODS

Fourteen patients with mitral valve prolapse were included in this study. The MR protocol, performed on a 3 T MR scanner, included MOLLI sequences for T1 maps acquisition and a standard SR-turboFlash sequence for dynamic acquisition. DCE data were acquired for at least 120 s. We implemented a full DCE analysis pipeline with a pre-processing step using an innovative motion correction algorithm (RC-REG algorithm) and a post-processing step using the extended Tofts Model (ECV_ETM). Estimated ECV_ETM maps were compared to standard T1-based ECV maps (ECV_T1) with both a Pearson correlation analysis and a group-wise analysis.

RESULTS

Image and map quality assessment showed systematic improvements using the proposed workflow. Strong correlation was found between ECV_ETM, and ECV_T1 values (r-square = 0.87).

CONCLUSION

A DCE analysis workflow based on RC-REG algorithm and ETM analysis can provide good quality parametric maps. Therefore, it is possible to extract ECV values from a 2 min-long DCE acquisition that are strongly correlated with ECV values from the T1 based method.

Early Impact of the COVID-19 Pandemic on Congenital Heart Surgery Programs Across the World: Assessment by a Global Multi-Societal Consortium

The coronavirus disease 2019 (COVID-19) pandemic currently gripping the globe is impacting the entire health care system with rapidly escalating morbidities and mortality. Although the infectious risk to the pediatric population appears low, the effects on children with congenital heart disease (CHD) remain poorly understood. The closure of congenital heart surgery programs worldwide to address the growing number of infected individuals could have an unintended impact on future health for COVID-19-negative patients with CHD. Pediatric and congenital heart surgeons, given their small numbers and close relationships, are uniquely positioned to collectively assess the impact of the pandemic on surgical practice and care of children with CHD. We present the results of an international survey sent to pediatric and congenital heart surgeons characterizing the early impact of COVID-19 on the care of patients with CHD.

The World Database for Pediatric and Congenital Heart Surgery: Update

Following several years of planning and design, the World Database for Pediatric and Congenital Heart Surgery (WDPCHS) went live on January 1, 2017. The first operational year of this valuable database has proven very successful. As of February 28, 2018, more than 4,500 patients have been submitted from 39 centers; participation currently spans 19 countries over 6 continents, with 120 more centers in the enrollment pipeline. This update, the first in a series, is intended to provide World Society for Pediatric and Congenital Heart Surgery members and others who care for children with congenital heart disease with a broad overview of current progress and ongoing activities surrounding the WDPCHS.

Pediatric Acquired von Willebrand Disease With Berlin Heart Excor Ventricular Assist Device Support

BACKGROUND

The balance of hemostasis and anticoagulation is a concern for patients dependent upon ventricular assist devices (VADs). Bleeding is a common complication with both short- and long-term use of these devices. A better understanding of the risk factors and etiologies of bleeding associated with these devices is needed and could improve the overall results. We sought to determine the relationship of mechanical circulatory assist device use with acquired von Willebrand disease (avWD) in children.

METHODS

Data were analyzed retrospectively via review of the medical record of 19 consecutive patients who were supported with the Berlin EXCOR VAD for greater than 24 hours. Laboratory testing for avWD was performed at the discretion of the clinical team, often in association with clinical bleeding.

RESULTS

Of 19 pediatric patients, 10 (52.6%) had laboratory testing consistent with avWD. Median time to detection of avWD was 35 days postimplantation of device (range 0-310 days). Both minor mucosal bleeding and bleeding requiring intervention were highly prevalent in patients in whom avWD was identified (10/10 [100%] and 7/10 [70%]). The mean age of all patients was 3.3 years, but patients found to have avWD tended to be older (mean 5.3 years) and supported with larger volume VADs.

CONCLUSIONS

This experience demonstrates a high prevalence of avWD following EXCOR implantation. Bleeding, older age, and larger VAD size may be associated with avWD. These results should stimulate critical evaluation of individualized anticoagulation regimens in pediatric VAD patients.

Abstract 220: Technical Performance Scores Predict Outcomes Following Congenital Heart Surgery: Multicenter Validation

BACKGROUND: In previous work from a single center, Technical Performance Score (TPS), a tool that assesses technical adequacy of repair, has been shown to be strongly associated with outcomes in congenital cardiac surgery. We sought to validate the efficacy of TPS in a multicenter environment.

METHODS: All patients (1 day to 62 years) who were discharged from January 1 to December 31, 2011; and who underwent 9 congenital cardiac procedures (Arterial switch operation [84], Bidirectional Glenn [75], Atrioventricular canal repair [135], Fontan [97], Arch repair on pump [58], Stage I Procedure [85], Pulmonary valve replacement [116], Tetralogy of Fallot repair [112], and Ventricular septal defect repair [163]); from 5 centers were included. Based on echocardiograms (echo) prior to discharge or death, and unplanned reinterventions at surgical site; TPS was assigned using previously established criteria. Case complexity was determined by RACHS-1 category. Outcomes included (a) major postoperative adverse events (AE) excluding unplanned reinterventions, (b) length of ventilation, and (c) postoperative hospital stay. Adjusted analysis used logistic/linear regression to determine odds ratio (OR) and regression coefficient (b) for each outcome.

RESULTS: There were 925 hospital discharges: 418 (45%) were RACHS-1 category 2, 295 (32%) category 3, 85 (9%) category 4, 86 (9%) category 6 and the cohort included 41 (4%) adults. TPS were as follows: 491 (53%) class 1-optimal, 263 (28%) class 2-adequate, 131 (14%) class 3-inadequate and 40 (4%) had no TPS assigned because of a lack of or incomplete echos (NA). There were 26 (2.8%) deaths (81% of deaths were in class 3) and 105 (11%) adverse events. Occurrence of major adverse events, ventilation time and hospital length of stay were all significantly higher in class 3 (Figure). On multivariable analysis adjusting for age, RACHS-1, prematurity, and presence of non-cardiac anomalies; Class 3 TPS was associated with a higher odds of AE (OR 7.4, CI 4.1-13.2, p<0.001), longer ventilation (b 1.9, CI 1.6-2.2, p<0.001), and hospital stay (b 1.6, CI 1.4 to 1.8, p<0.001).

CONCLUSION: TPS predicts outcomes after congenital heart surgery in a multicenter cohort, and can serve as quality assessment tool. Outcomes may be favorably influenced by focusing on technical excellence.

Delayed arterial switch operation for d-transposition of the great arteries and glucocorticoid remediable aldosteronism

The Jatene arterial switch operation (ASO) for dextro-transposition of the great arteries is ideally performed within the first 2 weeks of life. Clinical circumstances, however, may dictate a delayed ASO and left ventricle "retraining" prior to the procedure. Glucocorticoid remediable aldosteronism (GRA) accounts for 0.5% to 1% of primary aldosteronism. It presents as severe hypertension in infants and children, with poor response to standard antihypertensive medications. To the authors' knowledge, this is the first reported case of GRA in the context of transposition physiology. The management of GRA and a rationale for delayed ASO are discussed.

Pregnancy impairs resistance of C57BL/6 mice to Leishmania major infection

To determine if gestational factors affect the severity of L. major infection, this study assessed the levels of IL-4 mRNA and IFN-gamma mRNA in popliteal lymph node cells of pregnant C57BL/6 mice mated at 5 hours, 16 hours and 15 days post L. major infection using PCR. Infected pregnant C57BL/6 mice developed larger cutaneous footpad lesions compared with non-pregnant infected C57BL/6 mice. The resolution of footpad lesions commenced after 8th week in C57BL/6 mice mated at 16 hrs post L. major infection but 12 weeks in C57BL/6 mice mated at 5 hrs and 15 days post L. major infection. C57BL/6 mice that were infected 20 days post partum resolved L. major infection effectively. But, the lesions in infected pregnant C57BL/6 mice and infected non-pregnant C57BL/6 mice were not as large as in susceptible BALB/c mice. The mean litter weights were similar in pregnant infected C57BL/6 mice mated at different stages of L. major infection but were slightly lower than weights of litters from pregnant uninfected C57BL/6 mice. In 5 days infected pregnant C57BL/6 mice, the levels of IFN-gamma were raised compared with the levels of IL-4 but those mated at 15 days post L. major infection had highest level of IFN-gamma mRNA. In 10 days pregnant infected C57BL/6 mice, levels of IL-4 were raised compared with IFN-gamma but mice mated at 16 hrs post L. major infection had highest level of IL-4. In 15 days pregnant infected mice, the levels of IL-4 were higher than IFN-gamma irrespective of the stage of L. major infection when the mice were mated. Mice infected with L. major 20 days post-partum produced more IFN-gamma than IL-4 from 16 hrs post L. major infection onwards. It may be concluded that increased IL-4 in pregnant infected C57BL/6 mice impairs the resistance of C57BL/6 mice to L. major infection especially in mice that were pregnant before effective immunity (5 hours post L. major infection) is mounted against L. major infection.

[Kingella kingae osteoarticular infections in children. A report of a series of eight new cases]

Kingella kingae is a Gram-negative bacillus which belongs to the Neisseriaceae family. Its involvement in osteoarticular infections is relatively recent.

METHODS AND RESULTS

We report eight cases of Kingella kingae osteoarticular infections that have been diagnosed at the paediatric surgical centre of Rouen University Hospital since October 1995. Six boys and two girls (mean age: 30.6 months) presented with osteomyelitis in six cases and arthritis in two. Only 75% of patients had a fever at time of diagnosis. The biological findings were slightly modified. All samples were obtained from blood, bone or joint fluid. These samples were systematically inoculated into a blood culture tube. Positive Kingella kingae culture was achieved in seven local samples and in one blood culture. All children received two antibiotics via intravenous injection while waiting for the bacteriologic results. Later, the antibiotic treatment (amoxycillin) was given per os. The mean duration of treatment was 33 days. Patients were given intravenous treatment for a period of only ten days. Six patients were followed up for a period of more than 18 months and outcome was always uneventful.

DISCUSSION

Kingella kingae is usually present in the nasopharyngeal mucosa and spreads in the blood due to various infections. Different types of Kingella kingae infection have been reported with a large frequency of osteoarticular infection.

CONCLUSION

This type of infection does not present any unusual characteristics as compared to other osteoarticular infections. Because of its antibiotic sensitivity treatment duration could be reduced. Kingella kingae is a fragile microbe and its culture is often difficult; therefore, it is important to use blood culture tubes to inoculate joint fluid and bone samples.