Cardiac Society of Australia and New Zealand

The specialty of pediatric cardiac critical care has undergone rapid scientific and clinical growth in the last 25 years. The Board of Directors of the Pediatric Cardiac Intensive Care Society assembled an updated list of sentinel references focused on the critical care of children with congenital and acquired heart disease. We encouraged board members to select articles that have influenced and informed their current practice or helped to establish the standard of care. The objective of this article is to provide clinicians with a compilation and brief summary of these updated 100 useful references. The list of 'One Hundred Useful References for Pediatric Cardiac Intensive Care' (2004) and relevant literature to the practice of cardiac intensive care. A subset of Pediatric Cardiac Intensive Care Society board members compiled the initial list of useful references in 2004, which served as the basis of the new updated list. Suggestions for relevant articles were submitted by the Pediatric Cardiac Intensive Care Society board members and selected pediatric cardiac intensivists with an interest in this project following the Society's meeting in 2010. Articles were considered for inclusion if they were named in the original list from 2004 or were suggested by Pediatric Cardiac Intensive Care Society board members and published before December 31, 2011. Following submission of the complete list by the Pediatric Cardiac Intensive Care Society board and contributing Society members, articles were complied by the two co-first authors (D.A., D.K.). The authors also performed Medline searches to ensure comprehensive inclusion of all relevant articles. The final list was then submitted to the Pediatric Cardiac Intensive Care Society board members, who ranked each publication. Rankings were compiled and the top 100 articles with the highest scores were selected for inclusion in this publication. The two co-first authors (D.A., D.K.) reviewed all existing summaries and developed summaries of the newly submitted articles. An updated compilation of 100 useful references for the critical care of children with congenital and acquired heart disease has been compiled and summarized here. Clinicians and trainees may wish to use this document as a reference for education in this complex and challenging subspecialty.

There are substantial knowledge gaps, practice variation, and paucity of controlled trials owing to the relatively small number of patients with critical heart disease. The Pediatric Cardiac Intensive Care Society has recognised this knowledge gap as an area needing a more comprehensive and evidence-based approach to the management of the critically ill child with heart disease. To address this, the Pediatric Cardiac Intensive Care Society created a scientific statements and white papers committee. Scientific statements and white papers will present the current state-of-the-art in areas where controversy exists, providing clinicians with guidance in diagnostic and therapeutic strategies, particularly where evidence-based data are lacking. This paper provides a template for other societies and organisations faced with the task of developing scientific statements and white papers. We describe the methods used to perform a systematic literature search and evidence rating that will be used by all scientific statements and white papers emerging from the Pediatric Cardiac Intensive Care Society. The Pediatric Cardiac Intensive Care Society aims to revolutionise the care of children with heart disease by shifting our efforts from individual institution-based practices to national standardised protocols and to lay the ground work for multicentre high-impact research directions.

Cardiac societies recommend the intake of 1 g/day of the two omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) for cardiovascular disease prevention, treatment after a myocardial infarction, prevention of sudden death, and secondary prevention of cardiovascular disease. These recommendations are based on a body of scientific evidence that encompasses literally thousands of publications. Of four large scale intervention studies three also support the recommendations of these cardiac societies. One methodologically questionable study with a negative result led a Cochrane meta-analysis to a null conclusion. This null conclusion, however, has not swayed the recommendations of the cardiac societies mentioned, and has been refuted with good reason by scientific societies. Based on the scientific evidence just mentioned, we propose a new risk factor to be considered for sudden cardiac death, the omega-3 index. It is measured in red blood cells, and is expressed as a percentage of EPA + DHA of total fatty acids. An omega-3 index of >8% is associated with 90% less risk for sudden cardiac death, as compared to an omega-3 index of <4%. The omega-3 index as a risk factor for sudden cardiac death has striking similarities to LDL as a risk factor for coronary artery disease. Moreover, the omega-3 index reflects the omega-3 fatty acid status of a given individual (analogous to HbA1c reflecting glucose homeostasis). The omega-3 index can therefore be used as a goal for treatment with EPA and DHA. As is the case now for LDL, in the future, the cardiac societies might very well recommend treatment with EPA and DHA to become goal oriented (e.g. an omega-3 index>8%).

Polyunsaturated n-3 fatty acid preparations containing eicosapentaenoic acid (EPA) and docosahexanaenoic acid (DHA), or EPA only, have long been recommended in the management of hypertriglyceridaemia, especially when severe (triglyceride levels ≥500mg/dL), at the dose of 2-4g/d, mostly for the prevention of acute pancreatitis. The presented article reviews clinical trials and their metaanalyses which evaluated the effect of n-3 fatty acids on cardiovascular disease risk, and regulatory agencies' and cardiac societies' positions regarding their use. The findings indicate that only EPA is effective. Particular clinical benefit (25% reduction of cardiovascular events) was observed in the recently published REDUCE-IT trial which evaluated EPA (icosapent ethyl) at the dose of 4 g/d for 4.9 years (median), compared to placebo, in hypertriglycerydaemic patients at high or very high cardiovascular risk. This positive effect has been reflected in the expert opinions which recommend eicosapent ethyl (4 g/d) in patients similar to those participating in the REDUCE-IT trial. Additional data in favour of the above position have been provided by the EVAPORATE trial results which showed reduced progression of coronary atherosclerosis with EPA at the dose of 4 g/d. The clinical studies and metaanalyses strongly point out that only EPA (icosapent ethyl), especially at dose of 4 g/d, is effective in reducing cardiovascular events in very high and high risk patients with hypertriglyceridemia. The use of EPA + DHA preparations in doses up to 1 g/d does not prevent recurrent cardiovascular events.

Commentary: Presurgical frailty assessment can predict adverse outcomes in patients undergoing cardiac surgery… but where do we go from here?

The 15th biennial Pan-African Society of Cardiology (PASCAR) congress held in Mombasa, Kenya, in November 2021, convened in its legacy of being the largest Pan-African conference on cardiovascular diseases (CVDs). The congress brough together members of cardiovascular societies from across the continent in the shared mission of advancing cardiovascular health in Africa. In partnership with the Kenyan Cardiac Society (KCS), the specific aims of the PASCAR conference were to (1) advance knowledge on CVDs in the region; (2) share local data, clinical cases, challenges and solutions and reinforce collaborative capacity initiatives in research and workforce training; (3) engage with policy makers to address health-system issues affecting access to CVD care in Africa; and (4) bring together local and international thought leaders in cardiovascular medicine to strengthen the partnerships between PASCAR, KCS, other African cardiac societies and key global stakeholders. Due to the COVID-19 pandemic, this congress demonstrated great success in providing both an in-person and a virtual platform of attendance, therefore making this an inaugural hybrid PASCAR congress, with inclusive and widespread participation from across the globe. We highlight the key areas of focus, various educational programmes and innovative initiatives that shaped the 15th PASCAR congress, including expert consensus on the future directions for advancing CVD care in Africa.

The Congenital Cardiac Anesthesia Society was formed in 2005 by representatives from many of the busiest congenital cardiac surgical programs in North America and is now in the process of partnering with The Society of Thoracic Surgeons to create a joint congenital cardiac surgery and congenital cardiac anaesthesia database. Even the busiest of congenital cardiac programs have a low frequency of anaesthesia-related cardiac complications and deaths. One of the only mechanisms for accurately determining the incidence and outcomes of low frequency events is to aggregate large amounts of data from multiple sources. To that end, the Congenital Cardiac Anesthesia Society has joined with the Society of Thoracic Surgeons Congenital Database Task Force to incorporate anaesthesia-specific data points into their surgical registry, which is now the largest single reporting site for children and adults undergoing surgical repair of congenital cardiac malformations in North America. The Joint Congenital Cardiac Anesthesia Society--Society of Thoracic Surgeons Database will therefore become an optional module of The Society of Thoracic Surgeons Congenital Heart Surgery Database. Initial data fields have been selected and are presented in this article. Efforts are ongoing to make this initiative a global project. Initial collaborative discussions have taken place about the possibility of linking this initiative with the European Association of Cardiothoracic Anesthesiologists. It is certainly possible and desirable that the planned anaesthesia module of The Society of Thoracic Surgeons Congenital Heart Database has an identical module in the congenital heart database of The European Association for Cardio-Thoracic Surgery and The European Congenital Heart Surgeons Association. This project should also ideally spread beyond North America and Europe. Efforts to involve Africa, Asia, Australia, and South America are necessary and already underway. The creation of a joint cardiac surgery and anaesthesia database is another step towards the ultimate goal of creating a database for congenital heart disease that spans both geographical and subspecialty boundaries.

Education of paediatric advanced practice providers takes a generalist approach which lacks in-depth exposure to subspecialties like paediatric cardiac intensive care. This translates into a knowledge gap related to congenital cardiac physiology and management for APPs transitioning to the paediatric cardiac ICU. A specialised interprofessional peer-reviewed curriculum was created and distributed through the Pediatric Cardiac Intensive Care Society. This curriculum includes a textbook which is complemented by a didactic and simulation review course. Course evaluations were collected following each course, and feedback from participants was incorporated into subsequent courses. Pediatric Cardiac Intensive Care Society partnered with the Pediatric Nursing Certification Board to develop a 200-question post-assessment (exam) bank. From December 2017 to January 2022, 12 review courses were taught at various host sites (n = 314 participants). Feedback revealed that courses improved preparedness for practice, contributed to advanced practice provider empowerment, and emphasised the importance of professional networking. 97% of attendees agreed/strongly agreed that the course improved clinical knowledge, 97% agreed/strongly agreed that the course improved ability to care for patients, and 88% agreed/strongly agreed that the course improved confidence to practice. 49% of participants rated the course as extremely effective, 42% very effective, 6% moderately effective, and 3% as only slightly effective. A standardised subspecialty curriculum dedicated to advanced practice provider practice in cardiac intensive care was needed to improve knowledge, advance practice, and empower APPs managing critically ill patients in the cardiac ICU. The developed curriculum provides standardised learning, increasing advanced practice provider knowledge acquisition, and confidence to practice.

Outcomes for children with heart disease improved over the past decades. Quality improvement (QI) research in paediatric cardiac critical care is a key driver of improvement. The availability and variability of QI research across the field is unknown. This project represents a step in understanding the role. The Pediatric Cardiac Intensive Care Society (PCICS) can serve to support institutions' needs, drive collaborations, and utilise available infrastructure at member institutions for improvement work. The PCICS Quality Improvement and Safety Committee developed a survey to assess the state of QI research. The survey was disseminated over several months and available via QR code at the World Congress of Pediatric Cardiology and Cardiac Surgery in 2023. Fifty-eight respondents completed the survey representing at least 38 unique institutions. Most respondents participated in QI research (52/58, 90%). Most QI projects were single centre (41% of respondents), and of those, the majority were from a minority of institutions (13 institutions [34% of total institutions]). QI support is available at slightly more than half of units, and 55% (32/58) have access to a QI specialist. QI support and rate of publications is significantly lower for small/medium units as compared to large units. Respondents suggested most interest from PCICS in networking with other members with similar project ideas (50/58, 86%). PCICS member institutions are committed to QI research, with limitations in support, local specialists, and networking. Increasing connectivity and accessibility to QI resources may reduce burden to individual members and institutions to achieve QI research.

The Cope rearrangement has been used as the key step of several natural products but to date there is only one limited example in the literature that is capable of performing an asymmetric variant of this reaction. The first half of this dissertation focuses on our efforts towards performing a catalytic asymmetric Cope rearrangement to access remote stereocenters. The rearrangement of 2-formyl-1,5-dienes was achieved with both Brønsted and Lewis acid catalysts. The best Lewis acid catalyst was determined to be gold(III)chloride. As there are no examples of asymmetric Au(III) catalysis, we designed and synthesized bis-alpha-chiral dipyrromethanes as potential new ligands for organometallic asymmetric Cope rearrangements.This work also focuses on the design and synthesis of functionalized deep cavitands for use as biomimetic C-H oxidation catalysts. Enzymes are capable of performing site-selective oxidations by incorporating substrates in their binding pockets and selectively oxidizing the C-H bond closest in proximity to the active site of the enzyme. Cavitands are capable of selectively binding guests of the appropriate size and shape, much like enzymes. Specifically, this work involves the synthesis of cavitands that contain deep cavities with functionalized rims that possess the ability to complex to metals such as iron or copper. These deep functionalized cavitands were found to be capable of binding amines and other small guests as well as performing unprecedented anion binding. Metal coordination was also achieved at the rims of the cavitand making these metallobound cavitands potential enzymes mimics by binding a guest in its cavity and selectively oxidizing the groups closest in proximity to the catalytic site, i.e. the metal bound rims.

You shouldn’t take it with you: Postmortem device reuse

To the Editor: In a recent study on twins, IJzerman et al1 report an association between low birth weight and a short pre-ejection period at rest and during stress tests. They interpret their findings as evidence for an increased sympathetic nervous activity in low birth weight subjects. These data elucidate an important aspect in the regulation of the sympathetic system in low birth weight subjects. However, on the background of a study of our group, which examined muscle sympathetic nerve activity (MSNA) in low birth weight singletons,2 the interpretation of the results may have to be modified. In our study, sympathetic neural activity to the muscle vascular bed was determined by specific intraneural measurement. Under resting conditions, MSNA was lower in low birth weight subjects as compared with a control group with normal birth weight. Baroreflex function was also examined and showed normal functional properties. Additionally, sympathoexcitatory maneuvers (inspiratory apnea …

This review discusses the historical aspects, current state of the art, and potential future advances in the areas of nomenclature and databases for the analysis of outcomes of treatments for patients with congenitally malformed hearts. We will consider the current state of analysis of outcomes, lay out some principles which might make it possible to achieve life-long monitoring and follow-up using our databases, and describe the next steps those involved in the care of these patients need to take in order to achieve these objectives. In order to perform meaningful multi-institutional analyses, we suggest that any database must incorporate the following six essential elements: use of a common language and nomenclature, use of an established uniform core dataset for collection of information, incorporation of a mechanism of evaluating case complexity, availability of a mechanism to assure and verify the completeness and accuracy of the data collected, collaboration between medical and surgical subspecialties, and standardised protocols for life-long follow-up. During the 1990s, both The European Association for Cardio-Thoracic Surgery and The Society of Thoracic Surgeons created databases to assess the outcomes of congenital cardiac surgery. Beginning in 1998, these two organizations collaborated to create the International Congenital Heart Surgery Nomenclature and Database Project. By 2000, a common nomenclature, along with a common core minimal dataset, were adopted by The European Association for Cardio-Thoracic Surgery and The Society of Thoracic Surgeons, and published in the Annals of Thoracic Surgery. In 2000, The International Nomenclature Committee for Pediatric and Congenital Heart Disease was established. This committee eventually evolved into the International Society for Nomenclature of Paediatric and Congenital Heart Disease. The working component of this international nomenclature society has been The International Working Group for Mapping and Coding of Nomenclatures for Paediatric and Congenital Heart Disease, also known as the Nomenclature Working Group. By 2005, the Nomenclature Working Group crossmapped the nomenclature of the International Congenital Heart Surgery Nomenclature and Database Project of The European Association for Cardio-Thoracic Surgery and The Society of Thoracic Surgeons with the European Paediatric Cardiac Code of the Association for European Paediatric Cardiology, and therefore created the International Paediatric and Congenital Cardiac Code, which is available for free download from the internet at [http://www.IPCCC.NET]. This common nomenclature, the International Paediatric and Congenital Cardiac Code, and the common minimum database data set created by the International Congenital Heart Surgery Nomenclature and Database Project, are now utilized by both The European Association for Cardio-Thoracic Surgery and The Society of Thoracic Surgeons. Between 1998 and 2007 inclusive, this nomenclature and database was used by both of these two organizations to analyze outcomes of over 150,000 operations involving patients undergoing surgical treatment for congenital cardiac disease. Two major multi-institutional efforts that have attempted to measure the complexity of congenital heart surgery are the Risk Adjustment in Congenital Heart Surgery-1 system, and the Aristotle Complexity Score. Current efforts to unify the Risk Adjustment in Congenital Heart Surgery-1 system and the Aristotle Complexity Score are in their early stages, but encouraging. Collaborative efforts involving The European Association for Cardio-Thoracic Surgery and The Society of Thoracic Surgeons are under way to develop mechanisms to verify the completeness and accuracy of the data in the databases. Under the leadership of The MultiSocietal Database Committee for Pediatric and Congenital Heart Disease, further collaborative efforts are ongoing between congenital and paediatric cardiac surgeons and other subspecialties, including paediatric cardiac anaesthesiologists, via The Congenital Cardiac Anesthesia Society, paediatric cardiac intensivists, via The Pediatric Cardiac Intensive Care Society, and paediatric cardiologists, via the Joint Council on Congenital Heart Disease and The Association for European Paediatric Cardiology. In finalizing our review, we emphasise that analysis of outcomes must move beyond mortality, and encompass longer term follow-up, including cardiac and non cardiac morbidities, and importantly, those morbidities impacting health related quality of life. Methodologies must be implemented in these databases to allow uniform, protocol driven, and meaningful, long term follow-up.

Institutional-Specific Risk Stratification of Children With Congenital Heart Disease Undergoing Noncardiac Procedures. What are the Risks of Anesthesia at Your Institution?

HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Personnel, Policy, Procedures and Follow-Up: A report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA) and the European Cardiac Arrhythmia Society (ECAS); in collaboration with the American College