Surgery For Congenital Heart Disease Research Articles

Empowering Little Fighters: Post-Cardiotomy Pediatric ECMO and the Journey to Recovery.

Extra Corporeal Membrane Oxygenation (ECMO) has long been used for cardiorespiratory support in the immediate post-paediatric cardiac surgery period with a 2-3% success as per the ELSO registry. Success in recovery depends upon the optimal delivery of critical care to paediatric patients and a comprehensive healthcare team. The survival benefit of children placed on central veno arterial (VA) ECMO following elective cardiac surgeries for congenital heart disease (n = 672) was studied in a cohort of 29 (4.3%) cases from the period of Jan 2018 to Dec 2022 in our cardiac surgical centre. Indications for placing these patients on central VA ECMO included inability to wean from cardiopulmonary bypass (CPB), low cardiac output syndrome, severe pulmonary arterial hypertension, significant bleeding, anaphylaxis, respiratory failure and severe pulmonary edema. The mean time to initiation of ECMO was less than 5 h and the mean duration of ECMO support was 56 h with a survival rate of 58.3%. Amongst perioperative complications, sepsis and arrhythmia on ECMO were found to be negatively associated with survival. Improvements in the pH, PaO2 levels and serum lactate levels after initiation of ECMO were associated with survival benefits. The early initiation of ECMO for paediatric cardiotomies could be a beacon of hope for families and medical teams confronting these challenging situations. Improvement in indicators of adequate perfusion and ventricular recoveries like pH and serum lactate and absence of arrhythmia and sepsis are associated with good outcomes.

Nosocomial Infections After Pediatric Congenital Heart Disease Surgery: Data from National Center for Cardiovascular Diseases in China.

Infection prevention and control (IPC) has a significant impact on the prognosis after pediatric cardiac surgery. This study aimed to provide surveillance data on the incidence and density of various infections during the COVID-19 epidemic and explore the influence of multi-drug resistant organisms (MDRO) on in-hospital prognosis after congenital heart disease surgery. This single-center retrospective study included pediatric patients who underwent cardiac surgery between 2021 and 2022. The results of the postoperative bacterial and fungal cultures and antimicrobial stewardship were collected. The demographic characteristics (age and weight), operation-related parameters (RACHS-1 grade, duration of cardiopulmonary bypass, and aortic cross clamp), and surgical outcomes (extracorporeal membrane oxygenation, delayed sternal closure, mortality, duration of mechanical ventilation, length of intensive care unit stay and hospital stay, and hospitalization costs) of MDRO and non-MDRO patients were compared. A total of 4776 patients were included. There were 101 infectious culture results after the operation, with a nosocomial infection rate of 2.1%. There were 40 MDRO specimens from 36 patients, 50 non-MDRO specimens from 30 patients, and 11 fungal specimens from 10 patients. The incidence of pneumonia was 1.5%, with a ventilator-associated pneumonia incidence density of 7.2/1000 patient-days. The incidence of sepsis was 0.4%, with a catheter-related bloodstream infection incidence density of 0.24/ 1000 patient-days. The incidence density of catheter-associated tract infection was 0.45/ 1000 patient-days. The incidence of surgical site infection was 0.06%. The culture proportion before commencing antibiotics was 93% and the antibiotic consumption intensity was 30.7 DDD/100 bed-days. The length of intensive care unit stay in MDRO infection patients increased compared with that in non-MDRO infection patients, 30 (18,52) vs 17 (7,62) days, p=0.05). The IPC performance of Fuwai Hospital achieved satisfactory results. MDRO infection can lead to prolonged intensive care unit stay.

Association of Vasoactive-Inotropic Score with Postoperative Outcomes in Children with Congenital Heart Diseases Undergoing Cardiac Surgery

Objectives: This cross-sectional study aimed to evaluate the association between the vasoactive-inotropic score (VIS) and post-operative morbidity and mortality in pediatric patients undergoing cardiac surgery for congenital heart diseases (CHDs). Methodology: A cross-sectional study was conducted at the Pediatric Cardiac Intensive Care Unit (PCICU) of the National Institute of Cardiovascular Diseases, Karachi, Pakistan, between October 2021 and March 2022. A total of 101 children up to 18 years of age admitted to the PCICU were included in the analysis. Demographic characteristics and peri-operative variables were recorded, and VIS scores were collected to assess their association with post-surgery outcomes. A score of ≥15 was considered high, while a score <15 was considered low. Results: Among the 101 children included in the study, 49 (48.5%) were male and 52 (51.5%) were female, with a mean age of 7.45±2.81 years. Fifteen (14.9%) patients had a high VIS score during their ICU stay, while 86 patients had a low VIS score. Low cardiac output was the most common post-operative morbidity observed in 9 (8.9%) children, followed by hepatic dysfunction and acute kidney injury, each reported in 8 (7.9%) children. Significant associations were found between high VIS and hepatic dysfunction (p<0.001), acute kidney injury (p<0.001), low cardiac output (p<0.001), neurological dysfunction (p=0.016), and mortality (p<0.001). Conclusion: High VIS scores were significantly associated with poor short-term morbidity and mortality in children undergoing corrective surgery for CHDs. The VIS system can aid in predicting disease progression, severity, and outcomes in pediatric cardiac surgical patients.

The Prevalence of Scoliosis after Fontan Circulation Surgery Followed-Up to Adolescence.

The advancement of surgical techniques and perioperative management for congenital heart disease (CHD) has increased life expectancy. The surgical creation of the Fontan circulation maintains pulmonary blood flow without relying on an effective pump from the abnormal heart, relying on peripheral vascular resistance to maintain effective flow through the lungs. Unfortunately, this delicate mechanism is compromised when scoliosis restricts ventilation, leading to Fontan failure and a poor prognosis for life. This report describes the prevalence of scoliosis with Fontan completion surgery and the role of screening and surgical correction. Ninety-six consecutive Japanese patients undergoing Fontan completion surgery for CHD between 2000 and 2017 were identified in our institutional records. The inclusion criterion was at least 7 years of follow-up after Fontan completion surgery, while the exclusion criteria were congenital, syndromic, and neuromuscular scoliosis. Radiographic and clinical parameters, including cardio-thoracic ratio (CTR) for cardiomegaly and cyanosis saturation, were compared between with and without scoliosis. There were 23 and 40 patients in the scoliosis and no scoliosis groups, respectively. The mean age at the final follow-up was 18.5 and 16.7 years in the scoliosis and no scoliosis groups, respectively (p=0.02). Mean CTR was 43.7% and 39.4% in the scoliosis and no scoliosis groups (p=0.016), and the mean saturation in room air at the final follow-up was 88.8% and 93.2%, respectively (p=0.036). There were no significant differences to clarify the risk factors with multivariate logistic regression analysis. The prevalence of scoliosis with Fontan completion surgery was 36.5%. Screening for scoliosis is important for children with Fontan circulation surgery as part of their routine follow-up at least until they reach adolescence.

The efficacy of nursing interventions in preventing surgical site infections in patients undergoing surgery for congenital heart disease.

Surgical site infections (SSIs) pose significant risks to patients undergoing surgery for congenital heart disease (CHD), impacting recovery and increasing healthcare burdens. This study assesses the efficacy of targeted nursing interventions in reducing SSIs and enhancing wound healing in this vulnerable patient group. A prospective cohort study was conducted from January 2022 to August 2023 at a single institution, involving 120 paediatric patients divided into control (standard postoperative care) and observation (specialized nursing interventions) groups. Nursing interventions included preoperative disinfection, strategic use of antibiotics, rigorous aseptic techniques and comprehensive postoperative care. Inclusion criteria encompassed a broad spectrum of CHD patients, while exclusion criteria aimed to minimize confounders. The Institutional Ethics Committee approved the study protocols. Baseline characteristics were comparable across groups, ensuring homogeneity. The observation group exhibited significantly lower SSI rates (1.7%) compared to the control group (11.6%), with a notable increase in optimal wound healing (Grade A) outcomes (73.3% vs. 30%). The differences in healing efficacy and infection rates between the two groups were statistically significant, emphasizing the effectiveness of the targeted nursing interventions in enhancing postoperative recovery for paediatric patients undergoing CHD surgery. The study demonstrates that targeted nursing interventions can significantly reduce SSI rates and improve wound healing in paediatric CHD surgery patients. These results underscore the importance of specialized nursing care in postoperative management. Future research, including larger-scale clinical trials, is necessary to validate these findings and develop comprehensive nursing care guidelines for this population.

Platelet reactivity in young children undergoing congenital heart disease surgery: a NITRIC randomized clinical trial substudy

IntroductionThe international NITRIC trial studied the hypothesis that nitric oxide (NO) applied into the cardiopulmonary bypass (CPB) oxygenator in infants would improve recovery after heart surgery. In a substudy, we evaluated the effect of NO applied into the CPB oxygenator on the (re)activity of platelets measured as fibrinogen binding (platelet aggregation) and P-selectin expression (platelet degranulation) in young children.MethodsPlatelet activity (without agonist exposure) and reactivity (after stimulation by an agonist) was studied in a single center substudy of the NITRIC trial, a multicenter, randomized trial that studied administration of 20 parts per million (ppm) NO during CPB in children younger than 2 years. Blood was collected at 4 time points (T1- T4); before CPB, after CPB start, before and after weaning. Flow cytometry-based platelet activity and reactivity in the presence of 5 agonists was tested. Differences on P-selectin expression and fibrinogen binding (median fluorescence intensity (MFI)) were analyzed with mixed effect modelling (MEM).ResultsBlood samples were obtained in 22 patients allocated to NO and 20 controls. Platelet counts dropped after T1 due to the hemodilution of blood in all patients (p < 0.001). Beta coefficients for NO allocation derived from the MEM models on fibrinogen binding and P-selectin expression were small (standardized beta coefficients on fibrinogen binding were 0.07[0.03, 0.11] and on P-selectin expression 0.05[0.03, 0.08]) and non-significant. CPB duration did not affect platelet reactivity (standardized beta coefficients 0.09[0.02, 0.12] with p > 0.27) in any of the MEMs.Conclusion20 ppm NO administration in the sweep gas of the CPB oxygenator did not affect platelet reactivity in young children undergoing heart surgery. Interestingly, duration of CPB exposure also did not have an effect on platelet (re)activity.Trial registrationANZCTR, ACTRN12617000821392. Registered 5 June 2017, https://anzctr.org.au/

Socioeconomic Influences on Outcomes Following Congenital Heart Disease Surgery.

Associations between social determinants of health (SDOH) and adverse outcomes for children with congenital heart disease (CHD) are starting to be recognized; however, such links remain understudied. We examined the relationship between community-level material deprivation on mortality, readmission, and length of stay (LOS) for children undergoing surgery for CHD. We performed a retrospective cohort study of patients who underwent cardiac surgery at our institution from 2015 to 2018. A community-level deprivation index (DI), a marker of community material deprivation, was generated to contextualize the lived experience of children with CHD. Generalized mixed-effects models were used to assess links between the DI and outcomes of mortality, readmission, and LOS following cardiac surgery. The DI and components were scaled to provide mean differences for a one standard deviation (SD) increase in deprivation. We identified 1,187 unique patients with surgical admissions. The median LOS was 11days, with an overall mortality rate of 4.6% and readmission rate of 7.6%. The DI ranged from 0.08 to 0.85 with a mean of 0.37 (SD 0.12). The DI was associated with increased LOS for patients with more complex heart disease (STAT 3, 4, and 5), which persisted after adjusting for factors that could prolong LOS (all p < 0.05). The DI approached but did not meet a significant association with mortality (p = 0.0528); it was not associated with readmission (p = 0.36). Community-level deprivation is associated with increased LOS for patients undergoing cardiac surgery. Future work to identify the specific health-related social needs contributing to LOS and identify targets for intervention is needed.

Institutional and Regional Variation in Opioid Prescribing for Hospitalized Infants in the US

High-risk infants, defined as newborns with substantial neonatal-perinatal morbidities, often undergo multiple procedures and require prolonged intubation, resulting in extended opioid exposure that is associated with poor outcomes. Understanding variation in opioid prescribing can inform quality improvement and best-practice initiatives. To examine regional and institutional variation in opioid prescribing, including short- and long-acting agents, in high-risk hospitalized infants. This retrospective cohort study assessed high-risk infants younger than 1 year from January 1, 2016, to December 31, 2022, at 47 children's hospitals participating in the Pediatric Health Information System (PHIS). The cohort was stratified by US Census region (Northeast, South, Midwest, and West). Variation in cumulative days of opioid exposure and methadone treatment was examined among institutions using a hierarchical generalized linear model. High-risk infants were identified by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes for congenital heart disease surgery, medical and surgical necrotizing enterocolitis, extremely low birth weight, very low birth weight, hypoxemic ischemic encephalopathy, extracorporeal membrane oxygenation, and other abdominal surgery. Infants with neonatal opioid withdrawal syndrome, in utero substance exposure, or malignant tumors were excluded. Any opioid exposure and methadone treatment. Regional and institutional variations in opioid exposure. Overall, 132 658 high-risk infants were identified (median [IQR] gestational age, 34 [28-38] weeks; 54.5% male). Prematurity occurred in 30.3%, and 55.3% underwent surgery. During hospitalization, 76.5% of high-risk infants were exposed to opioids and 7.9% received methadone. Median (IQR) length of any opioid exposure was 5 (2-12) cumulative days, and median (IQR) length of methadone treatment was 19 (7-46) cumulative days. There was significant hospital-level variation in opioid and methadone exposure and cumulative days of exposure within each US region. The computed intraclass correlation coefficient estimated that 16% of the variability in overall opioid prescribing and 20% of the variability in methadone treatment was attributed to the individual hospital. In this retrospective cohort study of high-risk hospitalized infants, institution-level variation in overall opioid exposure and methadone treatment persisted across the US. These findings highlight the need for standardization of opioid prescribing in this vulnerable population.

Associations between Child Opportunity Index and Pediatric Cardiac Surgical Outcomes

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. 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. 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 30days of hospital discharge in univariable (P<.094) and multivariable (P=.49) models. COI is associated with postoperative hospital length of stay but not all outcomes in patients aftercongenital heart surgery. By understanding the role of COI in outcomes related to cardiac surgery, targeted interventions can be developed to improve health equity.

Selected 2023 Highlights in Congenital Cardiac Anesthesia

This article reviews the highlights of pertinent literature of interest to the congenital cardiac anesthesiologist published in 2023. Following a search of the United States National Library of Medicine PubMed database, several topics emerged where significant contributions were made in 2023. The authors of this manuscript considered the following topics noteworthy to be included in this review: Advancements in percutaneous mechanical support in children with CHD, children with pulmonary hypertension undergoing surgery for congenital heart disease (CHD), Dexmedetomidine in pediatric cardiac surgery, and recommendations for pediatric heart surgery in the United States: Implications for pediatric cardiac anesthesia

Risk Factors of Chylothorax After Congenital Heart Surgery in Infants: A Single-Centre Retrospective Study.

Studies of chylothorax after congenital heart disease in infants are rare. Chylothorax has a higher incidence in infancy, but its risk factors are not well understood. The purpose of this study is to investigate the risk factors of chylothorax after congenital heart surgery in infants. This retrospective study included 176 infants who underwent congenital heart disease surgery at the Guangdong Cardiovascular Institute, China, between 2016 and 2020. According to the occurrence of chylothorax, the patients were divided into a control group (n = 88) and a case group (n = 88). Univariate and multivariate logistic regression were performed to analyse the incidence and influencing factors of chylothorax after congenital heart surgery in infants. Between 2016 and 2020, the annual incidence rate fluctuated between 1.55% and 3.17%, and the total incidence of chylothorax was 2.02%. Multivariate logistic regression analysis showed that postoperative albumin (p = 0.041; odds ratio [OR] = 0.095), preoperative mechanical ventilation (p = 0.001; OR = 1.053) and preterm birth (p = 0.002; OR = 5.783) were risk factors for postoperative chylothorax in infants with congenital heart disease. The total incidence of chylothorax was 2.02% and the annual incidence rate fluctuated between 1.55% and 3.17% between 2016 and 2020. Premature infants, longer preoperative mechanical ventilation and lower albumin after congenital heart surgery may be risk factors for chylothorax. In addition, infants with chylothorax are inclined to be infected, need more respiratory support, use a chest drainage tube for longer and remain longer in hospital.

Clinical characteristics and outcomes of patients who underwent neonatal cardiac surgery: ten years of experience in a tertiary surgery center

ObjectiveTo evaluate the outcomes after neonatal cardiac surgery at our institute, and identify factors associated with operative mortality.MethodsWe examined 224 neonates who underwent cardiac surgery at a single institution from 2013 to 2022. Relevant data, such as demographic information, operative details, and postoperative records, were gathered from medical and surgical records. Our primary focus was on the operative mortality.ResultsMedian age and weight at surgery were 12 (7–20) days and 3.4 (3.0–3.8) kg, respectively. Overall mortality was 14.3% (32/224). Mortality rates showed improvement over time (2013–2017 vs. 2018–2022), with rates decreasing from 21.9% to 10.6% (p = 0.023). ECMO use, extubation failure, lactate > 4.8 mmol/l and VIS > 15.5 on 24 h after operation were significantly associated with operative mortality, according to multivariate logistic regression analysis. Patients admitted to the cardiac intensive care unit (CICU) before surgery and those with prenatal diagnosis showed lower operative mortality. Median follow-up time of 192 hospital survivors was 28.0 (11.0–62.3) months. 10 patients experienced late deaths, and 7 patients required reinterventions after neonatal cardiac surgery. Risk factors for composite end-point of death and reintervention on multivariable analysis were: surgical period (HR = 0.230, 95% CI 0.081–0.654; p = 0.006), prolonged ventilation (HR = 4.792, 95% CI 1.296–16.177; p = 0.018) and STAT categories 3–5 (HR = 5.936, 95% CI 1.672–21.069; p = 0.006).ConclusionsOur institution has observed improved surgical outcomes in neonatal cardiac surgery over the past five years with low mortality, but late death and reintervention remain necessary in some patients. The location and prenatal diagnosis prior to surgery may affect the outcomes of neonates undergoing congenital heart disease operations.

The Association of High-Quality Hospital Use on Health Care Outcomes for Pediatric Congenital Heart Defects in a Universal Health Care System.

Congenital heart disease (CHD) has an incidence of 0.8% to 1.2% worldwide, making it the most common birth defect. Researchers have compared high-volume to low-volume hospitals and found significant hospital-level variation in major complications, health resource utilization, and mortality after CHD surgery. In addition, researchers found critical CHD patients at low-volume/non-teaching facilities to be associated with higher odds of inpatient mortality when compared to CHD patients at high-volume/teaching hospitals (odds ratio 1.76). We examined the effects of high-quality hospital (HQH) use on health care outcomes and health care costs in pediatric CHD care using an instrumental variable (IV) approach. Using nationwide representative claim data from the United States Military Health System from 2016 to 2020, TRICARE beneficiaries with a diagnosis of CHD were tabulated based on relevant ICD-10 (International Classification of Diseases, 10th revision) codes. We examined the relationships between annual readmissions, annual emergency room (ER) use, and mortality and HQH use. We applied both the naive linear probability model (LPM), controlling for the observed patient and hospital characteristics, and the two-stage least squares (2SLS) model, accounting for the unobserved confounding factors. The differential distance between the patient and the closest HQH at the index date and the patient and nearest non-HQH was used as the IV. This protocol was approved by the Institutional Review Board at the University of Maryland, College Park (Approval Number: 1576246-2). The naive LPM indicated that HQH use was associated with a higher probability of annual readmissions (marginal effect, 18%; 95% CI, 0.12 to 0.23). The naive LPM indicated that HQH use was associated with a higher probability of mortality (marginal effect, 2.2%; 95% CI, 0.01 to 0.03). Using the differential distance of closest HQH and non-HQH, we identified a significant association between HQH use and annual ER use (marginal effect, -14%; 95% CI, -0.24 to -0.03). After controlling for patient-level and facility-level covariates and adjusting for endogeneity, (1) HQH use did not increase the probability of more than one admission post 1-year CHD diagnosis, (2) HQH use lowered the probability of annual ER use post 1-year CHD diagnosis, and (3) HQH use did not increase the probability of mortality post 1-year CHD diagnosis. Patients who may have benefited from utilizing HQH for CHD care did not, alluding to potential barriers to access, such as health insurance restrictions or lack of patient awareness. Although we used hospital quality rating for congenital cardiac surgery as reported by the Society of Thoracic Surgeons, the contributing data span a 4-year period and may not reflect real-time changes in center performance. Since this study focused on inpatient care within the first-year post-initial CHD diagnosis, it may not reflect the full range of health system utilization. It is necessary for clinicians and patient advocacy groups to collaborate with policymakers to promote the development of an overarching HQH designation authority for CHD care. Such establishment will facilitate access to HQH for military beneficiary populations suffering from CHD.

Healthcare-associated infection management in 62 ICUs for patients with congenital heart disease in China: a survey study.

All patients with congenital heart disease (CHD) receive postoperative management in ICUs. Infection prevention and control (IPC) has a significant impact on prognosis. This study provides a preliminary understanding of the fundamental aspects of IPC in ICUs following CHD surgery in China. From September to October 2023, we initiated a survey on healthcare-associated infection (HAI) management in hospitals that perform CHD surgeries independently. The questionnaires were jointly completed by the ICU physicians and IPC personnel. Duplicate or unqualified questionnaires were excluded from the study. The contents of our questionnaires covered hospital and ICU capacity, performance of the infection control department, HAI surveillance, implementation of IPC measures, and antimicrobial stewardship (AMS). Qualified questionnaires were compared according to the volume of annual CHD surgeries performed in different ICUs. Group 1 was defined as volume more than 300 cases and group 2 was defined as volume less than or equal to 300 cases. Sixty-two of the 118 questionnaires were completed, with a response rate of 53%. The CHD surgical volume in 2022 of the 62 hospitals was 36342, accounting for 52% of the annual CHD surgical volume (69672) across the country. The postoperative infection rates obtained from the 15 ICUs varied from 1.3 to 15%, with a median rate of 4.5%. A total of 16 ICUs provided data on drug-resistant bacteria, Klebsiella pneumoniae exhibiting the highest frequency. More than 95% of ICUs have established complete HAI management systems. Information-based HAI surveillance was conducted in 89% of ICUs. Approximately 67% of ICUs stopped prophylactic antibiotics within 48 hours after surgery. In complex cases, carbapenems were administered empirically in 89% of ICUs. Group 1 had an advantage over group 2 in preventing multi-drug-resistant organisms (all instruments should be used alone 100% vs. 86%, P =0.047; cleaning and disinfection of environmental surfaces, 100% vs. 81%, P =0.035; antibiotic consumption control 85% vs. 61%, P =0.044) and in preventing surgical site infections (perioperative blood glucose monitoring, 88% vs. 67%, P =0.048). However, Group 1 did not perform well in preventing catheter-related bloodstream infection (delayed catheter removal due to convenience of laboratory tests, 31% vs. 6%, P =0.021) and catheter-associated urinary tract infection (delayed catheter removal due to muscle relaxant administration, 88% vs. 58%, P =0.022). A relatively complete HAI management system has been established throughout the country in ICUs for CHD patients. Information-based surveillance of HAI needs to be promoted, and actions should be taken to facilitate the implementation of IPC measures and AMS bundles. Training and feedback are critical for implementing IPC measures.

Nicardipine or Nitroprusside for Postoperative Blood Pressure Control in Infants After Surgery for Congenital Heart Disease: Single-Center Retrospective Noninferiority and Cost Analysis, 2016-2020.

Postoperative hypertension frequently occurs after surgery for congenital heart disease. Given safety concerns when using calcium channel blockers in infants along with the cost and side-effect profile of nitroprusside, we retrospectively assessed our experience of using nicardipine and nitroprusside for postoperative blood pressure control in infants who underwent surgery for congenital heart disease. We also investigated the cost difference between the medications. This study was a single-center retrospective, pre-post chart review of patients who had surgery for congenital heart disease between 2016 and 2020. The primary aim was a noninferiority comparison of achievement of blood pressure goal at 1-hour post-initiation of an antihypertensive agent. Secondary comparisons included achievement of blood pressure goal at 2 hours after medication initiation, Vasoactive-Inotropic Score (VIS), and blood transfusion, crystalloid volume, and calcium needs. Academic quaternary-care center. Infants under 1 year old who required treatment for hypertension with nitroprusside ( n = 71) or nicardipine ( n = 52) within 24 hours of surgery for congenital heart disease. None. We failed to identify any difference in proportion of patients that achieved blood pressure control at 1-hour after medication initiation (nitroprusside 52% vs. nicardipine 54%; p = 0.86), with nicardipine noninferior to nitroprusside within a 15% margin. Of patients who did not achieve control at 1-hour post-medication initiation, receiving nicardipine was associated with blood pressure control at 2 hours post-medication initiation (79% vs. 38%; p = 0.003). We also failed to identify an association between antihypertensive types and mean VIS scores, blood transfusion volumes, crystalloid volumes, and quantities of calcium administered. Index cost of using nitroprusside was 16 times higher than using nicardipine, primarily due to difference in wholesale cost. In our experience of achieving blood pressure control in infants after surgery for congenital heart disease (2016-2020), antihypertensive treatment with nicardipine was noninferior to nitroprusside. Furthermore, nicardipine use was significantly less expensive than nitroprusside. Our contemporary practice is therefore to use nicardipine in preference to nitroprusside.

Association Between Neighborhood Socioeconomic Factors and Length of Stay After Surgery for Congenital Heart Disease.

Neighborhood socioeconomic status, as measured by area deprivation index (ADI) is associated with longer length of stay (LOS) after surgery for hypoplastic left heart syndrome. We tested the hypothesis that LOS is associated with ADI in a large cohort of congenital heart disease (CHD) surgical cases of varying severity and sought to determine which other components of the ADI accounted for any associations. Retrospective analysis of a curated dataset. The Brokamp ADI was determined using residential addresses. Overall, ADI and each of its six individual components were dichotomized, and LOS compared between groups above versus below the median for the entire cohort and after stratifying by surgical The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) severity category. Single-center academic pediatric teaching hospital. CHD patients who underwent surgical repair/palliation between September 2007 and August 2022. None. A total of 2462 patients (52.7% male) were included. Median age was 254 (interquartile range [IQR] 95-1628) days and median LOS in the hospital was 8 (IQR 5-18) days. We failed to identify an association between Brokamp ADI, above versus below the median for the entire cohort, and LOS; nor in STAT categories 1-4. However, in STAT category 5 ( n = 129) those with ADI above the median (more deprived) had a significantly longer LOS (48 [20-88] vs. 36 [18-49] d, p = 0.034). Of the individual components of the ADI, only percent below poverty level and percent vacant houses were associated with LOS in STAT category 5. LOS after CHD surgery is associated with Brokamp ADI in STAT category 5 cases, we failed to identify an association in lower-risk cardiac operations.

Hospital Resources and Practice Patterns for Congenital Cardiac Surgery in Pakistan: A Nationwide Status Report.

Objective: Low- and middle-income countries such as Pakistan bear the brunt of the global burden of congenital heart disease (CHD), This nationwide study assessed hospital resources and surgical practice patterns pertaining to CHD surgery across Pakistan. Methods: A nationwide hospital facility survey was conducted, targeting all health centers performing CHD surgery in Pakistan. Descriptive data analysis was performed, with categorical variables being presented as frequencies and percentages and continuous variables being reported as means and standard deviations. Results: Seventeen surgeons across 17 different centers participated in the study. Eight of 17 (47%) surgeons were under 45 years of age, while the rest were older than 45 years. More respondents were employed at public/government-owned hospitals (11/17, 65%) and at specialized cardiac centers (13/17, 76%), with a majority of centers reported as having a special ICU designated for congenital cardiac patients (11/17, 65%). With regard to operative volume, 7 of 17 (41%) centers reported more than 350 cases per year, with 7 of 17 reported >10 neonatal cases per year (6/12, 50%). Only one center reported national and international collaborations for research, most centers carrying out less than five research projects in a year. Conclusion: This study has identified key areas that require the attention of local administrative bodies as well as international organizations and societies. The existing centers in Pakistan are unable to meet the demands of the population, leaving a large number of untreated patients, especially for neonatal lesions.

A Patient Similarity Network (CHDmap) to Predict Outcomes After Congenital Heart Surgery: Development and Validation Study.

Although evidence-based medicine proposes personalized care that considers the best evidence, it still fails to address personal treatment in many real clinical scenarios where the complexity of the situation makes none of the available evidence applicable. "Medicine-based evidence" (MBE), in which big data and machine learning techniques are embraced to derive treatment responses from appropriately matched patients in real-world clinical practice, was proposed. However, many challenges remain in translating this conceptual framework into practice. This study aimed to technically translate the MBE conceptual framework into practice and evaluate its performance in providing general decision support services for outcomes after congenital heart disease (CHD) surgery. Data from 4774 CHD surgeries were collected. A total of 66 indicators and all diagnoses were extracted from each echocardiographic report using natural language processing technology. Combined with some basic clinical and surgical information, the distances between each patient were measured by a series of calculation formulas. Inspired by structure-mapping theory, the fusion of distances between different dimensions can be modulated by clinical experts. In addition to supporting direct analogical reasoning, a machine learning model can be constructed based on similar patients to provide personalized prediction. A user-operable patient similarity network (PSN) of CHD called CHDmap was proposed and developed to provide general decision support services based on the MBE approach. Using 256 CHD cases, CHDmap was evaluated on 2 different types of postoperative prognostic prediction tasks: a binary classification task to predict postoperative complications and a multiple classification task to predict mechanical ventilation duration. A simple poll of the k-most similar patients provided by the PSN can achieve better prediction results than the average performance of 3 clinicians. Constructing logistic regression models for prediction using similar patients obtained from the PSN can further improve the performance of the 2 tasks (best area under the receiver operating characteristic curve=0.810 and 0.926, respectively). With the support of CHDmap, clinicians substantially improved their predictive capabilities. Without individual optimization, CHDmap demonstrates competitive performance compared to clinical experts. In addition, CHDmap has the advantage of enabling clinicians to use their superior cognitive abilities in conjunction with it to make decisions that are sometimes even superior to those made using artificial intelligence models. The MBE approach can be embraced in clinical practice, and its full potential can be realized.

The protocol of Enhanced Recovery After Cardiac Surgery (ERACS) in congenital heart disease: a stepped wedge cluster randomized trial

BackgroundThe Enhanced Recovery After Cardiac Surgery (ERACS) programs are comprehensive multidisciplinary interventions to improve patients’ recovery. The application of the ERAS principle in pediatric patients has not been identified completely.MethodsThis study is a multicenter, stepwise design, cluster randomized controlled trial. 3030 patients presenting during control and intervention periods are eligible if they are aged from 28 days to 6 years old and awaiting elective correction surgery of congenital heart disease with cardiopulmonary bypass. 5 centers are randomly assigned to staggered start dates for one-way crossover from the control phase to the intervention phase. In the intervention periods, patients will receive a bundle strategy including preoperative, intraoperative, and postoperative approaches. During the control phase, patients receive the usual care. The primary outcome consists of major adverse cardiac and cerebrovascular events (MACCEs), postoperative pulmonary complications (PPCs), and acute kidney injury (AKI).DiscussionThis study aims to explore whether the bundle of ERAS measurements could improve patients’ recovery in congenital heart surgery.Trial registrationhttp://www.clinicaltrials.gov. (NCT05914103).

Analysis of prescription compliance and influencing factors in cardiac rehabilitation after surgery in children with congenital heart disease based on generalized trust theory.

To understand the compliance, influencing factors, and action path of family cardiac rehabilitation exercise prescriptions for children after congenital heart disease surgery. A random sampling method was used to select 200 paediatric patients and their parents from a paediatric hospital in Shanghai. Among them, 57 cases (28.5%) of children's families followed the cardiac rehabilitation exercise prescription. Path analysis showed that peak oxygen uptake exerted a negative impact on the compliance of family cardiac-rehabilitation prescriptions for patients after congenital heart disease surgery through doctor-patient trust, with a standardized path coefficient of -0.246 (P = 0.001). Disease-related knowledge exerted a positive effect on the compliance of family cardiac-rehabilitation prescriptions for children after congenital heart surgery through doctor-patient trust, with a standardized path coefficient of 0.353 (P < 0.001). The dimension of friend support in social support had a direct positive effect on the compliance of family cardiac-rehabilitation prescriptions for children after cardiac surgery, with a standardized path coefficient of 0.641 (P = 0.006). The compliance of cardiac rehabilitation exercise prescription in children with congenital heart disease is not good and is affected by many factors, and there is a complex path relationship between various factors; the kilogram oxygen consumption of the child, the disease-related knowledge of the caregiver, and social support all play important roles in the compliance of the child's family's health prescription. ChiCTR2200062022.