Pediatric Congenital Heart Surgery Research Articles

Postoperative Organ Dysfunction Risk Stratification Using Extracellular Vesicle-Derived circRNAs in Pediatric Congenital Heart Surgery.

Breakthroughs in surgical and medical techniques have significantly improved outcomes for children with congenital heart disease (CHD), but research continues to address the ongoing challenge of organ dysfunction after surgery, particularly in neonates and infants. Our study explored circular RNAs (circRNAs) within plasma-derived extracellular vesicles (EVs) in neonates and infants undergoing CHD surgery. Post-surgery EV circRNAs showed dramatic expression changes between organ dysfunction (OD) and control groups. Tissue injury-related pathways were consistent across pre- and post-surgery in OD. The top two significant predicted tissue sources of these circRNAs originated from the respiratory system, aligning with the fact that all patients in the OD arm experienced respiratory dysfunction. Five of these circRNAs, namely circ-CELSR1, circ-PLXNA1, circ-OBSL1, circ-DAB2IP, and circ-KANK1, significantly correlated with PELOD (Pediatric Logistic Organ Dysfunction) score and demonstrated high performance (AUC = 0.95), supporting the potential of circRNAs as prognostic markers. These findings pave the way for EV circRNAs as promising tools for managing post-surgical organ dysfunction and potentially guiding therapeutic strategies in children with CHD.

Pilot Assessment of Platelet Thrombus Area and Contractile Force in Pediatric Congenital Heart Surgery Patients Using a Microfluidic Device

ObjectivesEvaluate maximum platelet contractile force and thrombus area before and after cardiopulmonary bypass (CPB) in pediatric patients having congenital heart disease (CHD) surgery using a microfluidic device. DesignProspective cohort study. SettingAcademic medical center. ParticipantsTwenty pediatric CHD patients ≤ 8 years of age with expected CPB time >30 minutes. InterventionsNone Measurements and Main ResultsBlood was collected at baseline and post-CPB. Maximum platelet contractile force and thrombus area were evaluated in vitro using a microfluidic device (ATLAS PST). Post-CPB samples were supplemented with recombinant von Willebrand Factor (rVWF) to explore impact on contractile force and thrombus area. At baseline, maximum thrombus area was 0.06 [0.05, 0.07] and maximum force was 123.3 nN [68.4, 299.5]. Linear mixed effects regression models showed that maximum thrombus area was larger post-CPB and post-CPB + rVWF compared to pre-CPB (Est=0.04, p=0.002 and Est = 0.09, p < .001, respectively). Maximum thrombus area was also larger post-CPB + rVWF compared to post-CPB (Est=0.04, p=0.001). Force was higher post-CPB + rVWF compared to pre-CPB (Est=173.32, p=0.044). ConclusionsIn pediatric CHD patients, microfluidic testing demonstrated that platelet thrombus area increased slightly after CPB, while platelet contractile force did not change. In vitro addition of rVWF further increased thrombus area, suggesting augmentation of primary hemostasis. Microfluidic assessment of platelet contractile force and thrombus area in pediatric CHD patients appears feasible and can demonstrate changes after CPB. Further studies are needed to determine its accuracy and clinical utility, as well as normal values for pediatric patients.

Risk Factors for Postoperative Chylothorax Occurrence Following Pediatric Congenital Heart Surgery

Objectives: Chylothorax, a rare but potentially life-threatening complication post congenital heart surgery, warrants early identification of risk factors to implement preventive strategies and timely interventions. This study aims to determine risk factors associated with chylothorax occurrence at our cardiac intensive care unit. Methods: We conducted a nested case-control study involving 2042 children who underwent congenital heart surgery at Nhi Dong 1 hospital (Ho Chi Minh City, Vietnam) from Feb 25th, 2015, to October 12th, 2019. Among these, 38 chylothorax cases were matched by sex and year of surgery to 76 randomly selected control patients. Univariate analysis and logistic regression were performed to identify independent factors associated with chylothorax occurrence after congenital heart surgery. Results: Neonatal cardiac surgery, RACHS-1 risk category ≥ 3, aortic arch repair, the arterial switch operation, prolonged bypass time (median 160 mins vs 87 mins) and aortic clamp time (median 89.5mins vs 51 mins), delayed sternal closure and unexpected reoperation were all associated with postoperative chylothorax occurrence on univariate analysis. Additionally, body weight &lt; 4.5 kg (p=0.027), postoperative dysrhythmias (p=0.004), and high volume of chest tube output (&gt; 10% of total expected blood volume) within the first 6 postoperative hours after cardiac intensive care unit admission (p=0.014) emerged as independent risk factors for postoperative chylothorax occurrence with odds ratios and 95% confident interval of 2.78 (1.12-6.87), 3.38 (1.29-8.86) &amp; 3.82 (1.55-9.39), respectively. These factors served as predictors of postoperative chylothorax occurrence with a sensitivity of 42.1%, specificity of 90.8%, positive predictive value of 69.6% and a negative predictive value of 75.8%. Conclusions: High chest tube output within the first 6 postoperative hours, postoperative dysrhythmias, and body weight of &lt; 4.5kg at surgery significantly increase the risk of postoperative chylothorax in our institution. Keywords: Postoperative chylothorax, chylothorax post pediatric cardiac surgery, pediatric chylothorax

Machine learning prediction model of major adverse outcomes after pediatric congenital heart surgery: a retrospective cohort study.

Major adverse postoperative outcomes (APOs) can greatly affect mortality, hospital stay, care management and planning, and quality of life. This study aimed to evaluate the performance of five machine learning (ML) algorithms for predicting four major APOs after pediatric congenital heart surgery and their clinically meaningful model interpretations. Between August 2014 and December 2021, 23000 consecutive pediatric patients receiving congenital heart surgery were enrolled. Based on the split date of 1 January 2019, the authors selected 13927 participants for the training cohort, and 9073 participants for the testing cohort. Four predefined major APOs including low cardiac output syndrome (LCOS), pneumonia, renal failure, and deep venous thrombosis (DVT) were investigated. Thirty-nine clinical and laboratory features were inputted in five ML models: light gradient boosting machine (LightGBM), logistic regression (LR), support vector machine, random forest, and CatBoost. The performance and interpretations of ML models were evaluated using the area under the receiver operating characteristic curve (AUC) and Shapley Additive Explanations (SHAP). In the training cohort, CatBoost algorithms outperformed others with the mean AUCs of 0.908 for LCOS and 0.957 for renal failure, while LightGBM and LR achieved the best mean AUCs of 0.886 for pneumonia and 0.942 for DVT, respectively. In the testing cohort, the best-performing ML model for each major APOs with the following mean AUCs: LCOS (LightGBM), 0.893 (95% CI: 0.884-0.895); pneumonia (LR), 0.929 (95% CI: 0.926-0.931); renal failure (LightGBM), 0.963 (95% CI: 0.947-0.979), and DVT (LightGBM), 0.970 (95% CI: 0.953-0.982). The performance of ML models using only clinical variables was slightly lower than those using combined data, with the mean AUCs of 0.873 for LCOS, 0.894 for pneumonia, 0.953 for renal failure, and 0.933 for DVT. The SHAP showed that mechanical ventilation time was the most important contributor of four major APOs. In pediatric congenital heart surgery, the established ML model can accurately predict the risk of four major APOs, providing reliable interpretations for high-risk contributor identification and informed clinical decisions-making.

A randomized controlled double-blinded study of dexmedetomidate in preventing intra operative and post-operative arrythymias in pediatric congenital heart surgery

A randomized controlled double-blinded study of dexmedetomidate in preventing intra operative and post-operative arrythymias in pediatric congenital heart surgery

Challenges of Congenital Heart Surgery in Brazil: It is Time to Designate Pediatric Congenital Heart Surgery Subspecialty.

Congenital heart disease (CHD) affects eight to ten out of every 1,000 births, resulting in approximately 23,057 new cases in Brazil in 2022. About one in four children with CHD requires surgery or other procedures in the first year of life, and it is expected that approximately 81% of these children with CHD will survive until at least 35 years of age. Professionals choosing to specialize in CHD surgery face numerous challenges, not only related to mastering surgical techniques and the complexity of the diseases but also to the lack of recognition by medical societies as a separate subspecialty. Furthermore, families face difficulties when access to services capable of providing treatment for these children. To address these challenges, it is essential to have specialized hospitals, qualified professionals, updated technologies, sustainable industry, appropriate financing, quality assessment systems, and knowledge generation. The path to excellence involves specialization across all involved parties. As we reflect on the importance of Pediatric Cardiovascular Surgery and Congenital Heart Diseases establishing themselves as a subspecialty of Cardiovascular Surgery, it is essential to look beyond our borders to countries like the United States of America and United Kingdom, where this evolution is already a reality. This autonomy has led to significant advancements in research, education, and patient care outcomes, establishing a care model. By following this path in Brazil, we not only align our practice with the highest international standards but also demonstrate our maturity and the ability to meet the specific needs of patients with CHD and those with acquired childhood heart disease.

Intraoperative Transfusion of Autologous Blood Protects from Acute Kidney Injury after Pediatric Congenital Heart Surgery.

Acute kidney injury (AKI) is a common complication after pediatric cardiac surgery. And autologous blood transfusion (ABT) is an important predictor of postoperative AKI. Unlike previous studies, which mainly focused on the correlation between ABT and AKI, the current study focuses heavily on the causal relationship between them, thus providing guidance for the treatment of patients during hospitalization to reduce the occurrence of AKI. A retrospective cohort of 3386 patients extracted from the Pediatric Intensive Care database was used for statistical analysis, multifactorial analysis, and causal inference. Characteristics that were correlated with ABT and AKI were categorized as confounders, instrumental variables, and effect modifiers, and were entered into the DoWhy causal inference model to determine causality. The calculated average treatment effect (ATE) was compared with the results of the multifactorial analysis. The adjusted odds ratio (OR) for ABT volume was obtained by multifactorial analysis as 0.964. The DoWhy model refute test was able to indicate a causal relationship between ABT and AKI. Any ABT reduces AKI about 15.3%-18.8% by different estimation methods. The ATE regarding the amount of ABT was -0.0088, suggesting that every 1 mL/kg of ABT reduced the risk of AKI by 0.88%. Intraoperative transfusion of autologous blood can have a protective effect against postoperative AKI.

Aerosolized lidocaine to reduce tracheal suction-associated pain after pediatric congenital heart surgery: A randomized, double-blind, placebo-controlled trial

BackgroundIn children undergoing heart surgery for congenital heart disease (CHD), postoperative pain is associated with changes in the respiratory system that can lead to complicated courses and poor outcomes. Respiratory therapy (RT) can restore respiratory function through manual techniques and tracheal suction (TS). However, TS itself can cause pain, leading to hemodynamic and respiratory manifestations, such as tachycardia, hyper- or hypotension, tachypnea, increased work-of-breathing, patient-ventilator asynchrony, among others. ObjectivesThe aim of this study was to investigate whether RT/TS increases pain and whether inhaled lidocaine can attenuate pain increase in infants and children undergoing surgery for CHD. MethodsDouble-blind, randomized, placebo-controlled trial at a pediatric intensive care unit in a Brazilian tertiary-care university hospital. Patients <18 years submitted to open-heart surgery for CHD were included and randomized to receive either aerosolized lidocaine (1 mg/kg) or placebo before RT/TS. Pain was assessed by the Face, Legs, Activity, Cry, Consolability pain scale – revised (FLACC-R), along with hemodynamic and ventilatory parameters, before and 10 min after RT/TS start on postoperative days 1, 3, and 7 given they were on mechanical ventilation. Results119 patients were included. RT/TS induced minor changes in pain, which were not attenuated by lidocaine (confirmed in multivariate analysis). RT/TS also caused minor, clinically not relevant effects in hemodynamic and ventilatory parameters, which were also not modified by lidocaine. ConclusionRespiratory therapy with tracheal suction did not increase postoperative pain in ventilated children after congenital heart surgery until the 7th day, nor did aerosolized lidocaine exhibit any clinically significant effect on pain or other hemodynamic or ventilatory parameters.Registered at REBEC: RBR-10vtd55m.

Evaluation and comparison of patch materials used for pulmonary arterioplasty in pediatric congenital heart surgery

ObjectiveTo evaluate the long-term performance of the patch materials we have used to augment the pulmonary arterial tree across a wide spectrum of diagnoses and anatomical locations. MethodsRetrospective, single-center review of 217 consecutive pediatric patients at a tertiary referral center from 1993 to 2020 who underwent patch arterioplasty of the pulmonary arterial tree from the pulmonary bifurcation to the distal pulmonary arterial branches. Reintervention data were collected and analyzed. Lesion-specific anatomy and other variables were analyzed as risk factors for reintervention. ResultsThere were 280 total operations performed (217 initial operations and 63 reoperations) and 313 patches used. The patches used were autologous pericardium (166, 53.0%), pulmonary homograft (126, 40.3%), and a heterogeneous group of other materials (21, 6.7%). Overall patient survival was 86.2%, freedom from reoperation was 81.0% and freedom from reintervention (FFR) was 70.6%, with a median follow-up of 13.8 years (interquartile range, 6.3-17.9 years). For all patches, 10-, 20-, and 27-year FFR was 76.6%, 70.6%, and 70.6%, respectively. FFR was similar among all 3 patch type groups (P = .29). Multivariable Cox regression analysis showed that diagnoses of pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries and hypoplastic left heart syndrome, patches placed at initial cardiac operation, and increasing number of cardiac operations were risk factors for reintervention. ConclusionsAutologous pericardium and pulmonary homograft patches performed similarly. Although patch type conferred no difference in need for reintervention, other risk factors did exist. Namely, diagnoses of pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries and hypoplastic left heart syndrome, patch placement at a patient's first cardiac operation, and increasing number of cardiac operations were risk factors for reintervention.

Is Dexmedetomedine the Jack of all perioperative trades?

Since it was first approved by the Food and Drug Administration in 1999 and in 2011 by the European Union, dexmedetomidine (DEX) has gained widespread use first in adults and later paediatric patients undergoing cardiac surgery. And considering this α2-adrenoceptor agonist’s side-effect profile, it is no wonder its perioperative application continues to increase. As an analgosedative that does not depress respiration, DEX’s beneficial properties extend from anaesthetic- and analgetic-sparing effects [1] enabling early extubation to delirium prophylaxis and overall faster recovery after surgery. Administering DEX is believed to reduce adverse neurocognitive outcomes in adults undergoing cardiovascular surgery [2]. Consistent with those findings, a recent meta-analysis on paediatric congenital heart surgery [3] reported reduced levels of S-100β and NSE, markers for postoperative cognitive function. In this issue, Bourgoin et al. [4] describe the efficacy of intraoperative high-dose DEX, administration that resulted in an 8.8% reduction in postoperative tachyarrhythmias in neonates and infants undergoing congenital heart surgery. They also confirmed a sparing effect for other analgesics, and a tendency towards shorter intubation time.

Haemodynamic effects of prophylactic post-operative hydrocortisone following cardiopulmonary bypass in neonates undergoing cardiac surgery.

Multiple studies have endeavoured to define the role of steroids in paediatric congenital heart surgery; however, steroid utilisation remains haphazard. In September, 2017, our institution implemented a protocol requiring that all neonates undergoing cardiac surgery with the use of cardiopulmonary bypass receive a five-day post-operative hydrocortisone taper. This single-centre retrospective study was designed to test the hypothesis that routine post-operative hydrocortisone administration reduces the incidence of capillary leak syndrome, leads to favourable postoperative fluid balance, and less inotropic support in the early post-operative period. Data were gathered on all term neonates who underwent cardiac surgery with the use of bypass between September, 2015 and 2019. Subjects who were unable to separate from bypass, required long-term dialysis, or long-term mechanical ventilation were excluded. Seventy-five patients met eligibility criteria (non-hydrocortisone group = 52; hydrocortisone group = 23). For post-operative days 0-4, we did not observe a significant difference in net fluid balance or vasoactive inotropic score between study groups. Similarly, we saw no major difference in secondary clinical outcomes (post-operative duration of mechanical ventilation, ICU/hospital length of stay, and time from surgery to initiation of enteral feeds). In contrast to prior analyses, our study was unable to demonstrate a significant difference in net fluid balance or vasoactive inotropic score with the administration of a tapered post-operative hydrocortisone regimen. Similarly, we saw no effect on secondary clinical outcomes. Further long-term randomised control studies are necessary to validate the potential clinical benefit of utilising steroids in paediatric cardiac surgery, especially in the more fragile neonatal population.

Antithrombin substitution practice in pediatric cardiac surgery: A European survey.

The antithrombin concentration of neonates is approximately half that of adults. Low preoperative antithrombin concentration in this population have been associated with increased transfusion requirements.1 Similarly, low antithrombin concentration result in poor response to unfractionated heparin and inability to establish adequate anticoagulation during extracorporeal circulation (e.g., cardiopulmonary bypass, CPB), placing patients at risk for thrombosis.2 Despite obvious mode of action, there are no well-described clinical benefits of antithrombin usage in clinical practice. The aim of this survey was to identify the practice of antithrombin usage in pediatric cardiac surgery across Europe. The authors developed a 55-item electronic questionnaire to evaluate the following areas: the local practice of antithrombin management and substitution, including antithrombin monitoring and target levels, antithrombin administration techniques, and monitoring of anticoagulation. The survey was endorsed by the European Association of Cardiothoracic Anesthesiology and Intensive Care (EACTAIC) and distributed among its members. Respondents had to identify themselves as pediatric cardiac anesthetists before they were allowed to enter the questionnaire. A total of 118 responses were received. The half of respondents confirmed that they were currently working as pediatric cardiac anesthesiologists and were allowed to participate in the survey. Sixty-eight percent of participants (39/57) regularly measure antithrombin concentration and 79% (31/39) regularly substitute antithrombin in different pathophysiological scenarios in pediatric congenital heart surgery (Table 1). Thirty-two percent (12/37) substitute antithrombin in all cardiac surgery cases with low antithrombin concentration. In the setting of CPB, 41% (15/37) substitute antithrombin. In patients <6 months of age scheduled for cardiac surgery, half of the respondents (54%, 20/37) not routinely substitute antithrombin. In pediatric patients with low antithrombin concentration on veno-arterial extracorporeal membrane oxygenation (ECMO), 78% (29/37) replace antithrombin. In all cardiac patients (with or without cardiac surgery), more than 65% (21/32) of respondents measure antithrombin concentration only when specifically indicated, 28% (9/32) before administration, and 25% (8/32) preoperatively (in case of cardiac surgery). In patients on veno-arterial ECMO, 50% (16/32) measure antithrombin once daily, 31% (10/32) before administration, 28% (9/32) only on specific indication, 25% (8/32) after administration or before ECMO implantation, respectively. The primary strategy for antithrombin concentration below target was immediate substitution in 54% (14/26) of respondents. Twenty-seven (7/26) percent opted for repeated measurements to make a final decision. In a situation with low antithrombin concentration and known heparin resistance, 100% (31/31) of responders substitute antithrombin. In a situation with known heparin resistance and unmeasured antithrombin concentration, half of the participants (52%, 16/31) did not substitute antithrombin. In unclear clinical situations with suspected low antithrombin concentration (e.g., disseminated intravascular coagulation), 77% (24/31) did not substitute antithrombin without a previous level measurement. Antithrombin substitution occurred in 66% (18/27) using calculations as provided by the manufacturer, in 22% (6/27) using a standard dose (e.g., 500 U antithrombin concentrate), and in 11% (3/27) using a calculation based on a custom formula. Antithrombin substitution - YES - Antithrombin substitution - NO - Antithrombin substitution - no answer - In this European survey examining the use of antithrombin in pediatric cardiac patients, we found widespread use of antithrombin measurement and substitution strategies. The most important areas for antithrombin monitoring and substitution were ECMO, in patients with inadequate elevation of activated clotting time during cardiac surgery with CPB, and in patients with known heparin resistance in combination with low antithrombin concentration. The most common consensus in the literature regarding antithrombin administration is inadequate response to heparin.3, 4 In our survey, antithrombin was substituted in all cases when a low antithrombin concentration was present in combination with detected heparin resistance. Regarding the use of antithrombin in different procedures without surgery, this study confirms large differences between institutions. One possible explanation is the lack of evidence in the literature for the use of antithrombin in specific cardiac lesions including specific cardiac surgery populations as for example cyanotic patients with high hematocrit. This survey underlines again the need for further, adequately powered studies regarding antithrombin monitoring and substitution in the pediatric cardiac patients undergoing surgery or interventions. Data sharing is not applicable to this article as no new data were created or analyzed in this study.

Determinants of Acute Kidney Injury in Children Undergoing Cardiopulmonary Bypass: Single-Center Experience in Saudi Arabia.

Introduction Cardiopulmonary bypass (CPB) is a machine used in open cardiac surgeries and has been linked to many complications, one of which is acute kidney injury (AKI). Also, the Kidney Disease Improving Global Outcomes (KDIGO) criteria are used to diagnose AKI in the pediatric population. The study aimed to investigatethe association between cardiopulmonary bypass duration and renal function impairment in pediatric patients who had cardiac surgery. Methods Thiswas an observational, cross-sectional study conducted at the King Abdulaziz Medical City, King Faisal Cardiac Center, the section of the Pediatric Cardiac Intensive Care Unit (PICU), Ministry of National Guard Health Affairs, from January 2016 to December 2019. Patients younger than 14 years old, those having a cardiac surgery where CPB was implemented, normal pre-operative kidney functions, and having a cardiac surgery longer than 60 minutes (min) were included. The exclusion criteria were patients known to have pre-operative renal impairment and patients with pre-operative hemodynamic instability or cardiac arrest. Demographics ofpre-operative, intra-operative, andpost-operativedatawere extracted, and Statistical Package for the Social Sciences (SPSS) version 25 (Armonk, NY: IBM Corp.) was used for analysis. For descriptive statistics, frequencies and percentages for qualitative data were examined, while mean and standard deviation (SD) or median and interquartile range (IQR) quantitativedata were used accordingly. Student's t-test,Mann-Whitney(median test), chi-square, or Fisher's exact tests were used for univariate analysis accordingly. Logistic regression analysis was used to determine significant predictors for developing AKI. A p-value of <0.05 would be considered significant. Results Of the 111 patients,87 patients were included in the analysis. The median age was six months, IQR two to 13 months, body mass index (BMI) mean of 13.8, and SD 3.6. There was similar sex distribution, male 47.1% vs. female 52.9%. There were no patients in Risk Adjustment for Congenital Heart Surgery (RACHS) who scored 5 or 6. The AKI prevalence was 31% (27/87) within three days after surgery. One patient had stage 2 AKI; the rest were mild. One patient (3.7%) died. The CPB time was significantly longer in patients who developed AKI 150 (104-202), vs. non-AKI 104(82-142) min, p=0.004. In the AKI group, the mean baseline (pre-operative) serum creatinine (sCr) was significantly lower, whereas, it was significantly higher at 24 hours (h), and 48 hpost-operation (p=0.001, 0.001, and 0.036, respectively). Additionally, the estimated Glomerular Filtration Rate (eGFR) was significantly higher in the AKI group at 24 h(p=0.007). In logistical regression analysis, CPB time (per minunit time) was a significant predictor for developing AKI, OR 1.015, p=0.011 as a measured outcome. However, only CPB time >180 minwas highly significant with OR 16.2, p=00.6 compared to CPB time 121-180 minOR 2.3, p=0.29 and CPB time 91-120 minOR 1.2, p=0.84. Conclusion Acute kidney injury is an expected complication of pediatric congenital heart surgery receiving CPB. Although in our single-center experience, CPB duration was a significant predictor for AKI; however, it is considered a mild complication that does not contribute significantly to short-term morbidity or mortality. A larger multicenter, national prospective data registryis recommended to explore long-term effects.

Abstract 11922: The Independent Effects of Race/Ethnicity and Local Childhood Opportunity on Outcomes in Pediatric Congenital Heart Surgery

Background: Disparities in congenital heart disease (CHD) outcomes based on race/ethnicity and social determinants of health coexist. We sought to determine the independent effects of these factors on outcomes after pediatric CHD surgery. Methods: Pediatric Health Information System encounters age &lt;18 years from 2003-2022 with ICD9/10 codes for CHD and cardiac surgery were linked to Zip Code-level Childhood Opportunity Index (COI), a score of neighborhood educational, environmental, and socioeconomic conditions. Independent effects of race/ethnicity and COI quintile on the outcome of death during surgical hospitalization were modeled with generalized estimating equations. Survival in neonates was modeled with Cox PH regression. Results: Of 193,028 encounters at 46 centers, Black, Asian, and Other groups had increased adjusted mortality compared to Non-Hispanic (NH) White. Compared to the middle COI quintile, the lowest quintile had a higher adjusted risk of death and the highest quintile was protective (Table 1a). In survival analysis of neonates (n=47,649; median follow-up 1.1 years), Black, Asian, and “Other” groups had worse survival than NH-White even after adjustment for COI quintile (Table 1b, Figure 1). Conclusions: Black, Asian, and “Other” children have increased in-hospital death after CHD surgery independent of local opportunity. Medium-term survival after neonatal surgery is similarly influenced, suggesting local opportunity is influential even at birth. Policies to improve local social determinants of health may improve outcomes, but persistent negative effects of minority status may be explained by other unmeasured forms of structural racism.

Octreotide for Acquired Chylothorax in Pediatric Patients Post-Cardiothoracic Surgery for Congenital Heart Disease: A Systematic Review.

Chylothorax is a life-threatening complication post-corrective congenital heart surgery. Octreotide is used for treatment of refractory chylothoraces, with no standardized treatment protocol and a paucity of literature describing its efficacy. Our aim was to provide an update on the safety and efficacy of octreotide for the treatment of refractory chylothoraces in neonatal and pediatric patients' post-corrective congenital heart surgery. We performed a systematic review of PubMed, Medline, CINAHL, and Cochrane Library databases. Only intravenous octreotide treatment was included. A total of 621 patients across 27 studies were included. Studies included were 11 case series, 5 case studies, and 11 retrospective cohort studies. Variation in treatment regimens were reported. Treatment efficacy was reported in 95% (23/27) of studies. Definitions of treatment efficacy were reported in 33% (9/27) of studies. No prospective or randomized control trials were available for inclusion. Octreotide efficacy is widely reported despite a lack of standardization on criteria for treatment initiation or what defines an appropriate response to therapy.Please check and confirm whether the edit made to the article title is in order.Yes.

Long-Term Follow-Up of Right Ventricle to Pulmonary Artery Biologic Valved Conduits Used in Pediatric Congenital Heart Surgery

Valved conduit reconstruction between the right ventricle (RV) and the pulmonary circulation is often necessary in the surgical treatment of complex congenital heart defects. The aim of this study is to evaluate the long-term performance of the three types of conduits we have used and assess risk factors for conduit failure. Retrospective, single-center review of 455 consecutive pediatric patients with 625 conduits from 1990 to 2019 undergoing RV-to-pulmonary artery (PA) reconstruction with a valved conduit. The three conduit types investigated were pulmonary homograft, aorta homograft, and bovine jugular vein (BJV) graft. Overall patient survival was 91.4%, freedom from conduit replacement (FCR) was 47.4%, and freedom from reintervention (FFR) was 37.8% with a median follow-up of 8.7 years (interquartile range 4.3–13.3 years). For pulmonary homografts, 10-, 20-, and 28-year FCR was 79.6%, 68.6%, and 66.0%, respectively. For aortic homografts, 10-, 20-, and 30-year FCR was 49.8%, 31.5%, and 23.0%, respectively. For BJV grafts, 10- and 19-year FCR was 68.1% and 46.0%, respectively. When controlling for baseline variables, FCR was similar for pulmonary homografts and BJV grafts. Overall patient survival was excellent. Risk factors for conduit failure in patients operated with reconstruction of the RV-PA outflow tract included low age, low weight, small conduit size, and certain cardiac diagnoses. There was no evidence for a shorter life span of the second graft. Pulmonary homografts and BJV grafts performed similarly but the risk of endocarditis was greater in the BJV group.

Selected 2021 Highlights in Congenital Cardiac Anesthesia

This article is a review of the highlights of pertinent literature of interest to the congenital cardiac anesthesiologist and was published in 2021. After a search of the United States National Library of Medicine PubMed database, several topics emerged where significant contributions were made in 2021. The authors of this manuscript considered the following topics noteworthy to be included in this review: risk stratification in adult congenital heart disease surgery, physician burnout in pediatric cardiac anesthesia, transfusion practice in pediatric congenital heart surgery, and racial disparity and outcomes in pediatric patients with congenital heart disease.

A Randomized Clinical Trial of Perfusion Modalities in Pediatric Congenital Heart Surgery Patients

BackgroundThe objective of this randomized clinical trial was to investigate the effects of perfusion modalities on cerebral hemodynamics, vital organ injury, quantified by the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) Score, and clinical outcomes in risk-stratified congenital cardiac surgery patients. MethodsThis randomized clinical trial included 159 consecutive congenital cardiac surgery patients in whom pulsatile (n = 83) or nonpulsatile (n = 76) perfusion was used. Cerebral hemodynamics were assessed using transcranial Doppler ultrasound. Multiple organ injury was quantified using the PELOD-2 score at 24, 48, and 72 hours. Clinical outcomes, including intubation time, intensive care unit length of stay (LOS), hospital LOS, and mortality, were also evaluated. ResultsThe Pulsatility Index at the middle cerebral artery and in the arterial line during aortic cross-clamping was consistently better maintained in the pulsatile group. Demographics and cardiopulmonary bypass characteristics were similar between the 2 groups. While risk stratification with The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) Mortality Categories was similar between the groups, Mortality Categories 1 to 3 demonstrated more patients than Mortality Categories 4 and 5. There were no differences in clinical outcomes between the groups. The PELOD-2 scores showed a progressive improvement from 24 hours to 72 hours, but the results were not statistically different between the groups. ConclusionsThe Pulsatillity Index for the pulsatile group demonstrated a more physiologic pattern compared with the nonpulsatile group. While pulsatile perfusion did not increase plasma-free hemoglobin levels or microemboli delivery, it also did not demonstrate any improvements in clinical outcomes or PELOD-2 scores, suggesting that while pulsatile perfusion is a safe method, it not a “magic bullet” for congenital cardiac operations.

Incidence of Medical Adhesive–Related Skin Injuries and Associated Factors After Pediatric Congenital Heart Surgery

PURPOSE: The aim of this study was to identify the incidence, characteristics, and factors associated with medical adhesive–related skin injuries (MARSI). DESIGN: Prospective cohort study. SUBJECTS AND SETTINGS: The sample comprised 136 children in the postoperative period after congenital heart surgery. The study setting was in a 31-bed pediatric surgical intensive care unit (ICU) of a university hospital in Sao Paulo, Brazil. METHODS: Patients were followed from admission, with daily skin assessments, until the onset of MARSI or ICU discharge. Outcomes were compared by Fisher's exact test, Pearson's χ2 test, Mann-Whitney test, Brunner-Munzel test, and Welch 2-sample t test. RESULTS: The incidence of MARSI was 60.3%, with 85 injuries in 82 patients. The highest occurrence was on postoperative day 2 (27 wounds; 31.8%). The most frequent medical adhesive associated with MARSI was transparent film dressing (n = 74; 86.6%). Factors associated with MARSI were age (P = .000), number of devices inserted (P = .000), Braden Q Scale score (P = .005), duration of surgery (P = .021), cardiopulmonary bypass duration (P = .000), duration of mechanical ventilation (P = .000), and length of ICU stay (P = .000). Children who developed MARSI received more blood components (P = .039), vasopressors (P = .000), and corticosteroids (P = 0.000); required longer sedation (P = .000); and had more edema (P = .001). CONCLUSION: This high incidence indicates the need for greater awareness and prompt action in response to MARSI. Polyurethane transparent film without concurrent use of a skin barrier product should be avoided.

Development of the ICF-CY Set for Cardiac Rehabilitation After Pediatric Congenital Heart Surgery.

BackgroundMost children with congenital heart disease (CHD) require surgical repair, and postoperative rehabilitation is an essential step to restore the quality of life. The present study constructs and confirms the International Classification of Functioning, Disability, and Health for Children and Youth core set for children with congenital heart disease 1 year after surgery (ICF-CY-CHDS).MethodsFrom February 2021 to August 2021, 340 children aged 3–6 years after CHD surgery were evaluated using the ICF-CY-CHDS and analyzed using the Rasch model.ResultsThe final ICF-CY-CHDS contained 22 categories; it exhibited a nonsignificant χ2 test result for the item-trait interaction (χ2 = 6736.37, p = 0.8660, Bonferroni-adjusted p = 0.0023). The average severity of children was less than the average difficulty of categories (−2.26 logit <0 logit). The weighted k of all the categories was 0.964 (p < 0.001), and the item separation index was 0.96. The area under the ROC curve of children with a diagnosis result of heart failure was 0.866 (95% CI: 0.801 ~0.931) with good sensitivity (0.875) and specificity (0.759).ConclusionThe ICF-CY-CHDS presents a preliminary practical direction during early cardiac rehabilitation after pediatric CHD surgery, and thus provides a basis and scope for clinical evaluation and intervention program formulation.