Publications by authors named "Nancy S Ghanayem"

99 Publications

Relationship between gestational age and outcomes after congenital heart surgery.

Ann Thorac Surg 2020 Oct 17. Epub 2020 Oct 17.

University of California-San Francisco, CA.

Background: Previous studies suggest that birth prior to 39 weeks gestational age (GA) is associated with higher perioperative mortality and morbidity after congenital heart surgery. The optimal approach to timing of surgery in premature infants remains unclear. We investigated the impact of GA at birth and corrected GA at surgery on post-operative outcomes using the Pediatric Cardiac Critical Care Consortium (PC) database.

Methods: Infants undergoing selected index cardiac operations before the end of the neonatal period were included (n=2,298). GA at birth and corrected GA at the time of index cardiac surgery were used as categorical predictors and fitted as a cubic spline to assess non-linear relationships. The primary outcome was hospital mortality. Multivariable logistic regression models assessed the association between predictors and outcomes while adjusting for confounders.

Results: Late-preterm birth (34-36 weeks) was associated with increased odds of mortality compared to full-term (39-40 weeks) birth while early-term birth (37-38 weeks) was not associated with increased mortality. Corrected GA at surgery of 34-37 weeks compared to 40-44 weeks was associated with increased mortality. When analyzing corrected GA at surgery as a continuous predictor of outcome, odds of survival improve as patients approach 39 weeks corrected GA.

Conclusions: Contrary to previous literature, we did not find an association between early-term birth and hospital mortality at PC hospitals. Our analysis of the relationship between corrected GA and mortality suggests that operating closer to full-term corrected GA may improve survival.
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http://dx.doi.org/10.1016/j.athoracsur.2020.08.027DOI Listing
October 2020

Interstage Home Monitoring for Infants With Single Ventricle Heart Disease: Education and Management: A Scientific Statement From the American Heart Association.

J Am Heart Assoc 2020 08 11;9(16):e014548. Epub 2020 Aug 11.

This scientific statement summarizes the current state of knowledge related to interstage home monitoring for infants with shunt-dependent single ventricle heart disease. Historically, the interstage period has been defined as the time of discharge from the initial palliative procedure to the time of second stage palliation. High mortality rates during the interstage period led to the implementation of in-home surveillance strategies to detect physiologic changes that may precede hemodynamic decompensation in interstage infants with single ventricle heart disease. Adoption of interstage home monitoring practices has been associated with significantly improved morbidity and mortality. This statement will review in-hospital readiness for discharge, caregiver support and education, healthcare teams and resources, surveillance strategies and practices, national quality improvement efforts, interstage outcomes, and future areas for research. The statement is directed toward pediatric cardiologists, primary care providers, subspecialists, advanced practice providers, nurses, and those caring for infants undergoing staged surgical palliation for single ventricle heart disease.
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http://dx.doi.org/10.1161/JAHA.119.014548DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7660817PMC
August 2020

Interventions Associated With Treatment of Low Cardiac Output After Stage 1 Norwood Palliation.

Ann Thorac Surg 2020 Jul 8. Epub 2020 Jul 8.

Department of Cardiothoracic Surgery, Cincinnati Children's Medical Center, Cincinnati, Ohio.

Background: Mortality after stage 1 palliation of hypoplastic left heart syndrome remains significant. Both cardiac output (CO) and systemic vascular resistance (SVR) contribute to hemodynamic vulnerability. Simultaneous measures of mean arterial pressure and somatic regional near infrared spectroscopy saturation can classify complex hemodynamics into 4 distinct states, with a low-CO state of higher risk. We sought to identify interventions associated with low-CO state occupancy and transition.

Methods: Perioperative data were prospectively collected in an institutional review board-approved database. Hemodynamic state was classified as high CO, high SVR, low SVR, and low CO using bivariate analysis. Associations of static and dynamic support levels and state classifications over 48 postoperative hours were tested between states and across transitions using mixed regression methods in a quasi-experimental design.

Results: Data from 10,272 hours in 214 patients were analyzed. A low-CO state was observed in 142 patients for 1107 hours. Both low CO and extracorporeal membrane oxygenation had increased mortality risk. The low-CO state was characterized by lower milrinone but higher catecholamine dose. Successful transition out of low CO was associated with increased milrinone dose and hemoglobin concentration. Increasing milrinone and hemoglobin levels predicted reduced risk of low CO in future states.

Conclusions: Bivariate classification objectively defines hemodynamic states and transitions with distinct support profiles. Maintaining or increasing inodilator and hemoglobin levels were associated with improved hemodynamic conditions and were predictive of successful future transitions from the low-CO state.
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http://dx.doi.org/10.1016/j.athoracsur.2020.05.068DOI Listing
July 2020

An Analysis of Hospital Mortality After Cardiac Operations in Children With Down Syndrome.

Semin Thorac Cardiovasc Surg 2020 Winter;32(4):947-957. Epub 2020 Jul 2.

Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas.

Children with Down syndrome (DS) have lower mortality compared to nonsyndromic (NS) children after atrioventricular septal defect (AVSD) repair. Limited data exist regarding hospital mortality and utilization after other congenital heart disease (CHD) operations in DS. We compared hospital mortality and utilization after CHD operations in both populations and hypothesized that the survival benefit in children with DS is not consistent across CHD lesions. The Texas Inpatient Public Use Datafile was queried for all patients <18 years old undergoing operations for CHD between 1999 and 2016. Hospital mortality, length-of-stay and charges were compared between DS and NS groups, stratified by CHD operation using mixed-effects multivariable analyses and propensity score matching analyses adjusting for prematurity, low birth weight, age, and sex. Over the 18-year period, 2841 cases with DS underwent CHD operations compared to 25,063 NS cases. The most common types of interventions performed in DS were AVSD repair, isolated ventricular septal defect (VSD) repair and tetralogy of Fallot (TOF) repair. By multivariable analyses, DS was associated with lower mortality after isolated AVSD repair (RR 0.40 [IQR 0.20-0.79]), and higher hospital mortality after bidirectional Glenn anastomosis (BDG) (RR 5.17 [IQR 2.10-12.77]) and TOF/pulmonary atresia repair (RR 9.71 [IQR 2.16-43.68]) compared to NS children. Similar results were noted using propensity score matching. Children with DS had lower mortality after AVSD repair than NS children, but higher mortality after operations for BDG and TOF/pulmonary atresia. Further study is needed to determine if the presence of pulmonary hypertension in DS modifies the association between DS and mortality depending on cardiac lesion.
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http://dx.doi.org/10.1053/j.semtcvs.2020.06.037DOI Listing
July 2020

Development of a validated risk score for interstage death or transplant after stage I palliation for single-ventricle heart disease.

J Thorac Cardiovasc Surg 2020 Oct 14;160(4):1021-1030. Epub 2019 Nov 14.

Department of Cardiology, Boston Children's Hospital, Boston, Mass. Electronic address:

Objective: To develop a risk score to predict mortality or transplant in the interstage period.

Background: The "interstage" period between the stage 1 and stage 2 palliation is a time of high morbidity and mortality for infants with single-ventricle congenital heart disease.

Methods: This was an analysis of patients with single-ventricle congenital heart disease requiring arch reconstruction who were enrolled in the National Pediatric Cardiology Quality Improvement Collaborative registry from 2008 to 2015. The primary composite endpoint was interstage mortality or transplant. Multivariable logistic regression and classification and regression tree analysis were performed on two-thirds of the patients ("learning cohort") to build a risk score for the composite endpoint, that was validated in the remaining patients ("validation cohort").

Results: In the 2128 patients analyzed in the registry, the overall event rate was 9% (153 [7%] deaths, 42 [2%] transplants). In the learning cohort, factors independently associated with the composite endpoint were (1) type of Norwood; (2) postoperative ECMO; (3) discharge with Opiates; (4) No Digoxin at discharge; (5) postoperative Arch obstruction, (6) moderate-to-severe Tricuspid regurgitation without an oxygen requirement, and (7) Extra Oxygen required at discharge in patients with moderate-to-severe tricuspid regurgitation. This model was used to create a weighted risk score ("NEONATE" score; 0-76 points), with >75% accuracy in the learning and validation cohorts. In the validation cohort, the event rate in patients with a score >17 was nearly three times those with a score ≤17.

Conclusions: We introduce a risk score that can be used post-stage 1 palliation to predict freedom from interstage mortality or transplant.
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http://dx.doi.org/10.1016/j.jtcvs.2019.11.001DOI Listing
October 2020

Patient With Poor Prognosis, Family Wishes to Pursue All Options, Care Team Cannot Reach Consensus.

Ann Thorac Surg 2019 11;108(5):1284-1286

Section of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas.

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http://dx.doi.org/10.1016/j.athoracsur.2019.06.004DOI Listing
November 2019

Norwood Procedure-Difficulty in Weaning From Cardiopulmonary Bypass and Implications for Outcomes.

Semin Thorac Cardiovasc Surg 2020 9;32(1):119-125. Epub 2019 Aug 9.

Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Hospital of WI, Milwaukee, Wisconsin. Electronic address:

Difficulty weaning from cardiopulmonary bypass (CPB) or the need to return to CPB (collectively D-CPB) may occur after the Norwood procedure. We sought to evaluate the relationship between D-CBP and survival. This was a retrospective chart review of all patients undergoing a Norwood procedure at our institution during the interval 2005-2017. Primary outcome was survival for the Norwood procedure. Secondary outcomes included various measures of morbidity. Successful wean from CBP (S-CPB) was defined as no need to return to full-flow CPB during the initial definitive wean or after separation from CPB; otherwise, the classification was difficulty with wean (D-CBP). Successful rescue in the D-CPB group was defined as not requiring extracorporeal life support either in the operating room or within the first 3 postoperative days. Of the 196 patients in the cohort, 49 were D-CPB. Survival for S-CPB was 92.5% (136/147) vs 71.4% (35/49) for D-CPB (P = 0.001). Major morbidity occurred in 29.9% (44/147) in S-CPB vs 69.4% (34/49) in D-CPB (P < 0.001). With multivariable analysis, D-CPB was significantly associated with mortality (odds ratio = 8.09; confidence interval 2.72-24.05; P < 0.001). Successful rescue occurred in 30 of 49 patients in the D-CPB group and demonstrated survival similar to the S-CPB group. In the Norwood patient, D-CPB is an important intraoperative event and prognostic factor for mortality and morbidity. Successful rescue appears to ameliorate the impact of D-CPB on survival.
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http://dx.doi.org/10.1053/j.semtcvs.2019.08.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7007819PMC
June 2020

Identification of Time-Dependent Risks of Hemodynamic States After Stage 1 Norwood Palliation.

Ann Thorac Surg 2020 01 9;109(1):155-162. Epub 2019 Aug 9.

Herma Heart Institute, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin; Cincinnati Children's Medical Center, Cincinnati, Ohio; Texas Children's Hospital, Houston, Texas.

Background: Mortality after stage 1 palliation of hypoplastic left heart syndrome remains significant. Hemodynamic changes result from interaction of cardiac output (CO) and systemic vascular resistance (SVR). We sought to identify time-dependent changes in postoperative hemodynamic states and their associations with mortality.

Methods: Perioperative data were prospectively collected in an institutional review board-approved database. Hemodynamic state was classified as high CO, high SVR, low SVR, and low CO using bivariate analysis of mean arterial pressure and somatic regional near-infrared spectroscopic oximetry saturation. State classifications over 48 postoperative hours were modelled using multinomial logistic regressions for association with mortality.

Results: Data from 9614 of 10,272 hours in 214 patients were analyzed. Operative survival was 91%. The predominant state was high CO (46% time). Low CO state without extracorporeal membrane oxygenation (ECMO) was found in 52% of patients for 9.7% time. ECMO was employed in 24 (11.2%) patients for 10.4% time. State stability was 33%, with high SVR the least stable (17%) and high CO the most stable (53%). Transition from high CO increased in hours 1 to 12, mainly to low SVR. Transition to low CO was 18.4%, increasing in hours 1 to 12, mainly from high SVR. The transition risk to ECMO was 0.32%, and 0.74% during hours 1 to 12, only from low CO. Both low CO and ECMO had increased mortality risk.

Conclusions: Bivariate classification defines hemodynamic states with distinct physiologic, transition, and mortality risk profiles. High SVR state was unstable. Transition to ECMO occurred only from low CO, while the low SVR and high CO states were safest.
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http://dx.doi.org/10.1016/j.athoracsur.2019.06.063DOI Listing
January 2020

Outcomes Associated With Unplanned Interstage Cardiac Interventions After Norwood Palliation.

Ann Thorac Surg 2019 11 7;108(5):1423-1429. Epub 2019 Aug 7.

Division of Critical Care, Department of Pediatrics, Michael E. DeBakey Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas.

Background: Anatomic lesions are a common cause of decompensation during the interstage period after Norwood stage 1 palliation (S1P). This study describes the risk factors for and outcomes after unplanned surgical and catheter-based interstage cardiac interventions.

Methods: Participants in the National Pediatric Cardiology Quality Improvement Collaborative registry discharged from the hospital after S1P between 2008 and 2016 were studied. Variables at S1P, interstage, and at stage 2 palliation (S2P) hospitalizations were examined. Multivariable logistic regression was used to compare those who had an unplanned interstage intervention to those who did not.

Results: Of 1994 participants from 60 programs, 343 (17.1%) had at least 1 unplanned interstage intervention. Aortic valve dilation before S1P, longer S1P cardiopulmonary bypass time, pulmonary artery stent placement between S1P and discharge, aortic arch obstruction on the S1P discharge echocardiogram, and lower weight at S1P discharge were independently associated with receiving an unplanned interstage intervention. Interstage mortality between groups was similar at 6%, as was interstage duration. Participants undergoing unplanned interstage interventions were more likely to undergo heart transplant before S2P or deemed to be unsuitable for S2P (7.3% vs 2.7%, P < .001).

Conclusions: Unplanned interstage interventions after S1P did not increase interstage mortality, but participants with an unplanned intervention were less likely to progress to S2P. Residual anatomic lesions are risk factors for unplanned interstage interventions. For those with progressive ventricular dysfunction in the presence of arch obstruction by echocardiogram, aortic arch reintervention is warranted.
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http://dx.doi.org/10.1016/j.athoracsur.2019.06.041DOI Listing
November 2019

Safety and Efficacy of Vasopressin After Fontan Completion: A Randomized Pilot Study.

Ann Thorac Surg 2019 12 7;108(6):1865-1874. Epub 2019 Aug 7.

Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Anesthesia, Department of Anesthesia, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin.

Background: Arginine vasopressin is a nonapeptide hormone with effects on intracellular water transport and arterial tone that is used in distributive shock and following cardiopulmonary bypass. We sought to evaluate the safety and efficacy of vasopressin infusion on hemodynamics and fluid balance in the early postoperative period after Fontan completion.

Methods: We conducted a randomized, double-blinded, placebo-controlled study of vasopressin infusion for 24 hours after cardiopulmonary bypass for Fontan completion. Patient characteristics, hospital outcomes, and measures of hemodynamic parameters, urine output, chest tube drainage, fluid balance, laboratory data, and plasma arginine vasopressin concentrations were collected at baseline and for 48 postoperative hours. Data were analyzed using mixed-effect regressions.

Results: Twenty patients were randomized, 10 to vasopressin and 10 to placebo. Transpulmonary gradient (6.4 ± 0.5 vs 8.3 ± 0.5 mm Hg, P = .011) and chest tube drainage (23 ± 20 vs 40 ± 20 mL/kg, P = .028) for 48 hours after surgery were significantly lower in the vasopressin arm compared to placebo. Arginine vasopressin concentrations were elevated above baseline after surgery until 4 hours post cardiac intensive care unit admission in both arms, and higher in the vasopressin arm during postoperative infusion. No differences in sodium concentration, liver function, or renal function were noted between groups.

Conclusions: Vasopressin infusion after Fontan completion appears safe and was associated with reduced transpulmonary gradient and chest tube drainage in the early postoperative period. A larger multiinstitutional study may show further outcome benefit.
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http://dx.doi.org/10.1016/j.athoracsur.2019.06.053DOI Listing
December 2019

Impact of feeding mode on neurodevelopmental outcome in infants and children with congenital heart disease.

Congenit Heart Dis 2019 Nov 2;14(6):1207-1213. Epub 2019 Aug 2.

Section of Developmental Pediatrics, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas.

Objective: To investigate the impact of feeding mode on neurodevelopmental outcomes in children with congenital heart defects.

Design: A retrospective cohort study of 208 children with congenital heart disease (CHD), who had surgery from 1 January 2013 until 31 December 2016 at Texas Children's Hospital, Houston, TX, US.

Settings: University Hospital, Developmental Outcome Clinic.

Outcomes Measures: Standardized cognitive scores were assessed with Capute Scales and motor development with Revised Gesell Developmental Schedules. We analyzed anthropometrics, mode of feeding, surgical complexity, syndrome, and gender as predictors of developmental outcomes at four time points: hospital discharge, and 6, 12, and 24 months of age.

Results: Mode of feeding is associated with neurodevelopmental outcome in children with CHD. Children on enteral feeding tubes had significantly lower developmental quotient (DQ) scores in cognition, communication, and motor function at 12 and 24 months compared to orally fed children. There were greater proportions of developmental delays (DQ < 70) in enteral tube fed children at the 6, 12, and 24 months visits. Further, there was a strong association between presence of enteral feeding tube, syndrome, and developmental outcome. Greater surgical complexity, weight gain and ethnicity were not associated with the developmental outcomes.

Conclusions: Our findings suggest that the presence of an enteral feeding tube following corrective congenital heart surgery are at increased risk of neurodevelopmental delays at 12 and 24 months.
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http://dx.doi.org/10.1111/chd.12827DOI Listing
November 2019

Chest tube removal algorithm is associated with decreased chest tube duration in pediatric cardiac surgical patients.

J Thorac Cardiovasc Surg 2019 10 24;158(4):1209-1217. Epub 2019 Apr 24.

Division of Cardiothoracic Surgery, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis.

Objective: Management of chest tubes in adult and pediatric patients is highly variable. There are no published guidelines for pediatric cardiac surgical patients. Our center undertook a quality improvement project aimed at reducing chest tube duration and length of stay in postsurgical pediatric cardiac patients.

Methods: A work group identified 2 opportunities for reducing chest tube duration: standardizing removal criteria and increasing frequency of assessment for removal. An algorithm was created, and chest tube assessments were increased to twice daily. All postsurgical cardiac patients were managed according to the algorithm. Outcome measure reporting was limited to patients age 1 month to 18 years with a biventricular surgical procedure. Outcome measures included chest tube duration, cardiac intensive care unit and hospital length of stay, and cost of hospitalization. Process measure was documentation of chest tube assessments. The balancing measure was chest tube reinsertions.

Results: Between April 2016 and July 2018, 126 patients aged 1 month to 18 years underwent a biventricular surgical procedure. Mean chest tube duration decreased from 61 to 47 hours. Cardiac intensive care unit length of stay decreased from 141 hours to 89 hours, hospital length of stay decreased from 266 to 156 hours, and average hospitalization cost decreased from $75,881 to $48,118. There was no increase in chest tube reinsertions.

Conclusions: Implementation of a chest tube removal algorithm for pediatric cardiac surgery patients resulted in decreased chest tube duration and was associated with decreased length of stay and costs without an increase in reinsertions. More significant impact may be attainable with more aggressive approach to removal.
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http://dx.doi.org/10.1016/j.jtcvs.2019.03.120DOI Listing
October 2019

The Bayley-III scale may underestimate neurodevelopmental disability after cardiac surgery in infants.

Eur J Cardiothorac Surg 2020 01;57(1):63-71

Department of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Objectives: Neurodevelopmental disability is the most common complication among congenital heart surgery survivors. The Bayley scales are standardized instruments to assess neurodevelopment. The most recent edition (Bayley Scales of Infant and Toddler Development 3rd Edition, Bayley-III) yields better-than-expected scores in typically developing and high-risk infants than the second edition (Bayley Scales of Infant Development 2nd Edition, BSID-II). We compared BSID-II and Bayley-III scores in infants undergoing cardiac surgery.

Methods: We evaluated 2198 infants who underwent operations with cardiopulmonary bypass between 1996 and 2009 at 26 institutions. We used propensity score matching to limit confounding by indication in a subset of patients (n = 705).

Results: Overall, unadjusted Bayley-III motor scores were higher than BSID-II Psychomotor Development Index scores (90.7 ± 17.2 vs 77.6 ± 18.8, P < 0.001), and unadjusted Bayley-III composite cognitive and language scores were higher than BSID-II Mental Development Index scores (92.0 ± 15.4 vs 88.2 ± 16.7, P < 0.001). In the propensity-matched analysis, Bayley-III motor scores were higher than BSID-II Psychomotor Development Index scores [absolute difference 14.1, 95% confidence interval (CI) 11.7-17.6; P < 0.001] and the Bayley-III classified fewer children as having severe [odds ratio (OR) 0.24; 95% CI 0.14-0.42] or mild-to-moderate impairment (OR 0.21; 95% CI 0.14-0.32). The composite of Bayley-III cognitive and language scores was higher than BSID-II Mental Development Index scores (absolute difference 4.0, 95% CI 1.4-6.7; P = 0.003), but there was no difference between Bayley editions in the proportion of children classified as having severe cognitive and language impairment.

Conclusions: The Bayley-III yielded higher scores than the BSID-II and classified fewer children as severely impaired. The systematic bias towards higher scores with the Bayley-III precludes valid comparisons between early and contemporary cardiac surgery cohorts.
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http://dx.doi.org/10.1093/ejcts/ezz123DOI Listing
January 2020

Gestational Age, Birth Weight, and Outcomes Six Years After the Norwood Procedure.

Pediatrics 2019 05 12;143(5). Epub 2019 Apr 12.

Department of Pediatrics, The University of Utah, Salt Lake City, Utah.

Background: Preterm delivery and low birth weight (LBW) are generally associated with worse outcomes in hypoplastic left heart syndrome (HLHS), but an individual preterm or small neonate may do well. We sought to explore the interactions between gestational age, birth weight, and birth weight for gestational age with intermediate outcomes in HLHS.

Methods: We analyzed survival, growth, neurodevelopment, length of stay, and complications to age 6 years in subjects with HLHS from the Single Ventricle Reconstruction trial. Univariate and multivariable survival and regression analyses examined the effects and interactions of LBW (<2500 g), weight for gestational age, and gestational age category.

Results: Early-term delivery ( = 234) was more common than term ( = 219) delivery. Small for gestational age (SGA) was present in 41% of subjects, but only 14% had LBW. Preterm, compared with term, delivery was associated with an increased risk of death or transplant at age 6 years (all: hazard ratio = 2.58, confidence interval = 1.43-4.67; Norwood survivors: hazard ratio = 1.96, confidence interval = 1.10-3.49) independent of LBW and weight for gestational age. Preterm delivery, early-term delivery, LBW, and SGA were each associated with lower weight at 6 years. Neurodevelopmental outcomes were worst in the LBW cohort.

Conclusions: Preterm delivery in HLHS was associated with worse survival, even beyond Norwood hospitalization. LBW, SGA, and early-term delivery were associated with worse growth but not survival. LBW was associated with worse neurodevelopment, despite similar length of stay and complications. These data suggest that preterm birth and LBW (although often concomitant) are not equivalent, impacting clinical outcomes through mechanisms independent of perioperative course complexity.
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http://dx.doi.org/10.1542/peds.2018-2577DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6564065PMC
May 2019

Atrioventricular block after congenital heart surgery: Analysis from the Pediatric Cardiac Critical Care Consortium.

J Thorac Cardiovasc Surg 2019 03 24;157(3):1168-1177.e2. Epub 2018 Nov 24.

Department of Pediatrics, Division of Cardiology, University of California, San Francisco, San Francisco, Calif.

Objectives: Our primary aims were to describe the contemporary epidemiology of postoperative high-grade atrioventricular block (AVB), the timing of recovery and permanent pacemaker (PPM) placement, and to determine predictors for development of and recovery from AVB.

Methods: Patients who underwent congenital heart surgery from August 2014 to June 2017 were analyzed for AVB using the Pediatric Cardiac Critical Care Consortium registry. Predictors of AVB with or without PPM were identified using multinomial logistic regression. We used these predictors to model the probability of PPM for the subgroup of patients with intraoperative complete AVB.

Results: We analyzed 15,901 surgical hospitalizations; 422 (2.7%) were complicated by AVB and 162 (1.0%) patients underwent PPM placement. In patients with transient AVB, 50% resolved by 2 days, and 94% resolved by 10 days. In patients who received a PPM, 50% were placed by 8 days and 62% were placed by 10 days. Independent risk factors associated with PPM compared with resolution of AVB were longer duration of cardiopulmonary bypass (relative risk ratio, 1.04; P = .023) and a high-risk operation (relative risk ratio, 2.59; P < .001). Among patients with complete AVB originating in the operating room, those with the highest predicted probability of PPM had a PPM placed only 77% of the time.

Conclusions: In this cohort, postoperative AVB complicated almost 3% of congenital heart surgery cases and 1% of patients underwent PPM placement. Because almost all patients (94%) with transient AVB had resolution by 10 days, our results suggest there is limited benefit to delaying PPM placement beyond that time frame.
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http://dx.doi.org/10.1016/j.jtcvs.2018.09.142DOI Listing
March 2019

Variation in Adjusted Mortality for Medical Admissions to Pediatric Cardiac ICUs.

Pediatr Crit Care Med 2019 02;20(2):143-148

Department of Pediatrics, University of California San Francisco School of Medicine and Benioff Children's Hospital, San Francisco, CA.

Objectives: Pediatric cardiac ICUs should be adept at treating both critical medical and surgical conditions for patients with cardiac disease. There are no case-mix adjusted quality metrics specific to medical cardiac ICU admissions. We aimed to measure case-mix adjusted cardiac ICU medical mortality rates and assess variation across cardiac ICUs in the Pediatric Cardiac Critical Care Consortium.

Design: Observational analysis.

Setting: Pediatric Cardiac Critical Care Consortium clinical registry.

Patients: All cardiac ICU admissions that did not include cardiac surgery.

Interventions: None.

Measurements And Main Results: The primary endpoint was cardiac ICU mortality. Based on multivariable logistic regression accounting for clustering, we created a case-mix adjusted model using variables present at cardiac ICU admission. Bootstrap resampling (1,000 samples) was used for model validation. We calculated a standardized mortality ratio for each cardiac ICU based on observed-to-expected mortality from the fitted model. A cardiac ICU was considered a statistically significant outlier if the 95% CI around the standardized mortality ratio did not cross 1. Of 11,042 consecutive medical admissions from 25 cardiac ICUs (August 2014 to May 2017), the observed mortality rate was 4.3% (n = 479). Final model covariates included age, underweight, prior surgery, time of and reason for cardiac ICU admission, high-risk medical diagnosis or comorbidity, mechanical ventilation or extracorporeal membrane oxygenation at admission, and pupillary reflex. The C-statistic for the validated model was 0.87, and it was well calibrated. Expected mortality ranged from 2.6% to 8.3%, reflecting important case-mix variation. Standardized mortality ratios ranged from 0.5 to 1.7 across cardiac ICUs. Three cardiac ICUs were outliers; two had lower-than-expected (standardized mortality ratio <1) and one had higher-than-expected (standardized mortality ratio >1) mortality.

Conclusions: We measured case-mix adjusted mortality for cardiac ICU patients with critical medical conditions, and provide the first report of variation in this quality metric within this patient population across Pediatric Cardiac Critical Care Consortium cardiac ICUs. This metric will be used by Pediatric Cardiac Critical Care Consortium cardiac ICUs to assess and improve outcomes by identifying high-performing (low-mortality) centers and engaging in collaborative learning.
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http://dx.doi.org/10.1097/PCC.0000000000001751DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6373463PMC
February 2019

Gastrostomy Tubes in Post-Norwood Patients: Why, When and How are as Important as the Who.

Semin Thorac Cardiovasc Surg 2018 24;30(4):448-449. Epub 2018 Jul 24.

Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.

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http://dx.doi.org/10.1053/j.semtcvs.2018.07.011DOI Listing
January 2019

Transplant-Free Survival and Interventions at 6 Years in the SVR Trial.

Circulation 2018 05 1;137(21):2246-2253. Epub 2018 Feb 1.

University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.).

Background: In the SVR trial (Single Ventricle Reconstruction), 1-year transplant-free survival was better for the Norwood procedure with right ventricle-to-pulmonary artery shunt (RVPAS) compared with a modified Blalock-Taussig shunt in patients with hypoplastic left heart and related syndromes. At 6 years, we compared transplant-free survival and other outcomes between the groups.

Methods: Medical history was collected annually using medical record review, telephone interviews, and the death index. The cohort included 549 patients randomized and treated in the SVR trial.

Results: Transplant-free survival for the RVPAS versus modified Blalock-Taussig shunt groups did not differ at 6 years (64% versus 59%, =0.25) or with all available follow-up of 7.1±1.6 years (log-rank =0.13). The RVPAS versus modified Blalock-Taussig shunt treatment effect had nonproportional hazards (=0.009); the hazard ratio (HR) for death or transplant favored the RVPAS before stage II surgery (HR, 0.66; 95% confidence interval, 0.48-0.92). The effect of shunt type on death or transplant was not statistically significant between stage II to Fontan surgery (HR, 1.36; 95% confidence interval, 0.86-2.17; =0.17) or after the Fontan procedure (HR, 0.76; 95% confidence interval, 0.33-1.74; =0.52). By 6 years, patients with RVPAS had a higher incidence of catheter interventions (0.38 versus 0.23/patient-year, <0.001), primarily because of more interventions between the stage II and Fontan procedures (HR, 1.72; 95% confidence interval, 1.00-3.03). Complications did not differ by shunt type; by 6 years, 1 in 5 patients had had a thrombotic event, and 1 in 6 had had seizures.

Conclusions: By 6 years, the hazards of death or transplant and catheter interventions were not different between the RVPAS versus modified Blalock-Taussig shunt groups. Children assigned to the RVPAS group had 5% higher transplant-free survival, but the difference did not reach statistical significance, and they required more catheter interventions. Both treatment groups have accrued important complications.

Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00115934.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.117.029375DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5963989PMC
May 2018

Duration of Postoperative Mechanical Ventilation as a Quality Metric for Pediatric Cardiac Surgical Programs.

Ann Thorac Surg 2018 Feb 5;105(2):615-621. Epub 2017 Oct 5.

Departments of Critical Care Medicine and Paediatrics, The Hospital for Sick Children, University of Toronto School of Medicine, Toronto, Ontario, Canada.

Background: Few metrics exist to assess quality of care at pediatric cardiac surgical programs, limiting opportunities for benchmarking and quality improvement. Postoperative duration of mechanical ventilation (POMV) may be an important quality metric because of its association with complications and resource utilization. In this study we modelled case-mix-adjusted POMV duration and explored hospital performance across POMV metrics.

Methods: This study used the Pediatric Cardiac Critical Care Consortium clinical registry to analyze 4,739 hospitalizations from 15 hospitals (October 2013 to August 2015). All patients admitted to pediatric cardiac intensive care units after an index cardiac operation were included. We fitted a model to predict duration of POMV accounting for patient characteristics. Robust estimates of SEs were obtained using bootstrap resampling. We created performance metrics based on observed-to-expected (O/E) POMV to compare hospitals.

Results: Overall, 3,108 patients (65.6%) received POMV; the remainder were extubated intraoperatively. Our model was well calibrated across groups; neonatal age had the largest effect on predicted POMV. These comparisons suggested clinically and statistically important variation in POMV duration across centers with a threefold difference observed in O/E ratios (0.6 to 1.7). We identified 1 hospital with better-than-expected and 3 hospitals with worse-than-expected performance (p < 0.05) based on the O/E ratio.

Conclusions: We developed a novel case-mix-adjusted model to predict POMV duration after congenital heart operations. We report variation across hospitals on metrics of O/E duration of POMV that may be suitable for benchmarking quality of care. Identifying high-performing centers and practices that safely limit the duration of POMV could stimulate quality improvement efforts.
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http://dx.doi.org/10.1016/j.athoracsur.2017.06.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5783731PMC
February 2018

Anatomic Repair of Congenitally Corrected Transposition of the Great Arteries: Single-Center Intermediate-Term Experience.

Pediatr Cardiol 2017 Dec 16;38(8):1696-1702. Epub 2017 Sep 16.

Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.

We present our experience for patients who have undergone an anatomic repair (AR) for congenitally corrected transposition of the great arteries (CCTGA) at the Children's Hospital of Wisconsin. A retrospective chart review of patients who underwent AR for CCTGA from 2001 to 2015 was performed. The cohort consisted of 15 patients (74% male). Median age of anatomic repair was 15 months (range 4.5-45.6 months). Four patients had a bidirectional Glenn (BDG) prior to AR. At the time of AR,-9 (60%) underwent Senning/Rastelli procedure, 4 (26.6%) had double switch operation, and 2 (13.3%) underwent only Senning with VSD closure. Median duration of follow-up was 5.5 years (0.05-14 years). Reoperations prior to discharge included BDG, revision of pulmonary venous baffle, closure of residual VSD, and pacemaker placement. Late reoperations included left ventricular outflow tract obstruction repair, conduit replacement, melody valve placement, and pacemaker implantation. At their most recent follow-up, no patient had heart failure symptoms and only 1 had severely diminished function that improved with cardiac resynchronization therapy. Moderate mitral regurgitation was noted in 15% (2/13), and severe in 7% (1/13). Moderate tricuspid regurgitation was noted in 15% (2/13). One patient, 7% (1/13), developed moderate aortic insufficiency. There was a 100% survival at the time of the most recent follow-up. Patients with CCTGA who have undergone AR have excellent functional status and mid-term survival but reinterventions are common. Longer term studies are needed to determine both the extent and spectrum of reinterventions as well as long term survival.
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http://dx.doi.org/10.1007/s00246-017-1715-5DOI Listing
December 2017

Resource Utilization Associated with Extracardiac Co-morbid Conditions Following Congenital Heart Surgery in Infancy.

Pediatr Cardiol 2017 Jun 29;38(5):1065-1070. Epub 2017 Apr 29.

Critical Care, Department of Pediatrics, Pediatric Division of Special Needs, Milwaukee, WI, USA.

Congenital heart disease (CHD) is often associated with chronic extracardiac co-morbid conditions (ECC). The presence of ECC has been associated with greater resource utilization during the operative period; however, the impact beyond hospital discharge has not been described. This study sought to understand the scope of chronic ECC in infants with CHD as well as to describe the impact of ECC on resource utilization after discharge from the index cardiac procedure. IRB approved this retrospective study of infants <1 year who had cardiac surgery from 2006 and 2011. Demographics, diagnoses, procedures, STAT score, and ECC were extracted from the medical record. Administrative data provided frequency of clinic and emergency room visits, admissions, cumulative hospital days, and hospital charges for 2 years after discharge from the index procedure. Data were compared using Mann-Whitney Rank Sum Test with p < 0.05 considered significant. ECC occurred in 55% (481/876) of infants. Median STAT score was higher in the group with ECC (3 vs. 2, p < 0.001). Resource utilization after discharge from the index procedure as defined by median hospital charges (78 vs. 10 K, p < 0.001 and unplanned hospital days 4 vs. 0, p < 0.001) was higher in those with ECC, and increased with the greater number of ECC, even after accounting for surgical complexity. STAT score and the presence of multiple ECC were associated with higher resource utilization following the index cardiac surgical procedure. These data may be helpful in deciding which children might benefit from a cardiac complex care program that partners families and providers to improve health and decrease healthcare costs.
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http://dx.doi.org/10.1007/s00246-017-1620-yDOI Listing
June 2017

Side-to-Side Tracheobronchoplasty to Reconstruct Complex Congenital Tracheobronchial Stenosis.

Ann Thorac Surg 2017 Aug 31;104(2):666-673. Epub 2017 Mar 31.

Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Cardiothoracic Surgery, Children's Hospital of Wisconsin, Milwaukee, Wisconsin. Electronic address:

Background: Long segment tracheobronchial stenosis is a rare congenital anomaly that can also occur in combination with abnormal bronchial arborization. Long segment tracheal reconstruction in the setting of a supernumerary bridging bronchus has been reported; however, these repairs can be particularly complex. We present our experience using the bridging bronchus to augment long segment tracheal stenosis with a side-to-side tracheobronchoplasty.

Methods: Four patients with complex long segment tracheobronchial stenosis involving a bronchus suis (right upper lobe bronchus) and a bridging bronchus presented with refractory respiratory distress requiring urgent tracheal reconstruction. Patient 1 was initially managed with modified slide tracheoplasty and tracheostomy. Patients 2, 3, and 4 were managed with single-stage procedures. All patients underwent definitive long segment tracheobronchoplasty consisting of a side-to-side anastomosis between the bridging bronchus and the right upper lobe bronchus.

Results: Age at surgery was 569, 69, 24, and 142 days, respectively. Weight at surgery was 9.3, 4.3, 2.7, and 5.9 kg. All patients were weaned from mechanical ventilation at 84, 13, 47, and 8 days after side-to-side tracheobronchoplasty. All patients were alive and free from tracheostomy at follow-up of 6.7, 3.8, 2.7, and 0.5 years.

Conclusions: Side-to-side tracheal reconstruction is feasible in severe cases of long segment tracheal stenosis with a right upper lobe bronchus and a bridging bronchus. This technique can be successfully applied in high-risk patients and in the neonatal period and can provide excellent midterm results.
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http://dx.doi.org/10.1016/j.athoracsur.2017.01.011DOI Listing
August 2017

Turnstyle gridlock: Passenger (corpuscular) overload or slow-moving train?

J Thorac Cardiovasc Surg 2017 04 19;153(4):956. Epub 2016 Nov 19.

Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wis.

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http://dx.doi.org/10.1016/j.jtcvs.2016.11.021DOI Listing
April 2017

Postoperative Cerebral and Somatic Near-Infrared Spectroscopy Saturations and Outcome in Hypoplastic Left Heart Syndrome.

Ann Thorac Surg 2017 May 21;103(5):1527-1535. Epub 2016 Dec 21.

Herma Heart Center, Milwaukee, Wisconsin; Children's Hospital of Wisconsin, Milwaukee, Wisconsin.

Background: Circulatory vulnerability reflected by low systemic venous oxygen saturation after surgical palliation of hypoplastic left heart syndrome predicts adverse neurologic outcome and reduced survival, and targeting venous saturation may improve outcome. We herein test the hypothesis that near-infrared spectroscopy (NIRS)-derived cerebral and somatic/renal regional saturations can predict survival.

Methods: Patient data, from a prospective Institutional Review Board-approved registry of hemodynamic measures after initial palliation of hypoplastic left heart syndrome, were analyzed with logistic and multivariable mixed regression methods to determine relationships between standard hemodynamic measures, direct and NIRS measures of saturation, and outcome. The primary outcome measure was survival through hospital discharge and 30 days.

Results: From the entire cohort of 329 patients, complete data for comparative analysis of physiologic predictors were available from 194 patients. The early survival rate was 92.1%; extracorporeal membrane oxygenation was used in 8.8% of patients. The mean arterial pressure, arterial cerebral, and somatic cerebral NIRS saturation differences were significantly higher for survivors versus nonsurvivors. Multivariable analysis found cerebral and somatic NIRS saturations, heart rate, and arterial pressure as predictors of outcome. Bivariate analysis of mean arterial pressure and somatic saturation allowed early identification of low cardiac output and high mortality risk.

Conclusions: Continuous noninvasive measurement of regional cerebral and somatic NIRS saturations in the early postoperative period can predict outcomes of early mortality and extracorporeal membrane oxygenation use in hypoplastic left heart syndrome. Because outcomes were strongly determined by NIRS measures at 6 hours, early postoperative NIRS measures may be rational targets for goal-directed interventions.
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http://dx.doi.org/10.1016/j.athoracsur.2016.09.100DOI Listing
May 2017

Mechanical Circulatory Support of the Fontan Patient.

Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2017 Jan;20:20-27

Department of Pediatrics, Division of Critical Care, Medical College of Wisconsin, Milwaukee, WI; Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, WI.

Because of the inadequacies inherent to a circulation supported by a single ventricle, many Fontan patients will experience failure of their circulation. To date, there is no medical regimen that reliably and consistently restores circulatory function in these patients. Because of the shortage of donor organs and the fact that many of these patients present with features that either preclude or render heart transplantation a high risk, there is an intense need to better understand how mechanical circulatory support (MCS) may benefit these patients. In this report, we share our experience of successful MCS and transplantation of three patients. Our experience and that of others is very encouraging, but also preliminary. In general, a systemic ventricular assist device, with or without a Fontan fenestration, is a reasonable consideration for a patient presenting with predominantly systolic dysfunction. A pulmonary/systemic venous assist device may be sufficient for the patient with preserved systolic function and failure of the systemic venous/lymphatic system; however, this remains speculative. The more comprehensive approach of a total artificial heart or bilateral support is attractive in theory, but beset by the need for a more complex operation. In all scenarios, early referral, before organ failure, is paramount to successful MCS.
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http://dx.doi.org/10.1053/j.pcsu.2016.09.009DOI Listing
January 2017

Center Variability in Timing of Stage 2 Palliation and Association with Interstage Mortality: A Report from the National Pediatric Cardiology Quality Improvement Collaborative.

Pediatr Cardiol 2016 Dec 24;37(8):1516-1524. Epub 2016 Aug 24.

Divison of Cardiology, Department of Pediatrics, Medical College of Wisconsin, 9000 W Wisconsin Ave, Milwaukee, WI, 53226, USA.

For infants with single-ventricle lesions with aortic arch hypoplasia, the interstage period from discharge following stage 1 palliation (S1P) until stage 2 palliation (S2P) remains high risk. Significant variability among institutions exists around the timing of S2P. We sought to describe institutional variation in timing of S2P, determine the association between timing of S2P and interstage mortality, and determine the impact of earlier S2P on hospital morbidity and mortality. The National Pediatric Cardiology Quality Improvement Collaborative registry was queried. Centers were divided based on median age at S2P into early (n = 15) and late (n = 16) centers using a cutoff of 153 days. Groups were compared using Chi-squared or Wilcoxon rank-sum test. Multivariable logistic regression was used to determine risk factors for interstage mortality. The final cohort included 789 patients from 31 centers. There was intra- and inter-center variability in timing of S2P, with the median age by center ranging from 109 to 214 days. Late centers had a higher mortality (9.9 vs. 5.7 %, p = 0.03) than early centers. However, the event rate (late: 8.2 vs. early: 5.8 deaths per 10,000 interstage days) was not different by group (p = 0.26). Survival to hospital discharge and hospital length of stay following S2P were similar between groups. In conclusion, in a large multi-institution collaborative, the median age at S2P varies among centers. Although optimal timing of S2P remains unclear, centers performing early S2P did not experience worse S2P outcomes and experienced less interstage mortality.
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http://dx.doi.org/10.1007/s00246-016-1465-9DOI Listing
December 2016

Near Infrared Spectroscopy as a Hemodynamic Monitor in Critical Illness.

Pediatr Crit Care Med 2016 08;17(8 Suppl 1):S201-6

1Division of Critical Care Medicine, Department of Pediatrics, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI. 2Department of Anesthesia, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI.

Objectives: The objectives of this review are to discuss the technology and clinical interpretation of near infrared spectroscopy oximetry and its clinical application in patients with congenital heart disease.

Data Source: MEDLINE and PubMed.

Conclusion: Near infrared spectroscopy provides a continuous noninvasive assessment of tissue oxygenation. Over 20 years ago, near infrared spectroscopy was introduced into clinical practice for monitoring cerebral oxygenation during cardiopulmonary bypass in adults. Since that time, the utilization of near infrared spectroscopy has extended into the realm of pediatric cardiac surgery and is increasingly being used in the cardiac ICU to monitor tissue oxygenation perioperatively.
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http://dx.doi.org/10.1097/PCC.0000000000000780DOI Listing
August 2016

Adverse events in children implanted with ventricular assist devices in the United States: Data from the Pediatric Interagency Registry for Mechanical Circulatory Support (PediMACS).

J Heart Lung Transplant 2016 05 17;35(5):569-77. Epub 2016 Mar 17.

Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.

Background: Ventricular assist devices (VADs) have been used in children on an increasing basis in recent years. One-year survival rates are now >80% in multiple reports. In this report we describe adverse events experienced by children with durable ventricular assist devices, using a national-level registry (PediMACS, a component of INTERMACS) METHODS: PediMACS is a national registry that contains clinical data on patients who are <19 years of age at the time of VAD implantation. Data collection concludes at the time of VAD explantation. All FDA-approved devices are included. PediMACS was launched on September 1, 2012, and this report includes all data from launch until August 2014. Adverse events were coded with a uniform, pre-specified set of definitions.

Results: This report comprises data from 200 patients with a median age of 11 years (range 11 days to 18 years), and total follow-up of 783 patient-months. The diagnoses were cardiomyopathy (n = 146, 73%), myocarditis (n = 17, 9%), congenital heart disease (n = 35, 18%) and other (n = 2, 1%). Pulsatile-flow devices were used in 91 patients (45%) and continuous-flow devices in 109 patients (55%). Actuarial survival was 81% at 6 months. There were 418 adverse events reported. The most frequent events were device malfunction (n = 79), infection (n = 78), neurologic dysfunction (n = 52) and bleeding (n = 68). Together, these accounted for 277 events, 66% of the total. Although 38% of patients had no reported adverse event and 16% of patients had ≥5 adverse events. Adverse events occurred at all time-points after implantation, but were most likely to occur in the first 30 days. For continuous-flow devices, there were broad similarities in adverse event rates between this cohort and historic rates from the INTERMACS population.

Conclusions: In this study cohort, the overall rate of early adverse events (within 90 days of implantation) was 86.3 events per 100 patient-months, and of late adverse events it was 20.4 events per 100 patient-months. The most common adverse events in recipients of pulsatile VADs were device malfunction, neurologic dysfunction, bleeding and infection. For continuous-flow VADs, the most common adverse events were infection, bleeding, cardiac arrhythmia, neurologic dysfunction and respiratory failure. Compared with an adult INTERMACS cohort, the overall rate and distribution of adverse events appears similar.
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http://dx.doi.org/10.1016/j.healun.2016.03.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5113942PMC
May 2016

Risk factors and outcomes of in-hospital cardiac arrest following pediatric heart operations of varying complexity.

Resuscitation 2016 08 13;105:1-7. Epub 2016 May 13.

Virtual PICU Systems, LLC, Los Angeles, CA, United States; Division of Critical Care Medicine, Department of Pediatrics and Anesthesiology, Children's Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, CA, United States.

Background: Multi center data regarding cardiac arrest in children undergoing heart operations of varying complexity are limited.

Methods: Children <18 years undergoing heart surgery (with or without cardiopulmonary bypass) in the Virtual Pediatric Systems (VPS, LLC) Database (2009-2014) were included. Multivariable mixed logistic regression models were adjusted for patient's characteristics, surgical risk category (STS-EACTS Categories 1, 2, and 3 classified as "low" complexity and Categories 4 and 5 classified as "high" complexity), and hospital characteristics.

Results: Overall, 26,909 patients (62 centers) were included. Of these, 2.7% had cardiac arrest after cardiac surgery with an associated mortality of 31%. The prevalence of cardiac arrest was lower among patients undergoing low complexity operations (low complexity vs. high complexity: 1.7% vs. 5.9%). Unadjusted outcomes after cardiac arrest were significantly better among patients undergoing low complexity operations (mortality: 21.6% vs. 39.1%, good neurological outcomes: 78.7% vs. 71.6%). In adjusted models, odds of cardiac arrest were significantly lower among patients undergoing low complexity operations (OR: 0.55, 95% CI: 0.46-0.66). Adjusted models, however, showed no difference in mortality or neurological outcomes after cardiac arrest regardless of surgical complexity. Further, our results suggest that incidence of cardiac arrest and mortality after cardiac arrest are a function of patient characteristics, surgical risk category, and hospital characteristics. Presence of around the clock in-house attending level pediatric intensivist coverage was associated with lower incidence of post-operative cardiac arrest, and presence of a dedicated cardiac ICU was associated with lower mortality after cardiac arrest.

Conclusions: This study suggests that the patients undergoing high complexity operations are a higher risk group with increased prevalence of post-operative cardiac arrest. These data further suggest that patients undergoing high complexity operations can be rescued after cardiac arrest with a high survival rate.
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http://dx.doi.org/10.1016/j.resuscitation.2016.04.022DOI Listing
August 2016

Training Pathways in Pediatric Cardiac Intensive Care: Proceedings From the 10th International Conference of the Pediatric Cardiac Intensive Care Society.

World J Pediatr Congenit Heart Surg 2016 Jan;7(1):81-8

The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA.

The increase in pediatric cardiac surgical procedures and establishment of the practice of pediatric cardiac intensive care has created the need for physicians with advanced and specialized knowledge and training. Current training pathways to become a pediatric cardiac intensivist have a great deal of variability and have unique strengths and weaknesses with influences from critical care, cardiology, neonatology, anesthesiology, and cardiac surgery. Such variability has created much confusion among trainees looking to pursue a career in our specialized field. This is a report with perspectives from the most common advanced fellowship training pathways taken to become a pediatric cardiac intensivist as well as various related topics including scholarship, qualifications, and credentialing.
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http://dx.doi.org/10.1177/2150135115614576DOI Listing
January 2016