The Risks of Being Tiny: The Added Risk of Low Weight for Neonates Undergoing Congenital Heart Surgery

Growth Failure in Children with Congenital Heart Disease

Background/Objectives: Growth failure is a common complication in children with congenital heart disease (CHD), yet its underlying mechanisms and consequences remain incompletely understood. This review aims to provide a comprehensive overview of growth failure in children with CHD and outline a framework of factors contributing to this condition. Methods: To lay the foundation for this narrative review, several databases were searched using broad search terms related to CHD and growth failure. Results: Growth failure is most pronounced during the first year of life, but often improves after achieving hemodynamic stability through surgical or medical interventions. However, children with complex conditions, such as single-ventricle physiology or multiple heart defects, may experience persistent growth impairment due to chronic disease effects. Specific features of CHD-cyanosis, pulmonary hypertension, and low cardiac output-can further hinder growth by disrupting endocrine function and impairing musculoskeletal development. Long-term use of medications and exposure to repeated diagnostic procedures also contribute to growth failure. Beyond physical effects, growth failure profoundly influences neurodevelopment, psychosocial well-being, and survival outcomes. Based on our review, we have developed a knowledge map to better understand the complexities of growth failure in children with CHD. Conclusions: A thorough understanding of the multifaceted contributors to growth failure in CHD is essential for identifying high-risk children and devising strategies to support optimal growth. Integrating this knowledge into clinical practice can improve long-term outcomes for children with CHD.

Perioperative Outcomes in Congenital Heart Disease: A Review of Clinical Factors Associated With Prolonged Ventilation and Length of Stay in Four Common CHD Operations

OBJECTIVES

Perioperative management strategies and outcomes for low-risk congenital heart disease (CHD) surgery vary between institutions. To date, no consensus exists on standardized management for pediatric patients undergoing cardiac surgery. This study seeks to benchmark the perioperative management of 4 common CHD lesions and explore clinical factors affecting postoperative outcomes.

DESIGN

A retrospective review of CHD procedures performed between 2015 and 2020.

SETTING

The study was conducted at a single academic tertiary pediatric hospital.

PARTICIPANTS

All patients presenting for repair of ventricular septal defects (VSDs), complete atrioventricular canal defects, tetralogy of Fallot (TOF), and transposition of the great arteries (TGA) were reviewed.

INTERVENTIONS

Demographic and clinical data were collected; clinical outcomes were defined as postoperative length of ventilation (LOV) and hospital length of stay, divided into reference and prolonged course groups analyzed for variables associated with differences in outcomes.

MEASUREMENTS AND MAIN RESULTS

We selected 931 patients for review. Prolonged length of ventilation and length of stay in all cohorts were associated with longer operative, cardiopulmonary bypass, and cross-clamp times; higher intraoperative requirements for inotropic support; more blood transfusions and higher opioid administration; lower pH preoperatively and higher lactic acid postoperatively. Worse outcomes were associated with younger age in VSD, older age in TGA, and lower weight in TOF and TGA. Worse outcomes were also associated with a higher preoperative hematocrit in VSD and TOF and elevated preoperative blood glucose in VSD and TGA.

CONCLUSIONS

A better understanding of clinical factors affecting outcomes may facilitate streamlining perioperative management strategies for pediatric patients undergoing low-risk cardiac surgery.

Using artificial intelligence to predict post-operative outcomes in congenital heart surgeries: a systematic review

INTRODUCTION

Congenital heart disease (CHD) represents the most common group of congenital anomalies, constitutes a significant contributor to the burden of non-communicable diseases, highlighting the critical need for improved risk assessment tools. Artificial intelligence (AI) holds promise in enhancing outcome predictions for congenital cardiac surgery. This study aims to systematically review the utilization of AI in predicting post-operative outcomes in this population.

METHODS

Following PRISMA guidelines, a comprehensive search of Pubmed, Scopus, and Web of Science databases was conducted. Two independent reviewers screened articles based on predefined criteria. Included studies focused on AI models predicting various post-operative outcomes in congenital heart surgery.

RESULTS

The review included 35 articles, primarily published within the last four years, indicating growing interest in AI applications. Models predominantly targeted mortality and survival (n = 16), prolonged length of hospital or ICU stay (n = 7), postoperative complications (n = 6), prolonged mechanical ventilatory support time (n = 4), with additional focus on specific outcomes such as peri-ventricular leucomalacia (n = 2) and malnutrition (n = 1). Performance metrics, such as area under the curve (AUC), ranged from 0.52 to 0.997. Notably, these AI models consistently outperformed traditional risk stratification categories. For instance, in assessing the risk of morbidity and mortality, the AI models demonstrated superior performance compared to conventional methods.

CONCLUSION

AI-driven prediction models show significant promise in improving outcome predictions for congenital heart surgery. They surpass traditional risk prediction tools not only in immediate postoperative risks but also in long-term outcomes such as 1-year survival and malnutrition. Further studies with robust external validation are necessary to assess the practical applicability of these models in clinical settings. The protocol of this review was prospectively registered on PROSPERO (CRD42024550942).

The Role of Early and Delayed Surgery for Infants with Congenital Brain Tumors

PURPOSE

The present study aimed to evaluate the role of early and delayed surgery in congenital brain tumors and analyze the clinical outcomes of infantile brain tumors.

MATERIALS AND METHODS

We performed a retrospective cohort study on 69 infantile brain tumors at a single institution from January 2008 to June 2023. Outcomes were assessed as early mortality (within 30 days following surgery) to evaluate the risk of early surgery in congenital brain tumors. Outcomes of recurrence and overall survival were analyzed in infantile brain tumors.

RESULTS

Surgery-related early mortality appeared to occur in young and low-body-weight patients. Cut-off values of age and body weight were found to be 1.3 months and 5.2 kg to avoid early mortality. Three patients (3/10, 30%) showed early mortality in the early surgery group, and early mortality occurred in one patient (1/14, 7.14%) in the delayed surgery group, whose tumor was excessively enlarged. Younger age at diagnosis (< 3 months of age; hazard ratios [HR], 7.1; 95% confidence intervals [CI], 1.4 to 35.6; p=0.018) and leptomeningeal seeding (LMS; HR, 30.6; 95% CI, 3.7 to 253.1; p=0.002) were significant independent risk factors for high mortality in infantile brain tumors.

CONCLUSION

We suggest delaying surgery until the patient reaches 1.3 months of age and weighs over 5.2 kg with short-term imaging follow-up unless tumors grow rapidly in congenital brain tumors. Younger ages and the presence of LMS are independent risk factors for high mortality in infantile brain tumors.

Aortic Origin of a Branch Pulmonary Artery: Early and Mid-Term Single Center Outcomes

BACKGROUND

Anomalous origin of pulmonary artery (AOPA) is a rare congenital cardiac anomaly. It requires early surgical intervention (<6 months) to prevent irreversible pulmonary vaso-occlusive disease. This study was conducted to determine the surgical outcomes of this rare and intriguing anomaly.

METHODS

From January 2015 to 2022, we have studied, 20 patients who underwent surgical correction for this anomaly with a mean age of 6.25 ± 3.7 months. There were 12 patients of <6 months of age. Their preoperative, intraoperative, and postoperative data were collected. They were followed up at every three months for the first year, every six months for two years, and then annually.

RESULTS

Among three early mortalities, two were operated before six months of age and one was older than six months (ten months). Those patients presented after six months had longer ventilation time (P = .001). There was no difference in their pulmonary artery pressure (P = .06), right ventricle systolic pressure (RVSP) (P = .85), postoperative saturation (P = .51), inotropic score (P = .06), hospital and intensive care unit stay (P > .05), or mortality (P = .79). There was no late mortality at mean follow-up of 51.31 ± 20.27 months with Kaplan-Meier survival of 85% at 1, 5, and ten years. All patients were asymptomatic, with normal biventricular function and RVSP. One patient required balloon dilatation of the anastomotic site, with Kaplan-Meier event-free survival of 100% at one year, 92% at five and ten years.

CONCLUSION

Surgical correction of AOPA in patients beyond six months is still feasible with a higher early morbidity and comparable mortality with good clinical and echocardiographical outcomes at mid-term follow-up.

Critical Care Unit Characteristics and Extracorporeal Cardiopulmonary Resuscitation Survival in the Pediatric Cardiac Population: Retrospective Analysis of the Virtual Pediatric System Database

OBJECTIVES

Existing literature provides limited data about ICU characteristics and pediatric extracorporeal cardiopulmonary resuscitation (E-CPR) outcomes. We aimed to evaluate the associations between patient and ICU characteristics, and outcomes after E-CPR in the pediatric cardiac population.

DESIGN

Retrospective analysis of the Virtual Pediatric System database (VPS, LLC, Los Angeles, CA).

SETTING

PICUs categorized as either cardiac-only versus mixed ICU cohort type.

PATIENTS

Consecutive cardiac patients less than 18 years old experiencing cardiac arrest in the ICU and resuscitated using E-CPR.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Event and time-stamp filtering identified E-CPR events. Patient, hospital, and event-related variables were aggregated for independent and multivariable mixed effects logistic regression to assess the association between ICU cohort type and survival. Among ICU admissions in the VPS database, 2010-2018, the prevalence of E-CPR was 0.07%. A total of 671 E-CPR events (650 patients) comprised the final cohort; congenital heart disease (84%) was the most common diagnosis versus acquired heart diseases. The majority of E-CPR events occurred in mixed ICUs (67%, n = 449) and in ICUs with greater than 20 licensed bed capacity (65%, n = 436). Survival to hospital discharge was 51% for the overall cohort. Independent logistic regression failed to reveal any association between survival to hospital discharge and ICU type (ICU type: cardiac ICU, odds ratio [OR], 1.01; 95% CI, 0.71-1.44; p = 0.95). However, multivariable logistic regression revealed an association between cardiac surgical patients and greater odds for survival (OR, 2.03; 95% CI, 1.40-2.95; p < 0.001). Also, there was an association between ICUs with capacity greater than 20 (vs not) and lower survival odds (OR, 0.65; 95% CI, 0.43-0.96).

CONCLUSIONS

The overall prevalence of E-CPR among critically ill children with cardiac disease observed in the VPS database is low. We failed to identify an association between ICU cohort type and survival. Further investigation into organizational factors is warranted.

Neighborhood Childhood Opportunity, Race/Ethnicity, and Surgical Outcomes in Children With Congenital Heart Disease

BACKGROUND

Racial and ethnic disparities in outcomes for children with congenital heart disease (CHD) coexist with disparities in educational, environmental, and economic opportunity.

OBJECTIVES

We sought to determine the associations between childhood opportunity, race/ethnicity, and pediatric CHD surgery outcomes.

METHODS

Pediatric Health Information System encounters aged <18 years from 2016 to 2022 with International Classification of Diseases-10th edition 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. The associations of race/ethnicity and COI with in-hospital surgical death were modeled with generalized estimating equations and formal mediation analysis. Neonatal survival after discharge was modeled by Cox proportional hazards.

RESULTS

Of 54,666 encounters at 47 centers, non-Hispanic Black (Black) (OR: 1.20; P = 0.01), Asian (OR: 1.75; P < 0.001), and Other (OR: 1.50; P < 0.001) groups had increased adjusted mortality vs non-Hispanic Whites. The lowest COI quintile had increased in-hospital mortality in unadjusted and partially adjusted models (OR: 1.29; P = 0.004), but not fully adjusted models (OR: 1.14; P = 0.13). COI partially mediated the effect of race/ethnicity on in-hospital mortality between 2.6% (P = 0.64) and 16.8% (P = 0.029), depending on model specification. In neonatal multivariable survival analysis (n = 13,987; median follow-up: 0.70 years), the lowest COI quintile had poorer survival (HR: 1.21; P = 0.04).

CONCLUSIONS

Children in the lowest COI quintile are at risk for poor outcomes after CHD surgery. Disproportionally increased mortality in Black, Asian, and Other populations may be partially mediated by COI. Targeted investment in low COI neighborhoods may improve outcomes after hospital discharge. Identification of unmeasured factors to explain persistent risk attributed to race/ethnicity is an important area of future exploration.

Insight into the Role of the Child Opportunity Index on Surgical Outcomes in Congenital Heart Disease

OBJECTIVE

To use neighborhood-level Child Opportunity Index (COI) measures to investigate disparities in congenital heart surgery postoperative outcomes and identify potential targets for intervention.

STUDY DESIGN

In this single-institution retrospective cohort study, children <18 years old who underwent cardiac surgery between 2010 and 2020 were included. Patient-level demographics and neighborhood-level COI were used as predictor variables. COI-a composite US census tract-based score measuring educational, health/environmental, and social/economic opportunities-was dichotomized as lower (<40th percentile) vs higher (≥40th percentile). Cumulative incidence of hospital discharge was compared between groups using death as a competing risk, adjusting for clinical characteristics associated with outcomes. Secondary outcomes included hospital readmission and death within 30 days.

RESULTS

Among 6247 patients (55% male) with a median age of 0.8 years (IQR, 0.2-4.3), 26% had lower COI. Lower COI was associated with longer hospital lengths of stay (adjusted HR, 1.2; 95% CI, 1.1-1.2; P < .001) and an increased risk of death (adjusted OR, 2.0; 95% CI. 1.4-2.8; P < .001), but not hospital readmission (P = .6). At the neighborhood level, lacking health insurance coverage, food/housing insecurity, lower parental literacy and college attainment, and lower socioeconomic status were associated with longer hospital length of stay and increased risk of death. At the patient-level, public insurance (adjusted OR, 1.4; 95% CI, 1.0-2.0; P = .03) and caretaker Spanish language (adjusted OR 2.4; 95% CI, 1.2-4.3; P < .01) were associated with an increased risk of death.

CONCLUSIONS

Lower COI is associated with longer length of stay and higher early postoperative mortality. Risk factors identified including Spanish language, food/housing insecurity, and parental literacy serve as potential intervention targets.

Outcomes of patent foramen ovale greater than 3 mm at birth in extremely low birthweight infants

BACKGROUND

Foramen ovale (FO) is an obligate fetal shunt that typically resolves after birth, although patency throughout life is not uncommon. The natural history of patent FO (PFO) is known in term infants, but less is known about its course in extremely preterm infants. We describe the echocardiographic changes in FO size from birth to discharge in extremely low birth weight (ELBW) infants in this retrospective study.

METHODS

Cohort was divided based on size of FO at birth. Size of FO at discharge was measured and evaluated relative to postnatal weight gain. Demographics and clinical outcomes were compared between the two groups.

RESULTS

Of the 54 ELBW infants, 50 were born with FO less than 3 mm in diameter (small), and 4 were born with FO greater than 3 mm (large). Of small defects, the majority (44/50, 88%) did not increase in size with weight gain, and minority (6/50, 12%) increased in size, and three of these 6 patients, FO grew to be slightly larger than 3 mm. In contrast, all large defects (4 of 4, 100%) nearly doubled in size with postnatal growth. These 4 ELBW infants with enlargement of FO had a flap valve evident on echocardiogram obtained prior to discharge, and subsequently closed on outpatient follow-up echocardiograms, although time to resolution was variable (6 months - 3 years). One infant had presumptive resolution because of the presence of flap valve.

CONCLUSION

No maternal or neonatal demographic characteristics were predictive of FO enlargement, although, demonstrable flap valve on discharge echocardiogram correlated with resolution of FO on outpatient follow-up echocardiogram. Therefore, based on our data, we recommend that ELBW infants born with large FO should have echocardiographic re-evaluation of the atrial septal opening prior to discharge, to specify the presence of a flap valve or lack thereof, which is an important detail that can help a neonatologist determine the need for outpatient cardiac follow-up.

The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: Management of infants and neonates with tetralogy of Fallot

OBJECTIVE

Despite decades of experience, aspects of the management of tetralogy of Fallot with pulmonary stenosis (TOF) remain controversial. Practitioners must consider newer, evolving treatment strategies with limited data to guide decision making. Therefore, the TOF Clinical Practice Standards Committee was commissioned by the American Association for Thoracic Surgery to provide a framework on this topic, focused on timing and types of interventions, management of high-risk patients, technical considerations during interventions, and best practices for assessment of outcomes of the interventions. In addition, the group was tasked with identifying pertinent research questions for future investigations. It is recognized that variability in institutional experience could influence the application of this framework to clinical practice.

METHODS

The TOF Clinical Practice Standards Committee is a multinational, multidisciplinary group of cardiologists and surgeons with expertise in TOF. With the assistance of a medical librarian, a citation search in PubMed, Embase, Scopus, and Web of Science was performed using key words related to TOF and its management; the search was restricted to the English language and the year 2000 or later. Articles pertaining to pulmonary atresia, absent pulmonary valve, atrioventricular septal defects, and adult patients with TOF were excluded, as well as nonprimary sources such as review articles. This yielded nearly 20,000 results, of which 163 were included. Greater consideration was given to more recent studies, larger studies, and those using comparison groups with randomization or propensity score matching. Expert consensus statements with class of recommendation and level of evidence were developed using a modified Delphi method, requiring 80% of the member votes with 75% agreement on each statement.

RESULTS

In asymptomatic infants, complete surgical correction between age 3 and 6 months is reasonable to reduce the length of stay, rate of adverse events, and need for a transannular patch. In the majority of symptomatic neonates, both palliation and primary complete surgical correction are useful treatment options. It is reasonable to consider those with low birth weight or prematurity, small or discontinuous pulmonary arteries, chromosomal anomalies, other congenital anomalies, or other comorbidities such as intracranial hemorrhage, sepsis, or other end-organ compromise as high-risk patients. In these high-risk patients, palliation may be preferred; and, in patients with amenable anatomy, catheter-based procedures may prove favorable over surgical palliation.

CONCLUSIONS

Ongoing research will provide further insight into the role of catheter-based interventions. For complete surgical correction, both transatrial and transventricular approaches are effective; however, the smallest possible ventriculotomy should be utilized. When possible, the pulmonary valve should be spared; and if unsalvageable, reconstruction can be considered. At the conclusion of the operation, adequate relief of the right ventricular outflow obstruction should be confirmed, and identification of a significant fixed anatomical obstruction should prompt further intervention. Given our current knowledge and the gaps identified, we propose several key questions to be answered by future research and potentially by a TOF registry: When to palliate or proceed with complete surgical correction, as well as the ideal type of palliation; the optimal surgical approach for complete repair for the best long-term preservation of right ventricular function; and the utility, efficacy, and durability of various pulmonary valve preservation and reconstruction techniques.

Current Strategies to Optimize Nutrition and Growth in Newborns and Infants with Congenital Heart Disease: A Narrative Review

(1) Objective: This review aims to identify the clinical and practical barriers to optimizing nutrition in newborn infants with congenital heart disease (CHD) and to describe updated evidence-based recommendations for clinical and nutritional management of these patients in a narrative review. (2) Research Methods and Procedures: We conducted a search of the relevant literature published from 2000 to December 2021. (3) Results: CHD patients undergo several nutritional challenges related to the underlying cardiac disease anomaly, the potential increased risk of NEC, and delayed enteral feeding, resulting in inadequate energy intake and sub-optimal growth, increased morbidity and mortality. (4) Conclusions: To optimize nutrition and growth in newborn infants with CHD, standardized protocols should be implemented. Regular nutritional and growth assessment with a multi-disciplinary team is essential. We propose a decisional algorithm that may represent a potentially useful tool to guide clinicians to optimize growth and nutrition.