Transcatheter Ductal Stents Versus Surgical Systemic-Pulmonary Artery Shunts in Neonates With Congenital Heart Disease With Ductal-Dependent Pulmonary Blood Flow: Trends and Associated Outcomes From the Pediatric Health Information System Database

Background Surgical systemic-to-pulmonary artery shunts have been the standard approach to establish stable pulmonary blood flow in neonates with congenital heart disease with ductal-dependent pulmonary blood flow. More recently, transcatheter ductal stents have been performed as an alternative, less invasive intervention. We aimed to characterize trends in the utilization of surgical shunts versus ductal stents and compare associated outcomes. Methods and Results Using data from the Pediatric Health Information System, we retrospectively analyzed neonates with congenital heart disease with ductal-dependent pulmonary blood flow who underwent surgical shunt or ductal stent placement between January 2016 and December 2021. Patients were identified by International Classification of Diseases, Tenth Revision (ICD-10) diagnosis and procedure codes. The primary outcome was length of hospital stay. Secondary outcomes were reintervention risk and adjusted hospital costs. Of 936 patients included, 65.2% underwent a surgical shunt over the 6-year period. The proportion who underwent ductal stenting increased from 19% to 53.4% from 2016 to 2021. The median adjusted difference in postintervention length of hospital stay was 11 days greater for the surgical shunt cohort (95% CI, 7.2-14.8; P<0.001). The adjusted reintervention risks within 3 (odds ratio [OR], 3.37 [95% CI, 1.91-5.95], P<0.001) and 6 months (OR, 2.43 [95% CI, 1.62-3.64], P<0.001) were significantly greater in the ductal stent group. Median adjusted index hospital costs were $198 300 ($11 6400-$340 000) versus $120 400 ($81 800-$192 400) for the surgical shunt and ductal stent cohorts, respectively (P<0.001). Conclusions Ductal stenting has become an increasingly utilized palliative approach to secure pulmonary blood flow in neonates with congenital heart disease with ductal-dependent pulmonary blood flow in the United States. Ductal stenting is associated with decreased length of hospital stay and reduced overall cost for the index hospitalization but with a greater reintervention risk than surgical shunting.

Perioperative Anesthetic Management of the Pregnant Patient With Congenital Heart Disease Undergoing Cardiac Intervention: A Systematic Review

Maternal congenital heart disease is increasingly prevalent, and has been associated with a significantly increased risk of maternal, obstetric, and neonatal complications. For patients with CHD who require cardiac interventions during pregnancy, there is little evidence-based guidance with regard to optimal perioperative management. The periprocedural management of pregnant patients with congenital heart disease requires extensive planning and a multidisciplinary teams-based approach. Anesthesia providers must not only be facile in the management of adult congenital heart disease, but cognizant of the normal, but significant, physiologic changes of pregnancy.

Elective Non-Urgent Balloon-Atrial Septostomy in Infants with d-Transposition of the Great Arteries Does Not Eliminate the Need for PGE1 Therapy at the Time of Arterial Switch Operation

Once a mainstay in the treatment of neonates with d-transposition of the great arteries (d-TGA), the application of balloon atrial septostomy (BAS) in the d-TGA population has become more selective. Currently, there is no clear evidence for or against a selective BAS strategy. The aims of this single-center retrospective study were to determine the incidence of BAS in the neonatal d-TGA population in the current era, to measure the rate of procedural success, and to compare the outcomes and complication rates of patients who underwent BAS to those who underwent neonatal ASO alone. Between 2012 and 2018, 147 patients with d-TGA underwent initial medical management and ASO, 73 of which underwent BAS. The percentage of patients that underwent BAS decreased from 73 to 33% over the study time period. In patients with d-TGA with intact ventricular septum, 33% of patients remained off of PGE₁ at the time of surgery regardless of BAS. In d-TGA with ventricular septal defect, 85.7% of those that underwent BAS and 54.1% of those who did not remained off of PGE₁ at the time of surgery, however, this difference did not reach statistical significance. In this single institution retrospective cohort of patients with d-TGA, the performance of a technically successful balloon atrial septostomy did not eliminate the need for PGE₁ therapy at the time of definitive ASO. This was true regardless of the presence or absence of a ventricular septal defect.

Near-Infrared Spectroscopy in Pediatric Congenital Heart Disease

Near-infrared spectroscopy (NIRS) is widely used to monitor tissue oxygenation in the pediatric cardiac surgical population. Clinicians who use NIRS must understand the underlying measurement principles in order to interpret and use this monitoring modality appropriately. The aims of this narrative review are to provide a brief overview of NIRS technology, discuss the normative and critical values of cerebral and somatic tissue oxygen saturation and the interpretation of these values, present the clinical studies (and their limitations) of NIRS as a perioperative monitoring modality in the pediatric congenital heart disease population, and introduce the emerging and future applications of NIRS.

Elective Extracorporeal Membrane Oxygenation Support for High-Risk Pediatric Cardiac Catheterization

OBJECTIVE

The utility of extracorporeal membrane oxygenation (ECMO) as an elective support modality for high-risk cardiac procedures is extensively described in adults, but its use in children is limited to isolated reports. The objective of this study was to analyze the outcomes of patients who underwent elective cannulation to ECMO for this purpose.

DESIGN

Single-center, retrospective chart review.

SETTING

Free-standing pediatric tertiary care center.

PARTICIPANTS

Patients who underwent elective cannulation to ECMO for cardiorespiratory support during a high-risk cardiac catheterization procedure.

INTERVENTIONS

Elective ECMO cannulation for high-risk percutaneous cardiac interventions or electrophysiology procedures.

MEASUREMENTS AND MAIN RESULTS

Survival to discharge was 71.4% compared with 30% for patients who required extracorporeal cardiopulmonary resuscitation in the cardiac catheterization laboratory. The mean duration of cannulation was 137.43 hours (range 27-615 h, median 55 h). There were no major neurologic sequelae, but ECMO circuit thrombosis (57%) was relatively common.

CONCLUSION

The use of elective ECMO support for high-risk pediatric cardiac catheterizations can be accomplished safely and may allow for an improved rate of survival with lower rates of severe adverse events compared with extracorporeal cardiopulmonary resuscitation as rescue therapy.

Perioperative and Anesthetic Considerations in Interrupted Aortic Arch

Interrupted aortic arch (IAA) is defined as the loss of luminal continuity between the ascending and descending aorta and is classified based on the anatomic level of interruption. IAA is associated with a number of intracardiac anomalies with the most common being patent ductus arteriosus, ventricular septal defect, and left ventricular outflow obstruction. There is also a strong association between type B interruption and 22q11 deletion syndrome. The perioperative management of the neonate with IAA begins in the intensive care unit with optimization of end-organ perfusion and function. Survival depends on the prompt initiation of prostaglandin E1 in order to maintain ductal patency, careful management of the patient’s ratio of pulmonary to systemic blood flow (Qp:Qs), and a thorough understanding of the physiologic implications of the surgical plan, type of interruption, and associated syndromes and anomalies. This review will focus on the anatomy, physiology, and perioperative anesthetic management considerations specific to the management of IAA.

Adhesion and integration of tissue engineered cartilage to porous polyethylene for composite ear reconstruction

The objective of this study was to assess the ability of tissue engineered cartilage to adhere to and integrate with porous polyethylene (PPE) in vivo and to evaluate the biomechanical integrity of the bond formed at the interface. Porcine auricular, articular, and costal chondrocytes were suspended in fibrin gel polymer and placed between discs of PPE to form tri-layer constructs. Controls consisted of fibroblasts suspended in gel or gel alone between the discs. Constructs were implanted into nude mice for 6, 12, and 18 weeks. Upon harvest, specimens were evaluated for neocartilage formation and integration into the PPE, using histological, dimensional (mass, thickness, diameter), and biomechanical (adhesion strength, interfacial stiffness, failure energy and failure strain) analyses. Neotissue was formed in all experimental constructs, consisting mostly of neocartilage integrating with discs of PPE. Control samples contained only fibrous tissue. Biomechanical analyses demonstrated that adhesion strength, interfacial stiffness, and failure energy were all significantly higher in the chondrocyte-seeded samples than in fibroblast-seeded controls, with the exception of costal constructs at 12 weeks, which were not significantly greater than controls. In general, failure strains did not vary between groups. In conclusion, porous polyethylene supported the growth of neocartilage that formed mechanically functional bonds with the PPE.

Quality assurance guidelines for surgical outreach programs: a 20-year experience

Numerous American volunteer organizations travel throughout the developing world, providing surgical services to those in need. Medical staff who undertake such missions must contend with the realities inherent to providing healthcare abroad. Inadequate medical facilities and equipment, coupled with a short mission duration and the lack of substantial integration with the local medical community, greatly increase the risk of unnecessary medical complications. At present, there is no definitive set of quality assurance guidelines for the surgical outreach community. This report draws on 20 years of outreach experience to recommend a set of quality assurance guidelines for surgical outreach missions.