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AbstractObjective:We hypothesized that healthcare workers (HCWs) with high-risk exposures outside the healthcare system would have less asymptomatic coronavirus 2019 (COVID-19) disease and more symptoms than those without such exposures.Design:A longitudinal point prevalence study was conducted during August 17–September 4, 2020 (period 1) and during December 2–23, 2020 (period 2).Setting:Community based teaching health system.Participants:All HCWs were invited to participate. Among HCWs who acquired COVID-19, logistic regression models were used to evaluate the adjusted odds of asymptomatic disease using high-risk exposure outside the healthcare system as the explanatory variable. The number of symptoms between exposure groups was evaluated with the Wilcoxon rank-sum test. The risk of seropositivity among all HCS by work exposure was evaluated during both periods.Interventions:Survey and serological testing.Result:Seroprevalence increased from 1.9% (95% confidence interval [CI], 1.2%–2.6%) to 13.7% (95% CI, 11.9%–15.5%) during the study. Only during period 2 did HCWs with the highest work exposure (versus low exposure) have an increased risk of seropositivity (risk difference [RD], 7%; 95% CI, 1%–13%). Participants who had a high-risk exposure outside of work (compared to those without) had a decreased probability of asymptomatic disease (odds ratio [OR], 0.38; 95% CI, 0.16–0.86) and demonstrated more symptoms (median 3 [IQR, 2–6] vs 1 [IQR, 0–4]; P= .001).Conclusions:Healthcare-acquired COVID-19 increases the probability of asymptomatic or mild COVID-19 disease compared to community-acquired disease. This finding suggests that infection prevention strategies (including masks and eye protection) may be mitigating inoculum and supports the variolation theory in COVID-19.

The utility of hemodynamic ramp studies in single ventricle patients supported by continuous flow left ventricular assist devices (CF-LVADs) is largely unknown. We report the novel use of the hemodynamic ramp test to optimize a 26 year-old Fontan-palliated single-ventricle patient supported with a continuous-flow ventricular assist device (Heartware HVAD). Modest improvements in Fontan hemodynamics resulted in significant and persistent clinical improvement and symptomatic relief.

Objective To determine the incidence and significance of ventilator avoidance in patients with critical coronavirus disease 2019 (COVID-19).Methods This prospective observational cohort study evaluated hospital mortality and 1-year functional outcome among critically ill patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-associated acute respiratory distress syndrome (ARDS). The explanatory variable was ventilator avoidance, modeled as ‘initial refusal’ of intubation (yes/no). Modified Rankin Scale (mRS) scores were obtained from surviving patients (or their surrogates) via phone or email questionnaire.Results Among patients for whom intubation was recommended (n= 102), 40 (39%) initially refused (95% confidence interval [CI] 30%, 49%). The risk of death was 79.3% (49/62) in those who did not initially refuse intubation compared with 77.5% (31/40) in those who initially refused, with an adjusted odds ratio for death of 1.27 (95% CI 0.47, 3.48). The distribution of 1-year mRS scores was not significantly different between groups.Conclusion Among critically ill patients with COVID-19-associated ARDS, ventilator avoidance was common, but was not associated with increased in-hospital mortality or 1-year functional outcome.

Cardiac output is a useful measure of myocardial performance. Standard methods of determining cardiac output are not without risk and can be problematic in children. Arterial pulse wave analysis (PulseCO), a novel, minimally invasive cardiac output determination technique, offers the advantage of continuous monitoring, convenience, and low risk. This technique has not been validated in children. The purpose of this study was to validate PulseCO as an accurate means of noninvasively determining real-time cardiac output in children.

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OBJECTIVES

Objective:Vascular endothelial growth factor and basic fibroblast growth factor are potent stimulators of angiogenesis. Children with cyanotic congenital heart disease often experience the development of widespread formation of collateral blood vessels, which may represent a form of abnormal angiogenesis. We undertook the present study to determine whether children with cyanotic congenital heart disease have elevated serum levels of vascular endothelial growth factor and basic fibroblast growth factor. Methods:Serum was obtained from 22 children with cyanotic congenital heart disease and 19 children with acyanotic heart disease during cardiac catheterization. Samples were taken from the superior vena cava, inferior vena cava, and a systemic artery. Vascular endothelial growth factor and basic fibroblast growth factor levels were measured in the serum from each of these sites by enzyme–linked immunosorbent assay. Results:Vascular endothelial growth factor was significantly elevated in the superior vena cava (P= .04) and systemic artery (P= .02) but not in the inferior vena cava (P= .2) of children with cyanotic congenital heart disease compared to children with acyanotic heart disease. The mean vascular endothelial growth factor level, determined by averaging the means of all 3 sites, was also significantly elevated (P= .03). Basic fibroblast growth factor was only significantly elevated in the systemic artery (P= .02). Conclusion:Children with cyanotic congenital heart disease have elevated systemic levels of vascular endothelial growth factor. These findings suggest that the widespread formation of collateral vessels in these children may be mediated by vascular endothelial growth factor. (J Thorac Cardiovasc Surg 2000;119:534-9)

AbstractAn aberrant right subclavian artery arising from a left aortic arch is the most frequently described congenital aortic arch anomaly, occurring in 0.5 to 2.3% of the general population. Despite the retro-oesophageal course of the aberrant subclavian artery, an arterio-oesophageal fistula is an uncommon finding, only previously reported as a very rare complication in critically ill patients with oesophageal instrumentation or foreign body ingestion. We describe a unique case of a spontaneous aberrant right subclavian arterio-oesophageal fistula without an inciting event in a 17-month-child.

Transcatheter interventional procedures have become increasingly important for the treatment of congenital heart defects. Several devices are available for use in the United States; each device is effective for only a limited number of defects. Thus, there remains a need for additional safe and effective transcatheter occlusion devices. We developed a new transcatheter device that consists of a nylon sack attached to an end‐hole catheter. A wire is advanced through the catheter into the sack. The wire coils, filling the sack, occluding the vessel, and providing transmural pressure to maintain the sack position. Prior to releasing the device, it may be repositioned, removed, or exchanged for a different size device. The device is available in four sizes (3, 5, 7, and 9 mm). We evaluated this device in an animal model, occluding subclavian and carotid arteries, and surgically created aortopulmonary shunts. All vessels were occluded completely without complication. This device can occlude a tubular patent ductus arteriosus (PDA), aortopulmonary collateral, arteriovenous fistula, aneurysm, synthetic graft, vessel supplying a tumor, or other vascular structure. The device received approval from the Food and Drug Administration (FDA), and we have used the device to occlude various cardiovascular defects including: PDA, aortopulmonary collateral vessels, and intrapulmonary arteriovenous malformations. The results have been excellent. There are only two limitations to using the device; an 8Fr sheath is needed to deliver the device, and the vessel must be long enough for the sack to contact firmly against the vessel wall. When compared to other occlusion devices, this device has several advantages: the ability to reposition the device or remove it prior to release, several different sizes, and the device conforms to many vascular shapes making it another important tool in the transcatheter armamentarium.

Objectives. This report describes the results of the Food and Drug Administration’s phase 1 and 2 clinical trials of intravascular stents at Texas Children’s Hospital.

This retrospective analysis was designed to examine the intermediate and long-term effects of balloon angioplasty for native coarctation of the aorta and to determine whether any factors are predictive of outcome.

Varicella infections commonly follow a self-limited course with minimal sequelae in the nonimmunocompromised host. Superinfections with bacterial organisms usually are found only in early childhood.1Cardiac complications are rare and usually reflective of viral myocardial involvement, with any associated pericardial effusions ascribed to a reactive serositis.2,3We present a case of isolated staphylococcal pericarditis and symptomatic cardiac tamponade as an unusual complication of a varicella infection not previously associated with adolescent patients.

For the management of systemic venous and systemic venous baffle obstructions, both surgery and isolated balloon dilation of are often unrewarding. Since 1991 we have managed such obstructions with intravascular stents. Twelve pts aged 3 mths-20 yrs Imean 8.2 yrs), have had 21 stents implanted in 13 systemic venous obstructions: 9/13 in central veins and 4/13 post atrial baffles for TGA. 12/13 obstructions were acquired and 1/13 congenital. 8/13 obstructions were symptomatic (SVC syndrome 6/8) and 5/13 were asymptomatic.

Infants with tetralogy of Fallot (TOF) and small pulmonary arteries (PAs) may need palliation to improve pulmonary blood flow and allow growth of the PAs prior to complete repair. Shunts may become occluded, distort the PAs or cause pulmonary overcirculation. As an alternative palliation, we performed pulmonary balloon valvuloplasty (PBV) on infants with TOF and small PAs.