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Background: Surgeons may leave a residual atrial-level communication during complete repair of tetralogy of Fallot (TOF) in anticipation of restrictive right ventricle physiology or as routine practice. We investigated the impact of closing the interatrial communication at the time of definitive TOF repair., Methods: We retrospectively reviewed TOF patients who underwent definitive repair at age <12 months between June 2000 and January 2023. Propensity score matching identified 82 patients with a patent interatrial communication and 50 patients with no interatrial communication on postoperative echocardiography (as-treated analysis). The primary endpoint was maximum vasoactive-inotropic score (VIS) as a surrogate for low cardiac output syndrome., Results: A total of 132 patients (median age, 3.5 months; interquartile range [IQR], 1.8-5.8 months) were matched. There was no difference in maximum VIS (patent interatrial communication: 5.0 [IQR, 4.8-9.0] vs no interatrial communication: 6.0 [IQR, 5.0-8.0]; P = .78). Additionally, the duration of inotrope therapy (3.0 [IQR, 2.0-4.0] days vs 3.0 [IQR, 1.3-4.0] days; P = .57), peak lactate (2.2 [IQR, 1.9-3.0] mmol/L vs 2.3 [IQR, 1.9-3.2] mmol/L; P = .58), time to lactate clearance (0.2 [IQR, 0.0-0.3] days vs 0.1 [IQR, 0.0-0.3] days; P = .57), chest tube duration (4.0 [IQR, 3.0-6.0] days vs 4.0 [IQR, 3.0-5.0] days; P = .23), and length of intensive care unit stay (5.0 [IQR, 3.0-7.0] days vs 5.0 [IQR, 3.0-7.0] days; P = .71) were similar in the 2 groups. The median duration of follow-up was 5.5 years (IQR, 2.7-9.9 years). Among patients with a residual communication, patency rates were 93.6% at discharge and 53.7% at latest follow-up, with most having bidirectional shunting across the defect., Conclusions: Closure of the atrial-level communication during complete TOF repair does not significantly impact the immediate postoperative course or mid-term outcomes. Further investigation is warranted to better understand how patency influences long-term outcomes., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Left ventricular outflow tract obstruction (LVOTO) remains a significant complication after primary repair of interrupted aortic arch with ventricular septal defect (IAA-VSD). Clinical and echocardiographic predictors for LVOTO reoperation are controversial and procedures to prophylactically prevent future LVOTO are not reliable. However, it is important to identify the patients at risk for future LVOTO intervention after repair of IAA-VSD. Patients who underwent single-stage IAA-VSD repair at our center 2006-2021 were retrospectively reviewed, excluding patients with associated cardiac lesions. Two-dimensional measurements, LVOT gradients, and 4-chamber (4C) and short-axis (SAXM) strain were obtained from preoperative and predischarge echocardiograms. Univariate risk analysis for LVOTO reoperation was performed using unpaired t-test. Thirty patients were included with 21 (70%) IAA subtype B and mean weight at surgery 3.0 kg. Repair included aortic arch patch augmentation in 20 patients and subaortic obstruction intervention in three patients. Seven (23%) required reoperations for LVOTO. Patient characteristics were similar between patients who required LVOT reoperation and those who did not. Patch augmentation was not associated with LVOTO reintervention. Patients requiring reintervention had significantly smaller LVOT AP diameter preoperatively and at discharge, and higher LVOT velocity, smaller AV annular diameter, and ascending aortic diameter at discharge. There was an association between LVOT-indexed cross-sectional area (CSAcm 2 /BSAm 2 ) ≤ 0.7 and reintervention. There was no significant difference in 4C or SAXM strain in patients requiring reintervention. LVOTO reoperation was not associated with preoperative clinical or surgical variables but was associated with smaller LVOT on preoperative echo and smaller LVOT, smaller AV annular diameter, and increased LVOT velocity at discharge., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The burden of neonatal mortality is primarily borne by low- and middle-income countries (LMICs), including deaths due to healthcare-associated infections (HAIs). Few studies have assessed infection prevention and control (IP&C) practices in African units caring for small and/or sick newborns aimed to reduce HAIs., Methods: We performed a mixed-methods study composed of a survey and virtual tour to assess IP&C and related practices. We created a survey composed of multiple-choice and open-ended questions delivered to site respondents via Zoom or video equivalent. Respondents provided a virtual tour of their unit via video and the study team used a checklist to evaluate specific practices., Results: We recruited 45 units caring for small and sick newborns in 20 African countries. Opportunities to optimize hand hygiene, Water, Sanitation and Hygiene (WASH) practices, Kangaroo Mother Care, and IP&C training were noted. The virtual tour offered further understanding of IP&C challenges unique to individual sites. All respondents expressed the need for additional space, equipment, supplies, education, and IP&C staff and emphasized that attention to maternal comfort was important to IP&C success., Discussion: This study identified opportunities to improve IP&C practices using low-cost measures including further education and peer support through learning collaboratives. Virtual tours can be used to provide site-specific assessment and feedback from peers, IP&C specialists and environmental engineering experts., (Copyright © 2024 The Authors. Published by Elsevier GmbH.. All rights reserved.)

Objectives: This study aimed to explore how the unprecedented stressors associated with the COVID-19 pandemic may have contributed to heightened levels of depression and anxiety among pregnant Indigenous persons, and identify protective individual-level factors., Design: The current study used a mixed-methods design including standardised questionnaires and open-ended response questions. Using hierarchical regression models, we examined the extent to which COVID-19-related factors of service disruption (ie, changes to prenatal care, changes to birth plans and social support) were associated with mental well-being. Further, through qualitative analyses of open-ended questions, we examined the coping strategies used by pregnant Indigenous persons in response to the pandemic., Setting: Participants responded to an online questionnaire consisting of standardised measures from 2020 to 2021., Participants: The study included 336 self-identifying Indigenous pregnant persons in Canada., Results: Descriptive results revealed elevated rates of clinically relevant depression (52.7%) and anxiety (62.5%) symptoms among this population. 76.8% of participants reported prenatal care service disruptions, including appointment cancellations. Thematic analyses identified coping themes of staying informed, social and/or cultural connections and activities, and internal mental well-being strategies. Disruptions to services and decreased quality of prenatal care negatively impacted mental well-being of Indigenous pregnant persons during the COVID-19 pandemic., Conclusions: Given the potential for mental well-being challenges to persist and long-term effects of perinatal distress, it is important to examine the quality of care that pregnant individuals receive. Service providers should advance policies and practices that promote relationship quality and health system engagement as key factors linked to well-being during the perinatal period for Indigenous persons., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This prospective study of pregnant patients, Surveillance To Prevent AV Block Likely to Occur Quickly (STOP BLOQ), addresses the impact of anti-SSA/Ro titers and utility of ambulatory monitoring in the detection of fetal second-degree atrioventricular block (AVB)., Methods: Women with anti-SSA/Ro autoantibodies by commercial testing were stratified into high and low anti-52-kD and/or 60-kD SSA/Ro titers applying at-risk thresholds defined by previous evaluation of AVB pregnancies. The high-titer group performed fetal heart rate and rhythm monitoring (FHRM) thrice daily and weekly/biweekly echocardiography from 17-26 weeks. Abnormal FHRM prompted urgent echocardiography to identify AVB., Results: Anti-52-kD and/or 60-kD SSA/Ro met thresholds for monitoring in 261 of 413 participants (63%); for those, AVB frequency was 3.8%. No cases occurred with low titers. The incidence of AVB increased with higher levels, reaching 7.7% for those in the top quartile for anti-60-kD SSA/Ro, which increased to 27.3% in those with a previous child who had AVB. Based on levels from 15 participants with paired samples from both an AVB and a non-AVB pregnancy, healthy pregnancies were not explained by decreased titers. FHRM was considered abnormal in 45 of 30,920 recordings, 10 confirmed AVB by urgent echocardiogram, 7 being second-degree AVB, all <12 hours from normal FHRM and within another 0.75 to 4 hours to echocardiogram. The one participant with second/third-degree and two participants with third-degree AVB were diagnosed by urgent echocardiogram >17 to 72 hours from an FHRM. Surveillance echocardiograms detected no AVB when the preceding interval FHRM recordings were normal., Conclusion: High-titer antibodies are associated with an increased incidence of AVB. Anti-SSA/Ro titers remain stable over time and do not explain the discordant recurrence rates, suggesting that other factors are required. Fetal heart rate and rhythm (FHRM) with results confirmed by a pediatric cardiologist reliably detects conduction abnormalities, which may reduce the need for serial echocardiograms., (© 2023 American College of Rheumatology.)

INTRODUCTION: A recent finding of a deep venous thrombosis during spaceflight has prompted the need to clarify mechanisms and risks of venous thromboembolism (VTE). In turn, mitigation countermeasures, diagnostic modalities, and treatment options must be explored. The objective of this review was to synthesize current evidence on VTE in spaceflight. METHODS: A literature review was performed from inception to April 2023 pertaining to VTE in the context of spaceflight or ground-based analogs with human participants. PubMed was searched for papers written in English using the terms "spaceflight" or "weightlessness" and "thrombotic" or "embolism" or "thromboembolism" in "venous" or "veins". Papers using cellular or animal models were excluded. RESULTS: There were 63 papers captured; 7 original scientific studies, 3 narrative reviews, 2 systematic reviews, and 3 commentaries discussed VTE in spaceflight. Reference lists were screened. Important themes included: altered venous hemodynamics, increased fibrinogen and coagulation markers, hypoalbuminemia, and immune dysfunction. Additional risk factors may be seen in women, such as the use of oral contraceptives. DISCUSSION: Venous stasis and decreased shear stress secondary to fluid shifts may induce inflammatory changes in the venous system, resulting in endothelial damage and upregulation of the coagulation cascade. Additionally, women in space are subject to physiological factors increasing their VTE risk, such as the use of oral contraceptives, inducing increased blood viscosity and hypoalbuminemia. Efforts should also be placed in optimizing sensitivity and specificity of imaging markers, payload, and training ability, notably the use of vector flow imaging, and improving point-of-testing biomarkers, such as albumin and p-selectin. Levasseur S, Purvis N, Trozzo S, Chung SH, Ades M, Drudi LM. Venous thromboembolism in exploration class human spaceflight . Aerosp Med Hum Perform. 2024; 95(1):45-53.

A fetal cardiology consultation involves using two-dimensional drawings to explain the cardiac anatomy which can result in inherent variation in how the congenital heart disease (CHD) is conveyed. In this pilot study, we incorporated three-dimensional printed (3DP) models into fetal counseling to demonstrate feasibility and evaluate the impact on parental knowledge, understanding, and anxiety. Parents with a prenatal diagnosis of a muscular ventricular septal defect (VSD) and/or coarctation of aorta were enrolled. Providers were randomized into a Model or Drawing Group and crossed after six months. Parents completed a survey after the consultation which evaluated knowledge of the CHD lesion, expectant surgical management, self-rated understanding, attitude towards the visualization tool, and anxiety. Twenty-nine patients enrolled over a 12 month period. Twelve consultations were done for coarctation of aorta, 13 for VSD, and four for coarctation with a VSD. Both Model and Drawing groups scored similarly in self-reported understanding and confidence, helpfulness of and improvement in communication with the visualization tool. The Model group had higher scores on questions related to the CHD anatomy and surgical intervention [5 [4-5] versus 4 [3.5-5]], p = 0.23 although this didn't reach statistical significance. For the majority (83%) of consultations, the cardiologist agreed that the 3D model improved communication. In this pilot study, we demonstrate the use of 3DP cardiac models during prenatal CHD counseling is feasible and produces results related to parental understanding and knowledge that are equal to and possibly better than the current standard of care., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: During the COVID-19 pandemic, eHealth services enabled providers to reach families despite widespread social distancing restrictions. However, their rapid adoption often occurred without community partners' involvement and without an understanding of how they prioritize aspects of their mental health and associated service provision, both of which promote family and community-centered health care delivery. Establishing priorities in health care is essential for developing meaningful and reliable health services. As such, there is an urgent need to understand how eHealth service users, especially families who may have historically faced oppression and systemic barriers to service access, can best benefit from them. Arts-based approaches can elicit an understanding of priorities by providing an engaging and expressive means of moving beyond readily expressible discursive language and stimulating meaningful dialogue reflective of participants' lived experiences., Objective: The purpose of this research is to determine the priorities and preferences of youth; parents or caregivers; newcomers and immigrants; and Indigenous community members regarding the use of eHealth in supporting their mental health using an innovative arts-based priority-setting method., Methods: This study uses a mixed-methods approach combining qualitative, quantitative, and arts-based research. It follows a survey used to identify key knowledge partners who are interested in improving eHealth services for mental health support in Manitoba, Canada. Knowledge partners interested in group-based priority setting will be contacted to participate. We will facilitate approximately two focus groups across each subgroup of youth, parents or caregivers, newcomers or immigrants, and Indigenous community members using an integrative, quantitatively anchored arts-based method termed the "Circle of Importance" to understand participants' mental health priorities and how eHealth or technology may support their mental well-being. The Circle of Importance involves placing small objects, whose meaning is determined by participants, on a visual board with concentric circles that correspond to a 5-point Likert scale of importance. Following each focus group, we will evaluate participants' and focus group facilitators' experiences of the Circle of Importance using a survey and follow-up structured in-person interviews to garner how we can improve the arts-based approach used in the focus groups., Results: The PRIME (Partnering for Research Innovation in Mental Health through eHealth Excellence) theme received institutional ethics approval on August 23, 2023. Data collection is projected for August 2023, with follow-up focus groups occurring in early 2024 as required. Data analysis will occur immediately following data collection., Conclusions: Findings will directly inform a multiyear applied research agenda for PRIME aimed at improving mental health services through engaging key knowledge partners. The results may inform how arts-based methods in a priority setting can reflect aspects of experience beyond the capacities of qualitative or quantitative methods alone, and whether this approach aligns well with a positive experience of research participation., International Registered Report Identifier (irrid): PRR1-10.2196/50208., (©Mandy Archibald, Sharifat Makinde, Nicole Tongol, Sydney Levasseur-Puhach, Leslie Roos. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 07.11.2023.)

Objectives: Prematurity is a risk factor for in-hospital mortality after cardiac surgery. The structure of intensive care unit models designed to deliver optimal care to neonates including those born preterm with critical congenital heart disease is unknown. The objective of this study was to evaluate in-hospital outcomes after cardiac surgery across gestational ages in an institution with a dedicated neonatal cardiac program., Methods: This study is a single-center, retrospective review of infants who underwent cardiac surgical interventions from our dedicated neonatal cardiac intensive care program between 2006 and 2017. We evaluated in-hospital mortality and morbidity rates across all gestational ages., Results: A total of 1238 subjects met inclusion criteria over a 11-year period. Overall in-hospital mortality after cardiac surgery was 6.1%. The mortality rate in very preterm infants (n = 68; <34 weeks' gestation at birth) was 17.6% (odds ratio, 3.52 [1.4-8.53]), versus 4.3% in full-term (n = 563; 39-40 weeks) referent/control infants. Very preterm infants with isolated congenital heart disease (without evidence of other affected organ systems) experienced a mortality rate of 10.5% after cardiac surgery. Neither the late preterm (34-36 6/7  weeks) nor the early term (37-38 6/7 ) groups had significantly increased odds of mortality compared with full-term infants. Seventy-eight percent of very preterm infants incurred a preoperative or postoperative complication (odds ratio, 4.78 [2.61-8.97]) compared with 35% of full-term infants., Conclusions: In this study of a single center with a dedicated neonatal cardiac program, we report some of the lowest mortality and morbidity rates after cardiac surgery in preterm infants in the recent era. The potential survival advantage of this model is most striking for very preterm infants born with isolated congenital heart disease., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Type 2 diabetes is a complex chronic disease rapidly increasing among young people and disproportionately impacting Indigenous youth. Treatment programs are often inadequate for this population as they lack cultural relevance. A scoping review was conducted to explore traditional Indigenous approaches for diabetes prevention and management, to inform a program aimed at supporting Indigenous youth and families with type 2 diabetes. We seek to answer the following question: " Which traditional medicines and practices have been incorporated into intervention or prevention strategies for Indigenous people living with diabetes? " Search was done June 2021 using Ovid Medline, ESBCO and ProQuest databases. Terms included wellbeing, intervention, diabetes, and traditional approaches. Of the 2138 titles screened, 34 met inclusion criteria. Three studies integrated traditional Indigenous approaches into Western-based intervention programming. Content included traditional food and nutrition programs, gardening programs, Elder knowledge sharing, story telling, talking circles, feasting, prayer, traditional dancing, hunting, and school-based wellness curricula. Many were wholistic, co-created with community, Indigenous-led and held in accessible community spaces. The heterogeneity in approaches reflects the diversity of Indigenous nations and communities. This review identifies important elements to include in culturally relevant programs to address diabetes-related wellness.

There is increased interest in inclusion, diversity and representativeness in epidemiological and community health research. Despite this progress, misunderstanding and conflation of sex and gender have precluded both the accurate description of sex and gender as sample demographics and their inclusion in scientific enquiry aiming to distinguish health disparities due to biological systems, gendered experiences or their social and environmental interactions. The present glossary aims to define and improve understanding of current sex-related and gender-related terminology as an important step to gender-inclusive epidemiological research. Effectively, a proper understanding of sex, gender and their subtleties as well as acknowledgement and inclusion of diverse gender identities and modalities can make epidemiology not only more equitable, but also more scientifically accurate and representative. In turn, this can improve public health efforts aimed at promoting the well-being of all communities and reducing health inequities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: We aimed to investigate the utility of comprehensive screening fetal echocardiography (FE) for patients diagnosed with any type of fetal extracardiac malformation (ECM) at a single multidisciplinary fetal center., Methods: We retrospectively reviewed all patients presenting to our referral center for FE due to a prenatal diagnosis of ECM (January 2013-December 2018)., Results: Among 641 patients with ≥1 ECM referred for FE, 78 (12.2%) had CHD diagnosed at 25.6 ± 0.5 weeks. The frequency of CHD by type of ECM ranged from 35.1% for craniofacial to 9.8% for thoracic. Increasing number of fetal ECMs was strongly associated with CHD: odds ratio 2.01 (95% confidence interval: 1.06-3.69) for two ECMs, 9.57 (2.00-49.05) for three ECMs, and 11.68 (3.84-37.15) for more than three ECMs. Of fetuses with ECM and an abnormal genetic finding, 33.3% had CHD as compared to 10.9% of those without (p < 0.0001). Obstetric anatomy sonogram detected 43.6% of CHD., Conclusion: CHD was commonly diagnosed among fetuses with any type of ECM at our center but was not always detected on obstetric sonogram. As the presence of CHD may impact decision-making and perinatal care, patients with a diagnosis of any fetal ECM should be considered for FE., (© 2021 John Wiley & Sons Ltd.)

One third of fatal car accidents and so many tragedies are due to alcohol abuse. These sad numbers could be mitigated if everyone had access to a breathalyzer anytime and anywhere. Having a breathalyzer built into a phone or wearable technology could be the way to get around reluctance to carry a separate device. With this goal, we propose an inexpensive breathalyzer that could be integrated in the screens of mobile devices. Our technology is based on the evaporation rate of the fog produced by the breath on the phone screen, which increases with increasing breath alcohol content. The device simply uses a photodiode placed on the side of the screen to measure the signature of the scattered light intensity from the phone display that is guided through the stress layer of the Gorilla glass screen. A part of the display light is coupled to the stress layer via the evanescent field induced at the edge of the breath microdroplets. We demonstrate that the intensity signature measured at the detector can be linked to blood alcohol content. We fabricated a prototype in a smartphone case powered by the phone's battery, controlled by an application installed on the smartphone, and tested it in real-world environments. Limitations and future work toward a fully operational device are discussed.

Male genitalia present an extraordinary pattern of rapid divergence in animals with internal fertilization, which is usually attributed to sexual selection. However, the effect of ecological factors on genitalia divergence could also be important, especially so in animals with nonretractable genitalia because of their stronger interaction with the surrounding environment in comparison with animals with retractable genitalia. Here, we examine the potential of a pervasive ecological factor (predation) to influence the length and allometry of the male genitalia in guppies. We sampled guppies from pairs of low-predation (LP) and high-predation (HP) populations in seven rivers in Trinidad, and measured their body and gonopodium length. A key finding was that HP adult males do not have consistently longer gonopodia than do LP adult males, as had been described in previous work. However, we did find such divergence for juvenile males: HP juveniles have longer gonopodia than do LP juveniles. We therefore suggest that an evolutionary trend toward the development of longer gonopodia in HP males (as seen in the juveniles) is erased after maturity owing to the higher mortality of mature males with longer gonopodia. Beyond these generalities, gonopodium length and gonopodium allometry were remarkably variable among populations even within a predation regime, thus indicating strong context dependence to their development/evolution. Our findings highlight the complex dynamics of genitalia evolution in Trinidadian guppies., Competing Interests: None declared., (© 2021 The Authors. Ecology and Evolution published by John Wiley & Sons Ltd.)

The current pandemic has driven the medical community to adapt quickly to unprecedented challenges. Among these challenges is the need to minimize staff exposure to COVID-19 during neonatal cardiac procedures. In this report, we describe measures we have taken to protect health care workers while ensuring successful outcomes. These measures include wearing appropriate personal protective equipment, physical distancing, designating separate delivery and transport teams, and limiting the number of providers in direct contact with any patient who is infected or whose infection status is unknown., Learning Objectives: 1.To understand specific challenges caused by the COVID-19 pandemic for patients with congenital heart disease needing urgent neonatal intervention.2.To recognize measures that can be taken to minimize health care workers' exposures to the virus during high-risk neonatal cardiac procedures.3.To review the management of neonates with d-transposition of the great arteries and inadequate mixing., Competing Interests: The authors have no conflicts of interest to declare., (© 2020 Published by Elsevier B.V.)

Background We sought to assess the impact and predictors of coronavirus disease 2019 (COVID-19) infection and severity in a cohort of patients with congenital heart disease (CHD) at a large CHD center in New York City. Methods and Results We performed a retrospective review of all individuals with CHD followed at Columbia University Irving Medical Center who were diagnosed with COVID-19 between March 1, 2020 and July 1, 2020. The primary end point was moderate/severe response to COVID-19 infection defined as (1) death during COVID-19 infection; or (2) need for hospitalization and/or respiratory support secondary to COVID-19 infection. Among 53 COVID-19-positive patients with CHD, 10 (19%) were <18 years of age (median age 34 years of age). Thirty-one (58%) had complex congenital anatomy including 10 (19%) with a Fontan repair. Eight (15%) had a genetic syndrome, 6 (11%) had pulmonary hypertension, and 9 (17%) were obese. Among adults, 18 (41%) were physiologic class C or D. For the entire cohort, 9 (17%) had a moderate/severe infection, including 3 deaths (6%). After correcting for multiple comparisons, the presence of a genetic syndrome (odds ratio [OR], 35.82; P =0.0002), and in adults, physiological Stage C or D (OR, 19.38; P =0.002) were significantly associated with moderate/severe infection. Conclusions At our CHD center, the number of symptomatic patients with COVID-19 was relatively low. Patients with CHD with a genetic syndrome and adults at advanced physiological stage were at highest risk for moderate/severe infection.

Background: Our understanding of the impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on pregnancies and perinatal outcomes is limited. The clinical course of neonates born to women who acquired coronavirus disease 2019 (COVID-19) during their pregnancy has been previously described. However, the course of neonates born with complex congenital malformations during the COVID-19 pandemic is not known., Methods: We report a case series of seven neonates with congenital heart and lung malformations born to women who tested positive for SARS-CoV-2 during their pregnancy at a single academic medical center in New York City., Results: Six infants had congenital heart disease and one was diagnosed with congenital diaphragmatic hernia. In all seven infants, the clinical course was as expected for the congenital lesion. None of the seven exhibited symptoms generally associated with COVID-19. None of the infants in our case series tested positive by nasopharyngeal test for SARS-CoV-2 at 24 hours of life and at multiple points during their hospital course., Conclusions: In this case series, maternal infection with SARS-CoV-2 during pregnancy did not result in adverse outcomes in neonates with complex heart or lung malformations. Neither vertical nor horizontal transmission of SARS-CoV-2 was noted.

Approximately, 1.7 million individuals in the United States have been infected with SARS-CoV-2, the virus responsible for the novel coronavirus disease-2019 (COVID-19). This has disproportionately impacted adults, but many children have been infected and hospitalised as well. To date, there is not much information published addressing the cardiac workup and monitoring of children with COVID-19. Here, we share the approach to the cardiac workup and monitoring utilised at a large congenital heart centre in New York City, the epicentre of the COVID-19 pandemic in the United States.

Objectives: To describe fetal echocardiographic findings associated with lower urinary tract obstruction (LUTO) and to compare anatomic and hemodynamic measurements between fetuses with LUTO and gestational age (GA)-matched controls, with an emphasis on quantitative indices of diastolic function and cardiac output., Methods: This was a retrospective cohort study of fetuses diagnosed with severe LUTO with giant bladder, which underwent at least one fetal echocardiogram at our center between January 2005 and June 2018. Fetuses with major congenital heart disease were excluded. Control fetuses did not have any structural or functional abnormalities and were GA-matched to the LUTO fetuses based on the time of the first fetal echocardiogram. Cardiac anatomy and hemodynamic measurements were compared between fetuses with LUTO and controls. In infants with LUTO, serial fetal and postnatal echocardiographic data were assessed, when available, and clinical outcomes were reviewed., Results: Twenty-six fetuses with LUTO and at least one fetal echocardiogram available were identified, one of which was excluded due to hypoplastic left heart syndrome, leaving 25 LUTO fetuses in the final cohort. The mean GA at the first fetal echocardiogram was 25.4 ± 5.1 weeks in the LUTO group and 25.3 ± 5.0 weeks in the control group. Common findings in fetuses with LUTO included cardiomegaly (40%), pericardial effusion (44%), right ventricular (RV) hypertrophy (64%) and left ventricular (LV) hypertrophy (48%). Compared with GA-matched controls, LUTO fetuses had lower ascending aorta Z-score (-0.10 ± 0.94 vs -0.93 ± 1.03; P = 0.02) and aortic isthmus Z-score (-0.14 ± 0.86 vs -1.62 ± 1.11; P < 0.001), shorter mitral valve inflow time indexed to cardiac cycle length (0.46 ± 0.04 vs 0.41 ± 0.06; P = 0.002), and worse (increased) LV myocardial performance index (0.39 ± 0.03 vs 0.44 ± 0.04; P < 0.001). In addition, the ratio of RV to LV cardiac index was higher in LUTO fetuses compared with controls (1.62 ± 0.13 vs 1.33 ± 0.11; P < 0.001). Of the 25 LUTO pregnancies, two were lost to follow-up, three underwent elective termination of pregnancy and three ended in intrauterine fetal demise. Four (16%) patients had mildly hypoplastic left-heart structures, comprising two with aortic arch hypoplasia and two with mitral and aortic stenosis., Conclusion: In addition to presenting with cardiomegaly, pericardial effusion and ventricular hypertrophy, fetuses with LUTO demonstrate LV diastolic dysfunction and appear to redistribute cardiac output as compared to control fetuses, which may contribute to the development of left-heart hypoplasia. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd., (Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.)

Although low birth weight is a known risk factor for mortality in congenital heart lesions and may consequently delay surgical repair, outcomes in low-weight neonates undergoing the arterial switch operation (ASO) have not been well described. Our objective was to assess the safety of this procedure in infants weighing ≤2.5 kg at the time of surgery. We retrospectively analyzed outcomes for all neonates undergoing the ASO at our institution from 2005 to 2015. Our primary outcome of interest was major morbidity or operative mortality, assessed as a composite outcome. From 2005 to 2015, 217 neonates underwent the ASO, with 31 (14%) weighing ≤2.5 kg at the date of surgery, and 8 weighing <2.0 kg. Neonates weighing ≤2.5 kg were more likely to be premature than those weighing >2.5 kg, but there was no difference in the age at operation between these groups. Overall, 32 infants experienced a major morbidity or mortality, including 37.5% (n = 3) weighing <2.0 kg, 8.7% (n = 2) weighing 2.0-2.5 kg, and 14.5% (n = 7) weighing >2.5 kg (P = 0.141). One infant weighing <2.0 kg (1.1 kg) and 4 infants weighing >2.5 kg died. In multivariable models, odds of major morbidity or mortality were significantly higher for infants weighing <2 kg compared with infants weighing >2.5 kg (odds ratio 3.93, 95% confidence interval 1.04-14.85, P = 0.044), but there was no difference between infants weighing 2.0-2.5 kg and those weighing >2.5 kg (P = 0.225). The ASO can be performed safely in 2.0- to 2.5-kg neonates and yields results comparable with higher weight infants. Imposed delays for corrective surgery may not be necessary for these low-weight infants with transposition of the great arteries., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: Global and regional myocardial deformation have not been well described in fetuses with pulmonary atresia and intact ventricular septum (PA/IVS). Speckle-tracking echocardiography (STE), an angle-independent technique for assessing global and regional strain, may be a more sensitive way of determining ventricular systolic dysfunction compared with traditional 2D echocardiography. The aim of this study was to assess myocardial deformation in fetuses with PA/IVS compared with control fetuses and to determine if, in fetuses with PA/IVS, strain differs between those with and those without right ventricle-dependent coronary circulation (RVDCC)., Methods: This was a retrospective analysis of fetuses with PA/IVS examined at two medical centers between June 2005 and October 2017. Left ventricular (LV) and right ventricular (RV) regional and global longitudinal strain (GLS) and strain rate were obtained using STE, and comparisons were made between fetuses with PA/IVS and gestational age (GA)-matched controls. Postnatal outcome was assessed, including the presence of RVDCC., Results: Fifty-seven fetuses with PA/IVS and 57 controls were analyzed at a mean GA of 26.5 ± 5 weeks. LV-GLS was significantly decreased in fetuses with PA/IVS compared with controls (-17.4 ± 1.7% vs -23.7 ± 2.0%, P < 0.001). LV strain rate was also significantly decreased (-1.01 ± 0.21/s vs -1.42 ± 0.20/s, P < 0.001). Fetuses with PA/IVS had decreased strain in all segments. Similarly, RV strain was significantly decreased in fetuses with PA/IVS (-11.6 ± 3.8% vs -24.6 ± 2.5%, P < 0.0001). Thirty-six patients had postnatal cardiac catheterization performed to define coronary anatomy; 10 fetuses had RVDCC. Fetuses with RVDCC had decreased LV strain compared with those without (-15.8 ± 1.2% vs -17.9 ± 1.7%, P = 0.009). RV strain was also decreased in fetuses with RVDCC vs those without (-7.0 ± 2.9% vs -12.1 ± 3.2%, P = 0.0004)., Conclusions: Fetuses with PA/IVS have decreased global and regional LV and RV strain compared with controls. The finding of decreased LV strain may be due to altered ventricular mechanics in the context of a hypertensive right ventricle and/or abnormal coronary perfusion. Moreover, fetuses that were found to have RVDCC postnatally had decreased LV and RV strain compared with those that did not. These results encourage further investigation to assess whether fetal ventricular strain could be a prenatal predictor of RVDCC. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd., (Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.)

Purpose: To evaluate the efficacy and safety of early pars plana vitrectomy (PPV) for the treatment of acute infective endophthalmitis, and identify prognostic factors for better visual outcome., Design: Retrospective cohort study., Methods: Consecutive patients who underwent early PPV within 72 hours of presentation for the treatment of acute infective bacterial endophthalmitis and presented to a large tertiary referral center in New South Wales, Australia, between January 2009 and December 2013 were included. Changes in best-corrected visual acuity (VA) from baseline to 1 year were examined., Results: A total of 64 patients were included. The inciting events were cataract surgery (53%), intravitreal injection (36%), trabeculectomy (3%), and endogenous (3%). The mean VA improved from 3.1 logMAR (hand motion) at baseline to 1.02 (approximately 20/200) at 1 year, with 42% achieving final VA equal to or better than 0.477 logMAR (20/60) following early PPV. Positive prognostic factors were negative microbial cultures ( P < 0.01) and etiology of post-cataract surgery ( P < 0.01). In multivariable analyses adjusting for age and prognostic factors, patients with baseline VA of light perception and hand motion achieved greater visual gains than those with counting fingers, with gains of logMAR of -2.68, -2.09, and -0.85, respectively ( P < 0.0001)., Conclusions: Most patients who undergo early PPV experience substantial VA improvement. Negative microbial cultures and endophthalmitis after cataract surgery were associated with better final visual outcome. Patients with presenting VA of light perception or hand motion achieved higher visual gains than those with counting fingers, suggesting the possibility that early PPV may be beneficial in both groups., (Copyright 2019 Asia-Pacific Academy of Ophthalmology.)

Background: D-transposition of the great arteries (TGA) or TGA-type double outlet right ventricle (DORV) with ventricular septal defect (VSD) and left ventricular outflow tract obstruction (LVOTO) may be treated with the arterial switch operation (ASO), Rastelli, Réparation à l'Etage Ventriculaire (REV), or Nikaidoh procedures. We evaluated midterm results of these techniques., Methods: We retrospectively reviewed 42 cases of anatomic repair from 2005 to 2014 at our institution for TGA (n = 29) or TGA-type DORV (n = 13) with VSD and LVOTO. We analyzed outcomes (mortality, reoperation, residual/recurrent LVOT peak gradient ≥20 mm Hg, right ventricular outflow tract [RVOT] peak gradient ≥40 mm Hg) and performed a risk analysis. Mean follow-up was 5.77 ± 3.08 years., Results: Seventeen (40.5%) patients had an ASO with (n = 4) or without (n = 13) LVOTO resection. The Rastelli, REV, and Nikaidoh procedures were used in 14 (33%), 5 (12%), and 6 (14%) patients, respectively. There were no mortalities or moderate aortic insufficiency at last follow-up. Three (9%) patients developed LVOT gradient ≥20 mm Hg, while nine (21.4%) patients had RVOT obstruction. Reoperations included RVOT/pulmonary artery reoperation (n = 10; 23.8%) and LVOT reoperation (n = 1; 2.5%). Freedom from reoperation was 84% ± 6% and 75% ± 9% at one and three years, respectively, for the entire cohort with no differences between groups by type of operation (log-rank P = .64). The Nikaidoh procedure compared favorably to all other techniques in terms of reoperation (n = 0/6; 0% vs n = 13/36; 36%; P = .08)., Conclusions: Midterm outcomes after anatomic repair for TGA or TGA-type DORV with LVOTO and VSD are excellent but vary by surgical technique. The Nikaidoh procedure seems to compare favorably to the other techniques.

Background: Fetal atrioventricular block (AVB) occurs in 2% to 4% of anti-Ro antibody-positive pregnancies and can develop in <24 h. Only rarely has standard fetal heart rate surveillance detected AVB in time for effective treatment., Objectives: Outcome of anti-Ro pregnancies was surveilled with twice-daily home fetal heart rate and rhythm monitoring (FHRM) and surveillance echocardiography., Methods: Anti-Ro pregnant women were recruited from 16 international centers in a prospective observational study. Between 18 and 26 weeks' gestation, mothers checked FHRM twice daily with a commercially available Doppler monitor and underwent weekly or biweekly surveillance fetal echocardiograms. If FHRM was abnormal, a diagnostic echocardiogram was performed. Cardiac cycle length and atrioventricular interval were measured, and cardiac function was assessed on all echocardiograms. After 26 weeks, home FHRM and echocardiograms were discontinued, and mothers were monitored during routine obstetrical visits. Postnatal electrocardiograms were performed., Results: Most mothers (273 of 315, 87%) completed the monitoring protocol, generating 1,752 fetal echocardiograms. Abnormal FHRM was detected in 21 mothers (6.7%) who sought medical attention >12 h (n = 7), 3 to 12 h (n = 9), or <3 h (n = 5) after abnormal FHRM. Eighteen fetuses had benign rhythms, and 3 had second- or third-degree AVB. Treatment of second-degree AVB <12 h after abnormal FHRM restored sinus rhythm. Four fetuses had first-degree AVB diagnosed by echocardiography; none progressed to second-degree AVB. No AVB was missed by home FHRM or developed after FHRM., Conclusions: Home FHRM confirms the rapid progression of normal rhythm to AVB and can define a window of time for successful therapy. (Prospective Maternal Surveillance of SSA [Sjögren Syndrome A] Positive Pregnancies Using a Hand-held Fetal Heart Rate Monitor; NCT02920346)., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: To report the posterior segment and retinal vascular manifestations of calcific uremic arteriolopathy (calciphylaxis). Clinical findings are correlated with multimodal imaging results., Methods: Observational case report., Results: A 65-year-old white woman on hemodialysis was referred for assessment of poor vision bilaterally. Clinical examination demonstrated a crystalline retinopathy with stigma of previous retinal arterial occlusion. Fluorescein angiography revealed delayed retinal arterial filling bilaterally, sheathing of vessels, and peripheral nonperfusion. The crystals were hyperautofluorescent. Spectral domain and enhanced depth imaging optical coherence tomography localized the crystals within the retina with a predilection for the retinal arterial vasculature. The choriocapillaris was not involved. Two years prior, the patient developed necrotic skin lesions which were biopsied and confirmed the diagnosis of calciphylaxis., Conclusion: Calcific uremic arteriolopathy is an extremely rare cause of thrombogenic microangiopathy in end-stage renal disease patients. Retinal arterial occlusion appears to be a rare but significant cause of visual loss in this disease and is likely to be consequent to crystalline deposition in the retinal vasculature.

Background: Macular holes in children are generally associated with trauma., Case Presentation: We report the first case of an idiopathic full thickness macular hole in a 10-year-old girl. 23-gauge transconjunctival pars plana vitrectomy, induction of a posterior vitreous detachment, ILM blue-assisted internal limiting membrane peel, fluid-air exchange and air-26% sulfur hexafluoride (SF6) exchange was performed with subsequent macular hole closure., Conclusion: This is the first reported case of an idiopathic full thickness macular hole in a child. Treatment with pars plana vitrectomy with peeling of the ILM resulted in significant anatomic and functional improvement.

Survival is significantly compromised in infants born with congenital diaphragmatic hernia and major cardiac anomalies. Mortality is highest when congenital diaphragmatic hernia occurs in association with d-transposition of the great arteries. We present three infants with congenital diaphragmatic hernia associated with d-transposition of the great arteries from a single institution. All three infants survived to discharge after surgical repair/palliation of both the diaphragmatic hernia and heart defect and are doing well at last follow-up. The clinical course and management of these three patients are described.

Objective: Fetuses exposed to anti-SSA (Sjögren's) antibodies are at risk of developing irreversible complete atrioventricular block (CAVB), resulting in death or permanent cardiac pacing. Anti-inflammatory treatment during the transition period from normal heart rhythm (fetal heart rhythm (FHR)) to CAVB (emergent CAVB) can restore sinus rhythm, but detection of emergent CAVB is challenging, because it can develop in ⩽24 h. We tested the feasibility of a new technique that relies on home FHR monitoring by the mother, to surveil for emergent CAVB., Study Design: We recruited anti-SSA-positive mothers at 16 to 18 weeks gestation (baseline) from 8 centers and instructed them to monitor FHR two times a day until 26 weeks, using a Doppler device at home. FHR was also surveilled by weekly or every other week fetal echo. If FHR was irregular, the mother underwent additional fetal echo. We compared maternal stress/anxiety before and after monitoring. Postnatally, infants underwent a 12-lead electrocardiogram., Results: Among 133 recruited, 125 (94%) enrolled. Among those enrolled, 96% completed the study. Reasons for withdrawal (n=5) were as follows: termination of pregnancy, monitoring too time consuming or moved away. During home monitoring, 9 (7.5%) mothers detected irregular FHR diagnosed by fetal echo as normal (false positive, n=2) or benign atrial arrhythmia (n=7). No CAVB was undetected or developed after monitoring. Questionnaire analysis indicated mothers felt comforted by the experience and would monitor again in future pregnancies., Conclusion: These data suggest ambulatory FHR surveillance of anti-SSA-positive pregnancies is feasible, has a low false positive rate and is empowering to mothers.

Background: Repair of complete atrioventricular canal (CAVC) with tetralogy of Fallot (TOF) is a challenging operation increasingly being performed as a complete, primary repair in infancy. Previous studies have focused on perioperative outcomes; however, midterm valve function, ventricular function, and residual obstruction have received little attention., Methods: We retrospectively reviewed 20 patients who underwent CAVC/TOF repair (January 2005 to December 2014). A two-patch repair was used in all patients to correct the CAVC defect. Tetralogy of Fallot repair included transannular patch in 11 (65%) patients and valve-sparing in 6 (35%) patients., Results: The average age at surgery was 72 ± 122 weeks, 40% were male, and 80% had trisomy 21. Mean echo follow-up was 3.0 ± 3.0 years. There were no in-hospital or late mortalities. The rate of reoperation was 20%. At the latest follow-up, moderate left atrioventricular valve regurgitation was present in three (15%) patients and mild stenosis present in seven (35%) patients. One (5%) patient had moderate right ventricular outflow tract (RVOT) obstruction. The valve-sparing population was smaller at the time of surgery than the non-valve-sparing cohort (body surface area: 0.28 ± 0.04 vs 0.42 ± 0.11, P = .002) and less likely to have had a previous shunt (0% vs 64%, P = .01). Among the valve-sparing patients (six), at the latest follow-up, moderate pulmonary insufficiency was present in two (33%) patients., Conclusion: Repair of CAVC concomitant with TOF can be performed with low mortality and acceptable perioperative morbidity. Management of the RVOT remains a challenge for the long term.

Background: Hospital mortality of stage I palliation in patients with hypoplastic left heart syndrome and weighing less than or equal to 2.5 kg remains high. We aimed to (1) assess outcomes in this specific population in a dedicated neonatal cardiac program and (2) determine factors associated with poor outcomes., Methods: We retrospectively analyzed outcomes in patients weighing less than or equal to 2.5 kg who underwent a stage I palliation at our institution (2006 to 2014) and performed a risk analysis. Twenty-eight patients were included. Mean follow-up was 26.2 ± 27 months., Results: Median weight at surgery was 2.29 kg (range, 1.3 to 2.5 kg). A Sano conduit as opposed to a Blalock-Taussig shunt was placed in 22 patients (78.6%). Timing of surgery was delayed in 5 patients (18%) because of prematurity or extracardiac condition. Coronary fistulae, ventricular dysfunction, and greater than moderate atrioventricular valve regurgitation were present in 2 patients each. Hospital mortality rate was 10.7% (3 of 28 patients). One patient (3.7%) required an early, unplanned reintervention, and 1 patient underwent a late arch revision at the time of stage II. Late mortality or heart transplant rate was 8% (2 of 25 patients). Stage II and stage III procedures were performed in 19 (76%) and 8 (32%) survivors. Survival after stage 2 palliation was 100% (19 of 19 patients) and 87% after Fontan (7 of 8 patients). On univariate analysis, low birthweight (p = 0.03), delayed surgery (p = 0.05), preoperative comorbidities (p = 0.03), postoperative extracorporeal membrane oxygenation (p = 0.04), neurologic complications (p = 0.03), and dialysis (p = 0.04) were associated with higher hospital mortality., Conclusions: Stage-I palliation in patients with hypoplastic left heart syndrome weighing less than or equal to 2.5 kg can be achieved with good early and late outcomes. Very low birth weight, delayed surgery, comorbidities, and severe postoperative complications were associated with higher hospital mortality., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Repair of complete atrioventricular canal early in infancy has traditionally carried greater morbidity and mortality than repair performed later. However, an individualized anatomy-based repair may give young infants outcomes that are equivalent to older patients., Methods: We retrospectively reviewed 139 patients who underwent complete atrioventricular canal repair from January 2005 to December 2012. An individualized approach was used: 2-patch repair was performed in 98 patients for large ventricular septal defects and a modified single-patch ("Australian technique") was used in 41 for "shallow" ventricular septal defects., Results: The average age was 25.5 ± 3.9 weeks, 50% were boys, and 78% had trisomy 21. Mean follow-up was 5.1 ± 0.2 years, with 100% completeness of data. There were 3 in-hospital deaths (2.1%) and 1 late death (0.7%). A permanent pacemaker was required in 2 patients (1.4%). The rate for left atrioventricular valve reoperation was 8% at a mean of 211 ± 238 days after the original repair (range, 6 to 682 days). Compared with patients aged older than 3 months, the 39 patients (28%) who were younger than 3 months had similar perioperative courses and rate of reoperation. Compared with patients with an Australian repair, the 98 patients (71%) with a 2-patch repair were more likely to have trisomy 21 and had slightly increased cardiopulmonary bypass and cross-clamp times but similar outcomes. Multivariate analysis showed postoperative left atrioventricular valve regurgitation greater than 2 and left ventricular outflow tract obstruction were significant risk factors for reoperation on the left atrioventricular valve (both p < 0.05)., Conclusions: Repair of complete atrioventricular canal using an individualized surgical approach yields reoperation and early mortality rates similar for younger infants compared with older infants, obviating the need to delay operation in symptomatic patients., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)