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BACKGROUND The atretic connection between the left fourth and sixth aortic arches is a rare congenital cardiac anomaly with controversial debates on its origin. This anatomy has been previously reported with additional cardiac anomalies of maldevelopment. AIMS We present the successful surgical management of a 3-month-old female with Cornelia de Lange syndrome and coarctation of the aorta in the setting of this unique collateral channel. MATERIALS & METHODS We review the beneficial utility and novelty of three-dimensional computed tomography angiography for this anatomic lesion while also discussing the importance of multidisciplinary preoperative planning in the coordinated management of this arch anomaly and potential concomitant comorbid conditions. RESULTS The presented surgical case demonstrates the successful reconstruction of the aortic arch by coarctectomy with extended end-to-end anastomosis by a left posterolateral thoracotomy in a patient with a collateral arch channel and a hemodynamically significant aortic coarctation. CONCLUSION Atretic connection between the left fourth and sixth aortic arches remains a rare congenital anomaly and may occur in the setting of an aortic coarctation. Unclear arch anatomy and indeterminant proximal aortic sizing on echocardiogram should prompt cross-sectional imaging with computed tomography angiography to guide surgical technique selection for aortic arch reconstruction when a collateral arch channel or unique branching pattern is suspected.

Evaluate the use of coronary CTA as an initial assessment for determining Right Ventricle Dependent Coronary Circulation (RVDCC) in neonates with Pulmonary Atresia with Intact Ventricular Septum (PA IVS). Retrospective review of cases with coronary CTA and compare with available catheter angiography, pathology, surgical reports, and outcomes from Mar 2015 to May 2022. In our cohort of 16 patients, 3 were positive for RVDCC, confirmed by pathologic evaluation, and there was concordance for presence or absence of RVDCC with catheter angiography in 5 patients (4 negatives for RVDCC, 1 positive). Clinical follow up for the 8 patients that underwent RV decompression had no clinical evidence of myocardial ischemia. Our findings suggest that coronary CTA is reliable as first-line imaging for determination of RVDCC in neonates with PA IVS. These findings, if supported by further prospective study, may reserve invasive coronary angiography for cases with diagnostic uncertainty or at the time of necessary transcatheter interventions.

The use of paper or nylon bags (fruit bagging) to surround tree fruit during development provides protection from a variety of pest-disease complexes for peach without yield reduction and different-colored bags have the potential to improve fruit quality based on findings from other crops. An experiment was conducted in 2019 at two locations in central Florida on peach [Prunus persica (L.) Batch] ‘TropicBeauty’ and ‘UFSun’ to analyze the impact of a commercially available white paper fruit bag combined with a photoselective insert. The insert reduced the amount of light outside the spectrum range of interest for blue (400–500 nm), green (500–600 nm), or red (>600 nm) wavebands, or decreased fluence rate with a neutral density black (>725 nm) insert. Relative to ambient, temperature inside all bagging treatments during the daytime hours was increased by 5.1 °C. During the same time, relative humidity was reduced by 10.1%, but calculations revealed that the water vapor pressure was elevated only for treatments that had a plastic colored (blue, green, or red) insert. An orthogonal contrast revealed that the elevated water vapor around the fruit in a colored bag increased the concentration of chlorophyll at harvest but had no effect on other quality parameters. Compared with unbagged fruit, red-bagged fruit were 1.8 times firmer and green-bagged fruit and had a lower peel chroma. White-bagged (without photoselective insert) fruit had similar nutrient concentrations for the peel, flesh, and pit when compared with unbagged fruit. When bags remained on the fruit until harvest, anthocyanin concentration in unbagged fruit peel was double the amount in white bags and 6-fold more than the bags with color inserts. Different-colored bagging treatments did not influence insect attraction or fruit quality parameters, such as fruit size, diameter, difference of absorbance (DA) index, total soluble solids (TSS), titratable acidity (TA), pH, peel lightness, peel hue, flesh lightness, flesh hue, or flesh chroma. Relative to full sun, the colored bag treatments allowed between 3.7% (black) and 17.4% (red) of the photosynthetically active radiation (PAR). Additional research is needed to determine if an increase in fluence rate at specific spectral wavelengths can affect the quality for peach grown in bags in the field.

Cardiac tumors remain rare in children with benign pathologies predominating. Indications for surgical management often result from compromised ventricular chamber size, biventricular outflow tract obstruction, impaired ventricular function, or the presence of medically refractory dysrhythmias. We present a case of a six-month-old infant with two intracardiac fibromas originating in the interventricular septum. The fibromas were causing significant biventricular outflow obstruction. The patient successfully underwent tumor resection on cardiopulmonary bypass The literature on pediatric cardiac tumors is reviewed. Multi-disciplinary medical planning is necessary for successful anesthetic and surgical treatment of this high-risk patient population.

Surgical site infections (SSI) following congenital heart surgery (CHS) remain a significant source of morbidity. Delayed sternal closure (DSC) is often required to minimize the potential for hemodynamic instability. The purpose of this study was to determine the incidence of SSI among patients undergoing DSC versus primary chest closure (PCC) and to define a potential inflection point for increased risk of SSI as a function of open chest duration (OCD).A retrospective review of our institutional Society of Thoracic Surgeons dataset is to identify patients undergoing CHS at our institution between 2015 and 2020. Incidences of SSI were compared between DSC and PCC patients. DSC patients were evaluated to determine the association of OCD and the incidence of SSI.2582 operations were performed at our institution between 2015 and 2020, including 195 DSC and 2387 PCC cases. The incidence of SSI within the cohort was 1.8% (47/2,582). DSC patients had significantly higher incidences of SSI (17/195, 8.7%) than PCC patients (30/2387, 1.3%, p 0.001). Further, patients with an OCD of four or more days had a significantly higher incidence of SSI (11/62, 17.7%, p = 0.006) than patients with an OCD less than 4 days (6/115, 5.3%).The incidence of SSI following CHS is higher in DSC patients compared to PCC patients. Prolonged OCD of 4 days or more significantly increases the risk of SSI and represents a potentially modifiable risk factor for SSI predisposition. These data support dedicated, daily post-operative assessment of candidacy for chest closure to minimize the risk of SSI.

Fruit bagging is an acceptable cultural practice for organic production that provides a physical barrier to protect fruit. It can reduce pest and pathogen injury for a variety of fruit crops, but quality attributes have been inconsistent for peach [Prunus persica (L.) Batsch] and other bagged fruit. A 2-year experiment on a U.S. Department of Agriculture (USDA) organic-certified peach orchard in central Florida was conducted to analyze the effects of a commercially available paper bag designed for fruit protection and cardinal quadrant (north, south, east, and west sides) of the tree canopy on low-chill peach ‘TropicBeauty’ fruit quality. Protective bags appeared to delay fruit maturity. Flesh firmness and chlorophyll concentration of bagged fruit were 31% and 27% greater than unbagged fruit, respectively. Bagged fruit were protected as demonstrated with a reduction in mechanical injury by 95%, fruit fly injury by 450%, and scab-like lesions by 810%. Bagging reduced fruit brown rot (Monilinia fructicola) at harvest and 7 days after harvest; unbagged fruit were 2 and 3.5 times more likely to have rot at harvest and 7 days after harvest, respectively. Fruit bags did not affect yield, fruit size, total soluble solids, titratable acidity, pH, peel lightness, peel hue angle, or flesh color. Overall, canopy cardinal quadrant location had minimal effect on fruit quality or fruit injury. These results demonstrate that bagging peach fruit protects against various pests and diseases but has minimal effects on fruit quality. Broad adoption of this technology is highly dependent on available labor, market demands, and profitability but may be suitable for producers using direct-to-consumer market channels.

In this article, we introduce a p arallelizing a pproximatio n - d isc o very f ra mework, PANDORA, for automatically discovering application- and architecture-specialized approximations of provided code. PANDORA complements existing compilers and runtime optimizers by generating approximations with a range of Pareto-optimal tradeoffs between performance and error, which enables adaptation to different inputs, different user preferences, and different runtime conditions (e.g., battery life). We demonstrate that PANDORA can create parallel approximations of inherently sequential code by discovering alternative implementations that eliminate loop-carried dependencies. For a variety of functions with loop-carried dependencies, PANDORA generates approximations that achieve speedups ranging from 2.3x to 81x, with acceptable error for many usage scenarios. We also demonstrate PANDORA’s architecture-specialized approximations via FPGA experiments, and highlight PANDORA’s discovery capabilities by removing loop-carried dependencies from a recurrence relation with no known closed-form solution.

This cohort study investigates the association between the COVID-19 pandemic and waiting list times among pediatric heart transplant recipients in the US.

Elastic properties of the thoracic aorta are responsible for buffering systemic afterload, and may be particularly important in patients with Fontan circulation, in whom heart failure is a major source of attrition. The purpose of this study was to characterize regional stiffness in the ascending and descending aorta in patients with hypoplastic left heart syndrome and single left ventricle morphology after Fontan operation by cardiac magnetic resonance imaging, and to assess whether changes in aortic stiffness are associated with the ventricular function.Phase-contrast-derived pulse-wave velocity (PWV) and relative-area change (RAC) were measured in the ascending and descending aorta of patients with hypoplastic left heart syndrome (n = 9), patients with single left ventricle circulation (n = 18), and normal controls (n = 8) by magnetic resonance imaging. Stiffness metrics were then correlated with the ventricular volumetric and functional indices.Patients with hypoplastic left heart syndrome had elevated ascending aortic PWV along with reduced RAC when compared with controls (both P values .001). Patients with a single left ventricle presented no change in PWV but had reduced RAC in comparison to controls (P .01). There were no differences in PWV and RAC between all considered groups in the descending aorta. PWV and RAC measured in the ascending aorta correlated with end-systolic and end-diastolic volume indices, ventricular ejection fraction, and ventricular-vascular coupling ratio.Aortic stiffness is most elevated in patients with hypoplastic left heart syndrome, yet patients with single left ventricle morphology show signs of abnormal stiffness as well in the form of reduced aortic strain. Stiffness indices measured in the ascending aorta were associated with overall ventricular function and measures of aortoventricular coupling in both patient populations.

Objective This study used cardiac magnetic resonance imaging to evaluate flow characteristics and ventricular hemodynamics for children with single right (hypoplastic left heart syndrome) and single left (hypoplastic right heart syndrome) systemic ventricle anatomy after Fontan palliation compared with normal biventricular controls. Methods Twenty children with single ventricle anatomy (hypoplastic left heart syndrome, n = 10; hypoplastic right heart syndrome, n = 10) underwent standardized 4-dimensional flow cardiac magnetic resonance and were compared with age-matched controls (n = 10). End-diastolic volume was partitioned into 4 defined components of variable kinetic energy (direct flow, retained inflow, delayed ejection, and residual volume) and compared between groups. Further, volumetric and functional parameters as defined by cardiac magnetic resonance were evaluated. Results Children with hypoplastic left heart syndrome had significantly increased indexed end-diastolic and end-systolic volumes compared with both hypoplastic right heart syndrome and control groups. Flow component analysis demonstrated diastolic inefficiency in both hypoplastic left heart syndrome and hypoplastic right heart syndrome groups compared with controls as defined by decreased direct flow and increased residual volumes. Decreased direct flow correlated with decreased ejection fraction and increased end-diastolic and end-systolic volume indices. Increased residual volume correlated with decreased ejection fraction and increased end-systolic volume index. Conclusions Fontan-palliated patients with single ventricle physiology (hypoplastic left heart syndrome and hypoplastic right heart syndrome) demonstrate altered and inefficient flow patterns in the systemic ventricle as defined by 4-dimensional flow cardiac magnetic resonance compared with normal biventricular controls. Decreased direct flow and increased residual volume indicate that diastolic ventricular dysfunction is prevalent after Fontan palliation. This study provides a foundation for future predictive modeling and cardiac magnetic resonance flow diagnostic studies in this high-risk patient population.

Background The purpose of this study was to determine whether aortic biomechanical properties are abnormal in children with repaired truncus arteriosus (TA) and to concurrently evaluate left ventricular (LV) function post-repair utilizing a novel platform for regional ventricular function. Methods Cardiac magnetic resonance (CMR) studies from 26 children (mean age: 15.6 ± 7.2 years) post-TA repair were compared with 20 normal controls (mean age: 14.7 ± 2.6 years). Parameters of aortic stiffness (pulse wave velocity and relative area change) were measured. Flow hemodynamic metrics (aortic regurgitant fraction, peak systolic flow, and peak systolic velocity) and LV function (volumetric data, ejection fraction, regional wall strain) were also compared. Results Ascending aortic pulse wave velocity was elevated and relative area change was decreased in TA patients compared with controls. Patients post-TA repair demonstrated elevated end diastolic and end systolic volumes in addition to decreased regional wall strain and increased mechanical dyssynchrony. LV functional changes were independent of aortic biomechanical properties. Conclusions Children with repaired TA have increased ascending aortic stiffness and altered LV function as measured by CMR imaging. Longitudinal studies and advanced CMR assessments are warranted to better determine the long-term potential for late aortic complications and to optimize both the medical and surgical management of these patients after TA repair.

Objective Neonatal orthotopic heart transplantation was introduced in the 1980s as a treatment for complex congenital heart disease. Progress in single-ventricle palliation and biventricular correction has resulted in a decline in neonatal heart transplant volume. However, limited reports on neonatal heart transplants have demonstrated favorable outcomes. We report the long-term outcomes of patients with neonatal heart transplants at our institution spanning nearly 30 years. Methods A retrospective analysis of neonatal heart transplants and neonates listed for transplant was performed at Children's Hospital Colorado. Primary outcomes were early and late survival. Secondary outcomes were rejection episodes, retransplantation, and development of cardiac allograft vasculopathy or post-transplant lymphoproliferative disease. Results A total of 21 neonates underwent orthotopic heart transplantation at our institution. Among these, 10 neonates were transplanted from 1991 to 2000, 8 neonates were transplanted from 2001 to 2010, and 3 neonates were transplanted from 2011 to 2020. The average age of these patients was 17 days, and the average weight was 3.43 kg. Early survival was 95.2%. Survival at 1 and 5 years was 85.7% (confidence interval [CI], 61.9%-95.2%) and 75% (CI, 45.6%-85.5%), respectively. Of eligible patients, the 10-year and 20-year survival was 72.2% (CI, 45.1%-85.3%) and 50% (CI, 25.9%-70.1%), respectively. Conclusions Our institution reports favorable outcomes of neonatal heart transplantation. These results should be considered within the context of outcomes for patients awaiting transplant and the limited donor availability. However, the successful nature of these procedures suggest it may be necessary to reevaluate the indications for neonatal heart transplantation, particularly where risk of mortality and morbidity with palliative or corrective surgery is high.

Organic and conventional production are common in horticulture crops and each system may exert a different influence on the soil ecosystem, particularly the nematode community. Crop nutrient rate is an important choice in both production systems. The objectives of this study were to assess the impacts of (i) organic and conventional production systems and (ii) nutrient rate in both systems on the nematode community in carrot production. To investigate these objectives, field studies in organic and conventional production – which included fumigation with 1,3-dichloropropene – were conducted in North-Central Florida. In both production systems, nutrient rate treatments were 168, 224, 280, 336, and 392 kg N/ha. Poultry litter was the nitrogen source in organic production whereas synthetic, inorganic fertilizer was used in conventional production. All nematode trophic groups were consistently more abundant in organic than conventional production. The nematode community was more diverse and had greater trophic structure in organic production. Greater rates of organic nutrients increased enrichment opportunists (bacterivores and fungivores), but inconsistently across years. Conventional production had similar results except that only moderate nutrient rates increased fungivore abundances. Extreme enrichment opportunists (Rhabditis spp.) drove bacterivore trends in organic production whereas moderate enrichment opportunists (Cephalobus spp.) drove trends in conventional production. Nutrient rates did not affect omnivore-predators, herbivores, nematode community diversity, or structure in either system. In summary, type of production system, organic or conventional, exerts a strong influence on the nematode community, but nutrient rate has less consistent effects in horticulture production.

In this paper, we introduce PANDORA---a framework that complements existing parallelizing compilers by automatically discovering application- and architecture-specialized approximations. We demonstrate that PANDORA creates approximations that extract massive amounts of parallelism from inherently sequential code by eliminating loop-carried dependencies---a long-time goal of the compiler research community. Compared to exact parallel baselines, preliminary results show speedups ranging from 2.3x to 81x with acceptable error for many usage scenarios.

Although castor (Ricinus communis L.) oil has high commercial value for industrial uses as well as a feedstock for biodiesel, the United States has relied on imported castor oil since 1972. In Florida, the crop has been considered as an alternative crop to the more traditional agronomic row crops and would likely be produced under center pivot or other irrigation systems to maximize yield and fit with existing cropping systems. To develop an appropriate Kc value for the central Florida region, research was conducted at the University of Florida’s Plant Science Research and Education Unit in Citra, FL. Season-long crop transpiration was measured for the castor cultivar ‘Brigham’ in 2011 and 2012 and soil evaporation rates were quantified in 2012. Crop transpiration was obtained by sap flow analysis when the plots had reached complete canopy cover, were fully irrigated, and when daily solar radiation levels were at or above a historical radiation average to accurately reflect optimum growing conditions. Daily average plant transpiration (57,199 and 56,560 L ha−1 in 2011 and 2012, respectively) were predominantly greater than daily soil evaporation (38 L ha−1 in 2012), and as a result, the season long plant transpiration was the main factor included for the calculation of crop evapotranspiration (ETc). The ETc was evaluated against the reference evapotranspiration (ETo) from site specific meteorological data to calculate daily Kc values. The 10-day Kc averages were compared to published Kc values from the Food and Agriculture Organization (FAO) for castor. The crop developmental timeframes in this study were roughly aligned with the FAO timeframes when making these comparisons. The mid-season Kc values were similar to the FAO reference (1.19, Florida vs. 1.15 FAO ref.), but the late season Kc values for castor in Florida were higher as compared to the FAO reference (1.50 vs. 0.55, respectively). The increase in water use during this late season developmental period could be explained by a lack of physiological decline in this sub-tropical climate and continued irrigation application for this trial during the latter part of the season. These results provide appropriate Kc values for central Florida and will aid growers in irrigation decisions when producing castor in this region.

Background Ventricular tachyarrhythmias are the most common cause of death in patients with repaired tetralogy of Fallot (TOF), but predicting those at risk remains a challenge. An electrophysiology study (EPS) has been proposed to risk stratify patients with TOF. Objective We sought to evaluate a perioperative EPS-guided approach to risk stratify patients with TOF undergoing pulmonary valve replacement (PVR) and guide concomitant cryoablation. Methods A prospective cohort study of patients with TOF undergoing an EPS at the time of PVR from 2006 to 2017 was conducted at 2 centers. Patients inducible at the time of pre-PVR had undergone concomitant cryoablation in addition to PVR. A repeat post-PVR EPS was performed in those initially inducible to guide implantable cardioverter-defibrillator (ICD) implantation. Results Of 70 patients who underwent a pre-PVR EPS, 34 (49%) had inducible sustained ventricular tachycardia (VT): 25 monomorphic VT and 9 polymorphic VT. Among patients undergoing cryoablation, 14 (45%) had inducible VT and underwent ICD implantation. During a mean follow-up period of 6.1 ± 3.2 years, 3 patients (21%) had appropriate ICD shocks for symptomatic VT. There was an average of 2.3 shocks (range 1–4 shocks), and the mean time to first shock post–device implantation was 3.6 years (range 2.9–4.3 years). Among patients with negative pre- or post-PVR EPS results, 2 had VT requiring radiofrequency ablation and/or subsequent ICD implantation. There were no arrhythmic deaths. Conclusion A pre-PVR EPS identified patients with higher-risk TOF undergoing PVR. Despite empirical VT cryoablation at the time of PVR, a high percentage of patients remained inducible for VT. In this high-risk cohort, post-PVR EPS evaluation is important to identify patients at risk of VT despite cryoablation.

Pulmonary atresia with intact ventricular septum (PA/IVS) with right ventricular-dependent coronaries is a rare congenital cardiac anomaly. It has been associated with wide range of considerable anomalies including sinusoids, fistulae, coronary stenosis, or complete atresia. Coronary artery aneurysms in a neonate with PA/IVS have not been described. We report a case of neonate with pulmonary atresia with intact ventricular septum with giant coronary artery aneurysms.

Background: The purpose of this study was to characterize tachyarrhythmias in children following the Norwood procedure. Methods: This is a single-center retrospective study including all children who underwent stage I Norwood procedure (n = 98; January 2003-September 2011). The primary outcome measure is the development of tachyarrhythmia during hospitalization after the Norwood procedure. Secondary aims include quantification of mortality in patients with tachyarrhythmias and evaluation of potential risk factors for the development of tachyarrhythmia. Results: Tachyarrhythmia occurred in 33 (34%) of 98 patients. The median time to onset of tachyarrhythmia was ten days (0-47 days). Tachyarrhythmia conferred no increase in overall mortality ( P = .45), including operative mortality ( P = .37) or interstage mortality ( P = 1.00). There was no significant difference in the incidence of arrhythmia based on demographic, anatomic, or surgical variables, including shunt type ( P = .23) except that patients with tachyarrhythmias were slightly larger (median weight 3.2 kg) at the time of stage I than those without tachyarrhythmia (median weight 2.93 kg; P = .02]. The odds of arrhythmia in males were 8.7 times higher than that in females (95% confidence interval 2.9-31.3; P < .0001). Conclusions: Postoperative tachyarrhythmia is common, occurring in 34% of patients after the Norwood operation. Onset of tachyarrhythmia occurred later after the Norwood operation than reported previously, and male gender is a risk factor. Further studies to elucidate the etiology and the timing of tachyarrhythmias after the Norwood procedure are necessary.

While castor (Ricinus communis L.) oil is an essential component in many industrial products, the U.S. currently imports all castor oil stocks due to the lack of domestic production of the crop since 1972. To reestablish U.S. production of castor, regional agronomic assessments of cultivars and management systems are required to assess the economic sustainability of the crop. A comparison of two castor cultivars (Hale and Brigham) and management systems using plant growth regulators and harvest aids was conducted at two different locations (PSREU and WFREC) within Florida during two years (2011 and 2012) with the goal of assessing yield potential and phenological development of the crop in this semi-tropical climate. Yields were low in comparison to other U.S. regions where the crop has been tested with the highest yields being 1357 kg ha−1 for Brigham at PSREU in 2011 and the lowest being 686 kg ha−1 for Brigham at PSREU in 2012. Mold observed on both cultivars and significant rates of shatter could have led to upwards of 60% yield loss, indicating that yield potential in the region may be much higher. Oil percentages on average across sites and years were very consistent between the cultivars, with 45.0 and 45.4% for Brigham and Hale, respectively. Typical growth patterns of height, leaf area index (LAI), reproductive development, and root architecture were characterized for the region. The maximum height recorded for either cultivar did not exceed 115.2 cm and the maximum seasonal LAI value was 2.87. Brigham produced between 3 and 8 more racemes than Hale by the end of the season, depending on the site/year. The application of a mepiquat chloride based plant growth regulator (PGR) did not reduce plant height at either location and had no consistent impact on photosynthetic capacity of the crop. The harvest aid paraquat led to over six times more leaf desiccation and leaf defoliation within 11 days after treatment and was more effective overall than the tribufos harvest aid.

Delayed presentation of coarctation of the aorta can be associated with severe complications. A challenging case of aortoenteric fistula secondary to an aneurysm from coartation of the aorta presented with massive gastrointestinal hemorrhage. The clinical management of this patient and a review of the literature are presented.

Real time three-dimensional echocardiography (RT3DE) allows for accurate morphological characterization of congenital heart disease and complements two-dimensional (2D) echocardiography. Accurate evaluation of the mitral valve and supramitral ring prior to surgery aids the surgeon in successful resection of the ring and repair of associated mitral valve abnormalities. We report a case of congenital mitral valve stenosis from a supramitral ring in a young child using real time three-dimensional transesophageal echocardiography.

The effect of surgical history on graft outcomes in patients with functionally univentricular hearts (UH) is not well understood. We compared graft outcomes after heart transplantation in children with a UH between patients who received allografts without prior cardiac surgery (Group A) and patients who underwent transplantation after prior cardiac surgery (Group B).We reviewed all patients who received allografts for UH at our institution from 1990 to 2009. Differences in the probability of acute rejection (AR), incidence of graft vasculopathy (GV), and incidence of death or retransplantation were compared between Group A and Group B. Student's t-test, Mann-Whitney U-test, the log-rank test, logistic regression, and Cox proportional hazards modeling were used as appropriate.During the study period, 180 patients with a UH received allografts: 105 in Group A and 75 in Group B at a median (interquartile range) age of 84 (47-120) days vs 584 (168-2,956) days, respectively (p0.001). The odds of AR were higher in Group B (odds ratio, 2.7, 95% confidence interval, 1.3-5.4). Group A had lower univariable risks of GV (p = 0.034) and graft loss (p = 0.003). Median graft survival was 18 years in Group A vs 8 years in Group B. The risk of graft loss after 5 years post-transplant was higher in Group B patients who were aged ≥ 1 year at time of transplant (p0.001).Heart transplantation without prior cardiac surgery in patients with a UH was associated with better graft survival and lower probability of AR. The effect of age is complex and time-dependent, with age affecting outcomes after 5 years.

All-terrain vehicle (ATV) accidents leading to severe morbidity and mortality are common. At our institution, 2 children presented within weeks of each other after ATV accidents. Both children required cardiac valve surgery. The surgical management of these 2 children is discussed, and the literature is reviewed. On initial patient presentation, the diagnosis of a ruptured cardiac valve or ventricular septal defect (VSD) associated with these types of accidents is often delayed. We propose that patients presenting with evidence of high-energy blunt thoracic trauma after an ATV accident should undergo an electrocardiogram, cardiac enzyme assessment, and cardiac echocardiogram as part of the initial work-up to rule out significant myocardial injury.

A previously healthy, 13-year-old girl presented with new-onset dilated cardiomyopathy, and is placed on a left ventricular assist device (VAD). Herein we describe a unique VAD weaning protocol used to determine the timing and feasibility of a VAD explant.

Objective: Incision into the ventricular septum in complex biventricular repair is controversial, and has been blamed for impairing left ventricular function. This retrospective study evaluates the risk of a ventricular septal incision in patients undergoing double outlet right ventricle (DORV) repair and Ross—Konno procedure. Methods: From January 2003 to September 2007, 11 patients with DORV had a ventricular septum (VS) incision and 12 DORV patients did not. Sixteen patients had a Ross—Konno, and 16 had an isolated Ross procedure. The ventricular septalincisionwasmadetomatch atleastthediameterofa normalaorticannulus.In DORV,the VSDwasenlargedsuperiorly andtothe left.Inthe Ross—Konno, the aortic annulus was enlarged towards the septum posteriorly and to the left. Results: The median follow-up for the study is 19 months (1 month—4 years). For DORV, there were no significant differences in discharge mortality (p = 0.22), late mortality (p = 0.48), or late mortality plus heart transplant (p = 0.093). Although patients with DORVand VSD enlargement have a more complex postoperative course, there were no differences in ECMO use (p = 0.093), occurrence of permanent AV block (p = 0.55), left ventricular ejection fraction (LVEF) (p = 0.40), or shortening fraction (LVSF) (p = 0.50). Similarly, for the Ross—Konno there were no significant differences in discharge mortality (p = 0.30), late mortality (p = NS), LVEF (p = 0.90) and LVSF (p = 0.52) compared to the Ross, even though the Ross—Konno patients were significantly younger (p < 0.0001). Conclusion: Making a ventricular septal incision in DORV repair and in the Ross—Konno operation does not increase mortality and does not impair the LV function. The restriction of the VSD remains an important issue in the management of complex DORV. These encouraging results need to be confirmed by larger series.

Anomalous origin of the coronary arteries may limit the applicability of aortic valve sparing techniques during root replacement. We report a case of a right coronary artery that originated from the left sinus and coursed intramurally in a patient with an aortic root aneurysm. Attention to the anatomic relation between the anomalous coronary and aortic root structures and right coronary safety button reconstruction allowed safe aortic root replacement while preserving the native aortic valve.

Classic options for treatment of hypoplastic left heart syndrome include the Norwood procedure (NW) and heart transplantation (HT). Recently off-pump palliative procedures were introduced in the management of these patients. Risk factors influencing the decision between the NW with staged reconstruction or off-pump palliation and HT were assessed.Between January 2002 and January 2006, 69 patients with hypoplastic left heart syndrome were referred for either a NW (n = 33) or HT (n = 36). Patients referred for HT underwent off-pump palliation (catheter-based, n = 20, or surgical hybrid procedures, n = 7) until a donor organ became available: including patent ductus arteriosus stenting (80.6%), atrial septostomy (41.7%), and branch pulmonary artery banding (55.6%).Heart transplantation patients were more complex, based on a higher Aristotle Comprehensive Complexity score calculated at birth (HT 18.8 +/- 2.4 versus NW 17.7 +/- 1.7; p0.05). Presurgical death was significantly greater for HT referrals (HT 27.8% versus NW 3.0%; p0.01); however, there was no difference between the two groups in operative (HT 11.5% versus NW 21.9%; not significant) or overall mortality (HT 36.1% versus NW 24.2%; not significant). No independent risk factors for death were identified with HT; however, a lower birth weight (2.5 kg) and a higher Aristotle score (20) correlated with surgical death with NW (p0.01). Noticeably, surgical survival was 85.7% for infants with birth weight of 2.5 kg or greater undergoing NW.Overall survival is similar for hypoplastic left heart syndrome patients referred for the NW or HT. Lower birth weight and higher complexity are risk factors for patients undergoing NW. Off-pump palliation followed by HT or further staged palliation should be considered for these high-risk hypoplastic left heart syndrome patients.

Background: The STS-EACTS International Nomenclature for Congenital Heart Surgery (CHS) defines four anatomic subtypes of double outlet right ventricle (DORV) based on the relationship of the ventricular septal defect (VSD) with the great vessels and the presence of right ventricular outflow tract obstruction (RVOTO). We reviewed our experience with DORV patients and two ventricles that underwent repair, applying this nomenclature. Methods: Between January 2000 and January 2005, 50 patients with DORV and two viable ventricles underwent surgical intervention:44patientshadbiventricularrepair,3had1 1ventricularrepair,2underwentaFontan,and1diedpriortocorrectivesurgery.Median age at repair was 9.1 months (range: 4D—4Y). Eighteen patients (36%) were DORV-Fallot (including 5 with AVSD and heterotaxy), 9 (18%) were DORV-TGA (Taussig-Bing), 12 (24%) were DORV-VSD, and 11 (22%) were DORV non-committed VSD. Corrective surgery included 35 repairs with a VSD-aorta baffle RVOTO procedure and 12 arterial switches with a VSD-PA baffle (9 Taussig-Bing and 3 DORV-ncVSD). Associated procedures included 13 VSD enlargements, 8 subaortic resections, 9 arch repairs, 5 AVSD repairs, and 7 others. Results: There were three deaths in the 50 patients studied (overall mortality of 6%). Excluding one patient that died prior to corrective surgery and the two patients palliatedwith a Fontan procedure, the actual surgical mortality for a corrective repair was 4.3% (2/47 patients). Two surgical deaths occurred following, respectively, one repair of a Taussig-Bing with an interrupted arch and a Swiss cheese VSD and one repair of ncVSD-type with pulmonary atresia that had undergone a previous cavo-pulmonary anastamosis. No late deaths occurred. Two late reoperations included a heart transplant in a DORV-Fallot patient with Swiss cheese VSD and subaortic resection in a DORV-ncVSD patient. Angioplasties were needed for PA stenosis (n = 2) and aortic arch obstruction(n = 2).Four patients hadLV to aorta bafflegradients between10and 20 mmHg.All patientswere of NYHA class I/II.Conclusions: The STS-EACTS International Nomenclature provides more uniform analysis of outcomes with respect to acceptable surgical risk and mortality. Biventricular repair can be safely achieved on selected DORV, including DORV-ncVSD and DORV with AVSD and heterotaxy lesions traditionally indicated for a single ventricle palliative approach.

Elastin arteriopathy–associated supravalvar pulmonary stenosis is characterized by a thick intraluminal ringlike obstruction at the sinotubular junction of the pulmonary valve. Extension of disease into the branch pulmonary arteries is common. A three-sinus pulmonary trunk augmentation combined with bilateral branch pulmonary augmentation is presented. This approach normalizes the pulmonary trunk and allows optimal augmentation of the central pulmonary arteries.

Introduction: Infants with single ventricle physiology typically undergo cardiac catheterization prior to superior cavopulmonary anastomosis (SCPA) to assess operative suitability. Predictors of poor outcome at sea level include elevated central venous pressure (CVP), transpulmonary gradient (TPG), pulmonary vascular resistance (PVR) and pulmonary artery (PA) size. Living at higher altitude has vasoconstrictive effects on the pulmonary vasculature, and a prior study suggested that higher PA pressure may predict worse outcomes. The goal of this study was to determine which elements of the pre-SCPA catheterization were useful in predicting successful Fontan operation at altitude. Methods: A retrospective review revealed 150 patients who underwent pre-SCPA catheterization over a 10-year period. Pre-SCPA catheterization data were abstracted and subjects were grouped by progression to Fontan vs. aborted palliation, heart transplant or death. Statistical analysis included Wilcoxon Rank Sum tests, uni-variable logistic regression and receiver operator characteristic (ROC) curve analysis. Results: Differences between groups at cardiac catheterization are summarized in Table 1. Logistic regression showed that larger PA diameter was protective; left PA: OR: 0.73, 95% CI: 0.6-0.9, p = 0.01; right PA: OR:0.73, 95% CI: 0.6-0.9, p = 0.02. ROC analysis defined thresholds for minimum left PA and right PA diameter of Conclusions: Our data suggest that pulmonary arterial size, more so than measured pressure or resistance, influences ability to achieve Fontan palliation at higher altitude. We hypothesize that this may be a feature of differences in pulmonary arterial growth. An alternative approach to evaluating pulmonary arterial morphology during palliation, such as cross-sectional imaging, may help optimize individual patient hemodynamics and provide better predictors of outcome.

The failing Fontan circulation presents difficult treatment challenges. When Fontan revision and or intervention for treatable arrhythmias are not feasible, heart transplantation is the only therapeutic option. Particular challenges presented by these patients include limited ability to assess hemodynamics, complex anatomy, multiple prior procedures, and unique underlying pathologic states. These issues complicate the decision-making process for further surgical intervention verses transplantation. The pretransplant evaluation, transplant operation, and postoperative management are more problematic for these patients compared with most patients undergoing transplantation. Consequently, failing Fontan patients constitute one of the highest risk heart transplant subsets.

Traumatic airway perforation during endotracheal intubation is an uncommon but life-threatening complication in preterm infants. Death usually occurs at the time of the injury, but in rare cases where the infant survives the initial resuscitation, therapeutic options include conservative versus surgical management. We describe three cases of airway perforation treated successfully with surgical intervention and without lung resection, utilizing novel graft material and cardiopulmonary bypass to facilitate repair. In preterm infants who survive the initial injury we advocate for early identification and surgical management with cardiopulmonary bypass when feasible.

Background. Maintenance steroid (MS) use in pediatric heart transplantation (HT) varies across centers. The purpose of this study was to evaluate the impact of steroid-free maintenance immunosuppression (SF) on graft outcomes in pediatric HT. Methods. Patients younger than 18 years in the United States undergoing a first HT during 1990 to 2010 were analyzed for conditional 30-day graft loss (death or repeat HT) and death based on MS use by multivariable analysis. A propensity score was then given to each patient using a logistic model, and propensity matching was performed using pre-HT risk factors, induction therapy, and nonsteroid maintenance immunosuppression. Kaplan-Meier graft and patient survival probabilities by MS use were then calculated. Results. Of 4894 patients, 3962 (81%) were taking MS and 932 (19%) SF. Of the 4530 alive at 30 days after HT, 3694 (82%) and 836 (18%) were in the MS and SF groups, respectively. Unmatched multivariable analysis showed no difference in 30-day conditional graft survival between MS and SF groups (hazard ratio=1.08, 95% confidence interval=0.93Y1.24; P=0.33). Propensity matching resulted in 462 patients in each MS and SF group. Propensitymatched Kaplan-Meier survival analysis showed no difference in graft or patient survival between groups (P=0.3 and P=0.16, respectively). Conclusions. We found no difference in graft survival between SF patients and those taking MS. An SF regimen in pediatric HT avoids potential complications of steroid use without compromising graft survival, even after accounting for pre-HT risk factors.

Aorto-left ventricular tunnel (ALVT) is an abnormal congenital communication between the ascending aorta and the left ventricle. Prenatal diagnosis is rare and can be misinterpreted as aortic insufficiency on fetal echocardiogram. We present a case of ALVT diagnosed in a fetus who underwent successful early neonatal surgical repair.

Homografts are implanted in the right ventricular outflow tract (RVOT) of children, with the knowledge that reoperation might be required. We reviewed 14 years of homograft RVOT reconstruction to assess the feasibility of homograft replacement and to determine risk factors for homograft survival.From February 1985 through March 1999, 223 children (age 5 days to 16.9 years) underwent primary RVOT reconstruction with an aortic or pulmonary homograft. Of these, 35 patients underwent homograft explant at the implanting hospital with insertion of a second homograft from 2 months to 13.3 years after the first implantation. The primary operation and reoperation patient groups were compared with regard to incidence of early death, late death, homograft-related intervention without explant, and homograft explant.Actuarial survival and event-free curves for initial and replacement homografts were not significantly different. Univariable analysis was performed for the following risk factors: weight (p0.0001), age (p0.003), homograft diameter (p0.0001), homograft type (p0.01), surgery date (not significant [NS]), gender (NS), Blood Group match (NS), and type of distal anastomosis (NS). Multivariable analysis of significant univariable risks revealed small homograft diameter to be a significant risk factor (p0.001) for replacement.The RVOT homografts eventually require replacement. Patient and homograft survival for replacement homografts is similar to primary homografts. Reoperative homograft RVOT reconstruction is possible, with reasonably low morbidity and mortality.

Extracorporeal membrane oxygenation (ECMO) is widely used for postcardiotomy cardiogenic shock in children. However, the efficacy of ECMO for early post-heart transplant graft failure in infants has not been reported. Our aims were to determine: (1) the utility of ECMO in infants with severe donor-heart dysfunction, (2) predictors for requiring ECMO, and (3) the long-term outcome of surviving ECMO patients.All infants (age6 months at listing) undergoing heart transplantation were reviewed. Diagnostic categories were hypoplastic left heart syndrome (HLHS) and non-HLHS (complex congenital heart disease and cardiomyopathies). Continuous and categorical comparisons were by Wilcoxon's rank sum test and Fisher's exact test respectively.14 (12 HLHS, 2 non-HLHS) of 63 (46 HLHS, 17 non-HLHS) infants were placed on ECMO. Ten patients (71%) were successfully weaned from ECMO and 8 (57%) were discharged alive. All ECMO hospital survivors remain alive (mean follow-up 36.2 +/- 21.4 months, range 13.1-77.6 months). Mean duration of ECMO support was 68 hours in weaned patients vs 144 hours (p = 0.19) in nonweaned patients, and 64 hours in survivors vs 123 hours (p = 0.35) in nonsurvivors. ECMO deaths were due to sepsis (n = 3), intractable pulmonary hypertension (n = 2), and intracranial bleed (n = 1). Neurologic deficits occurred in 2 survivors. Median ICU and hospital stays for ECMO survivors were 29 and 33 days vs 7 (p = 0.0003) and 9 (p = 0.0004) days for non-ECMO patients. Age listed, age transplanted, wait time, body weight, donor/recipient weight ratio, total ischemia time, and diagnosis did not predict the need for ECMO.(1) ECMO is useful for post-heart transplant circulatory support in infants with early graft failure. (2) All survivors were weaned in fewer than 4 days. (3) Three-year survival of ECMO hospital survivors has been high, but neurologic complications are prevalent.

sion. The long-term graft patency of saphenous vein grafts is reported to be about 60% at 4 years. Percutaneous coronary intervention is the choice of revascularization for poor surgical candidates with calcified aortas. Technical and equipment advances have enabled stenting in the unprotected left main coronary artery to be performed with a high initial success rate and acceptable shortto intermediate-term outcomes. Favorable long-term outcomes have also been reported for patients with good left ventricular function, although restenosis occurs in 20% of patients. For patients with previously inserted multiple bare metal stents and restenosis, Furukawa and colleagues used sirolimuseluting stents and observed good 6-month outcomes. In conclusion, we report a case of TA with obliteration of the left coronary ostium. This was successfully treated with CABG, and the patient was event free at 1 year. CABG, although difficult in some cases of TA, remains the best revascularization option for patients with significant left main trunk stenosis.

Background The history of lung transplantation from the first human transplant performed in 1963 to the present is reviewed with particular focus on the added challenges because of the contaminated bronchus, exposure of the graft to airborne organisms, the poor blood supply to the bronchus, and the problem of reperfusion pulmonary edema. Methods The technical aspects of single and double sequential lung transplantation are reviewed, as are the current indications for single, double sequential, and heart/lung transplantation. Criteria for lung transplant recipients, in addition to their primary disease are noted, as are absolute and relative contraindications. The standard criteria for donor selection are also reviewed. Results The results of single, double sequential, and heart-lung transplantation over the past 10 years as reported by the International Society for Heart and Lung Transplantation Database are reviewed. In addition, the statistics of the lung and heart-lung transplantation program at the University of Colorado Health Sciences Center are reviewed, including the current immunosuppressive regimens and early and late monitoring for infection and rejection. This experience includes 3 early deaths in the first 53 patients for an operative mortality of 5.6%, with a 1-year actuarial survival of 90%. Conclusions During the past decade remarkable improvement in the result of single and double sequential lung transplantation have occurred. As 1-year, actuarial survival is now approaching 90% at some institutions. Living related lobar transplantation, new antirejection agents, chimerism, and xenograft transplantation are areas for continuing and future investigation. The shortage in donor organ supply continues to be a very significant factor in limiting human lung transplantation.

I NTRAOPERATIVE transesophageal echocardiography (TEE) is being used increasingly for monitoring of ventricular function and wall motion during coronary artery bypass grafting (CABG). Although the exact frequency of its use has not been well documented in the literature, a recent survey administered by the Society of Cardiovascular Anesthesiologists at their 1993 Annual Meeting indicated that nearly 39% of the respondents (n = 202) used TEE "routinely" during cardiac cases (although no distinction was made between CABG and valve surgery).* Although the respondents to this survey represent a biased sample of cardiovascular subspecialists, it appears that the intraoperative use of TEE has become popular. With the use of such a sensitive imagmg modality, the chance of detecting incidental abnormalities unrelated to the primary surgical procedure increases. A case is reported of an unsuspected finding on TEE that led to additional surgical intervention in an already high-risk patient undergoing CABG.

Supravalvar aortic stenosis is the most frequent operation required for Williams syndrome; however, coarctation repair is more common in patients requiring surgery in the first few months of life. We report on a child with Williams syndrome in whom extensive reoperation was required 5 months after neonatal aortic coarctation repair. A composite left subclavian artery flap and allograft patch aortoplasty of the aortic arch and descending aorta was performed through a left thoracotomy using cardiopulmonary bypass and circulatory arrest. Detailed anatomic evaluation of the aortic arch and descending aorta is recommended before initial coarctation repair in neonates with Williams syndrome.