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Objectives: To determine potentially modifiable risk factors for a complicated Glenn procedure (cGP) and whether a cGP predicted adverse neurodevelopmental and functional outcomes. A cGP was defined as post-operative death, heart transplant, extracorporeal life support, Glenn takedown, or prolonged ventilation., Methods: All 169 patients having a Glenn procedure from 2012 to 2017 were included. Neurodevelopmental assessments were performed at age 2 years in consenting survivors (n = 156/159 survivors). The Bayley Scales of Infant and Toddler Development-3 rd Edition (Bayley-III) and the Adaptive Behavior Assessment System-2 nd Edition (ABAS-II) were administered. Adaptive functional outcomes were determined by the General Adaptive Composite (GAC) score from the ABAS-II. Predictors of outcomes were determined using univariate and multiple variable linear or Cox regressions., Results: Of patients who had a Glenn procedure, 10/169 (6%) died by 2 years of age and 27/169 (16%) had a cGP. Variables statistically significantly associated with a cGP were the inotrope score on post-operative day 1 (HR 1.04, 95%CI 1.01, 1.06; p = 0.010) and use of inhaled nitric oxide post-operatively (HR 7.31, 95%CI 3.19, 16.76; p < 0.001). A cGP was independently statistically significantly associated with adverse Bayley-III Cognitive (ES -10.60, 95%CI -17.09, -4.11; p = 0.002) and Language (ES -11.43, 95%CI -19.25, -3.60; p = 0.004) scores and adverse GAC score (ES -14.89, 95%CI -22.86, -6.92; p < 0.001)., Conclusions: Higher inotrope score and inhaled nitric oxide used post-operatively were associated with a cGP. A cGP was independently associated with adverse 2-year neurodevelopmental and functional outcomes. Whether early recognition and intervention for risk of a cGP can prevent adverse outcomes warrants study.

Objective: This study aimed to determine whether or not transfusion of fresh red blood cells (RBCs) reduced the incidence of new or progressive multiple organ dysfunction syndrome compared with standard-issue RBCs in pediatric patients undergoing cardiac surgery., Methods: Preplanned secondary analysis of the Age of Blood in Children in Pediatric Intensive Care Unit study, an international randomized controlled trial. This study included children enrolled in the Age of Blood in Children in Pediatric Intensive Care Unit trial and admitted to a pediatric intensive care unit after cardiac surgery with cardiopulmonary bypass. Patients were randomized to receive either fresh (stored ≤7 days) or standard-issue RBCs. The primary outcome measure was new or progressive multiple organ dysfunction syndrome, measured up to 28 days postrandomization or at pediatric intensive care unit discharge, or death., Results: One hundred seventy-eight patients (median age, 0.6 years; interquartile range, 0.3-2.6 years) were included with 89 patients randomized to the fresh RBCs group (median length of storage, 5 days; interquartile range, 4-6 days) and 89 to the standard-issue RBCs group (median length of storage, 18 days; interquartile range, 13-22 days). There were no statistically significant differences in new or progressive multiple organ dysfunction syndrome between fresh (43 out of 89 [48.3%]) and standard-issue RBCs groups (38 out of 88 [43.2%]), with a relative risk of 1.12 (95% CI, 0.81 to 1.54; P  = .49) and an unadjusted absolute risk difference of 5.1% (95% CI, -9.5% to 19.8%; P  = .49)., Conclusions: In neonates and children undergoing cardiac surgery with cardiopulmonary bypass, the use of fresh RBCs did not reduce the incidence of new or progressive multiple organ dysfunction syndrome compared with the standard-issue RBCs. A larger trial is needed to confirm these results., (© 2023 The Author(s).)

Objectives: To determine common practice for fluid management after cardiac surgery for congenital heart disease among pediatric cardiac intensivists., Design: A survey consisting of 17 questions about fluid management practices after pediatric cardiac surgery. Distribution was done by email, social media, World Federation of Pediatric Intensive and Critical Care Societies website, and World Federation of Pediatric Intensive and Critical Care Societies newsletter using the electronic survey distribution and collection system Research Electronic Data Capture., Setting: PICUs around the world., Subjects: Pediatric intensivists managing children after surgery for congenital heart disease., Interventions: None., Measurements and Main Results: One-hundred eight responses from 18 countries and six continents were received. The most common prescribed fluids for IV maintenance are isotonic solutions, mainly NaCl 0.9% (42%); followed by hypotonic fluids (33%) and balanced crystalloids solutions (14%). The majority of the respondents limit total fluid intake to 50% during the first 24 hours after cardiac surgery. The most frequently used fluid as first choice for resuscitation is NaCl 0.9% (44%), the second most frequent choice are colloids (27%). Furthermore, 64% of respondents switch to a second fluid for ongoing resuscitation, 76% of these choose a colloid. Albumin 5% is the most commonly used colloid (61%). Almost all respondents (96%) agree there is a need for research on this topic., Conclusions: Our survey demonstrates great variation in fluid management practices, not only for maintenance fluids but also for volume resuscitation. Despite the lack of evidence, colloids are frequently administered. The results highlight the need for further research and evidence-based guidelines on this topic.

Objectives: To determine the clinical benefit of using colloids versus crystalloids for volume resuscitation in children admitted after cardiac surgery., Design: Retrospective pre-/postintervention cohort study., Setting: Stollery Children's Hospital tertiary care pediatric cardiac ICU., Patients: Children admitted to the pediatric cardiac ICU after cardiac surgery., Interventions: Fluid resuscitation policy change in which crystalloids replaced albumin 5% as the primary fluid strategy for resuscitation after cardiac surgery., Measurements and Main Results: Children who underwent cardiac surgery in the 6 months prior to the policy change (5% albumin group) were compared with children admitted during the 6 months after (crystalloid group). Demographic, perioperative, and outcome variables (fluid intake days 1-4 postoperative, vasoactive therapy, blood products, time to negative fluid balance, renal replacement therapies, mechanical ventilation, pediatric cardiac ICU, and length of stay) were collected. Data were analyzed using linear and logistic multivariate analysis. The study included 360 children. There was no association between fluid group and fluid intake (mL/kg) on day 1 postoperatively (coefficient, 2.84; 95% CI, 5.37-11.05; p = 0.497). However, crystalloid group was associated with significantly less fluid intake on day 2 (coefficient, -12.8; 95% CI, -22.0 to -3.65; p = 0.006), day 3 (coefficient, -14.9; 95% CI, -24.3 to -5.57; p = 0.002), and on the first 48 hours postoperative (coefficient, 10.1; 95% CI, -27.9 to -1.29; p = 0.032). Pediatric cardiac ICU stay (coefficient, -1.29; 95% CI, -2.50 to -0.08; p = 0.036) was shorter for the crystalloid group. There were no significant differences in the time to negative balance, need for renal replacement therapy, mechanical ventilation days, hospital stay, or pediatric cardiac ICU survival., Conclusions: In our study, the use of albumin 5% for resuscitation after cardiac surgery was not associated with less fluid intake but rather the opposite. Albumin administration did not provide measured clinical benefit while exposing children to side effects and generating higher costs to the healthcare system.

Objectives: Create trustworthy, rigorous, national clinical practice guidelines for the practice of pediatric donation after circulatory determination of death in Canada., Methods: We followed a process of clinical practice guideline development based on World Health Organization and Canadian Medical Association methods. This included application of Grading of Recommendations Assessment, Development, and Evaluation methodology. Questions requiring recommendations were generated based on 1) 2006 Canadian donation after circulatory determination of death guidelines (not pediatric specific), 2) a multidisciplinary symposium of national and international pediatric donation after circulatory determination of death leaders, and 3) a scoping review of the pediatric donation after circulatory determination of death literature. Input from these sources drove drafting of actionable questions and Good Practice Statements, as defined by the Grading of Recommendations Assessment, Development, and Evaluation group. We performed additional literature reviews for all actionable questions. Evidence was assessed for quality using Grading of Recommendations Assessment, Development, and Evaluation and then formulated into evidence profiles that informed recommendations through the evidence-to-decision framework. Recommendations were revised through consensus among members of seven topic-specific working groups and finalized during meetings of working group leads and the planning committee. External review was provided by pediatric, critical care, and critical care nursing professional societies and patient partners., Results: We generated 63 Good Practice Statements and seven Grading of Recommendations Assessment, Development, and Evaluation recommendations covering 1) ethics, consent, and withdrawal of life-sustaining therapy, 2) eligibility, 3) withdrawal of life-sustaining therapy practices, 4) ante and postmortem interventions, 5) death determination, 6) neonatal pediatric donation after circulatory determination of death, 7) cardiac and innovative pediatric donation after circulatory determination of death, and 8) implementation. For brevity, 48 Good Practice Statement and truncated justification are included in this summary report. The remaining recommendations, detailed methodology, full Grading of Recommendations Assessment, Development, and Evaluation tables, and expanded justifications are available in the full text report., Conclusions: This process showed that rigorous, transparent clinical practice guideline development is possible in the domain of pediatric deceased donation. Application of these recommendations will increase access to pediatric donation after circulatory determination of death across Canada and may serve as a model for future clinical practice guideline development in deceased donation.

Background: Cardiac catheterization is often required for patients on extracorporeal membranous oxygenation (ECMO) support, though its efficacy remains unclear. This study aimed to assess the impact of catheterization on successful ECMO weaning., Methods: This is a single-center retrospective study from 2000 to 2014. Patients with congenital heart disease who underwent cardiac catheterization while on cardiac ECMO support were included. Logistic regression analysis and Kaplan-Meier survival analysis with log-rank test were performed to determine predictors for successful weaning and patient outcome., Results: Forty-nine catheterizations in 47 patients with the median age of 65 days (range: 1 day-12 years) and the median body weight of 4.2 kg (range: 1.9-32.7 kg) were included. Median duration between ECMO cannulation and catheterization was 1 day (range: 0-11 days). Thirty-three patients (70%) succeeded in decannulation and 24 patients (51%) survived to hospital discharge. Absence of renal (P = 0.045) and respiratory complications (P = 0.031) were significant prognostic factors for successful weaning in multivariate analysis. Patients who received catheterization within 48 hr after ECMO cannulation demonstrated less respiratory complications (P = 0.006) and better survival at 30 days after ECMO initiation (P = 0.039) than those who underwent later catheterization. There was no mortality; however, nine major catheterization-related complications (18%) were detected., Conclusion: Catheterization for pediatric patients on ECMO support can be performed, although this group contained high risk of serious adverse events. The absence of ECMO complications is a predictor for successful weaning. An earlier catheterization appears to be associated with better short-term survival in this cohort. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Objective: To determine whether a collaborative learning strategy-derived clinical practice guideline can reduce the duration of endotracheal intubation following infant heart surgery., Design: Prospective and retrospective data collected from the Pediatric Heart Network in the 12 months pre- and post-clinical practice guideline implementation at the four sites participating in the collaborative (active sites) compared with data from five Pediatric Heart Network centers not participating in collaborative learning (control sites)., Setting: Ten children's hospitals., Patients: Data were collected for infants following two-index operations: 1) repair of isolated coarctation of the aorta (birth to 365 d) and 2) repair of tetralogy of Fallot (29-365 d). There were 240 subjects eligible for the clinical practice guideline at active sites and 259 subjects at control sites., Interventions: Development and application of early extubation clinical practice guideline., Measurements and Main Results: After clinical practice guideline implementation, the rate of early extubation at active sites increased significantly from 11.7% to 66.9% (p < 0.001) with no increase in reintubation rate. The median duration of postoperative intubation among active sites decreased from 21.2 to 4.5 hours (p < 0.001). No statistically significant change in early extubation rates was found in the control sites 11.7% to 13.7% (p = 0.63). At active sites, clinical practice guideline implementation had no statistically significant impact on median ICU length of stay (71.9 hr pre- vs 69.2 hr postimplementation; p = 0.29) for the entire cohort. There was a trend toward shorter ICU length of stay in the tetralogy of Fallot subgroup (71.6 hr pre- vs 54.2 hr postimplementation, p = 0.068)., Conclusions: A collaborative learning strategy designed clinical practice guideline significantly increased the rate of early extubation with no change in the rate of reintubation. The early extubation clinical practice guideline did not significantly change postoperative ICU length of stay.

Objectives: To evaluate management and outcomes of thrombosis after pediatric cardiac surgery and stratify thrombi according to risk of short- and long-term complications to better guide therapeutic choices., Study Design: Retrospective review was performed of 513 thrombi (400 occlusive) diagnosed after 213 pediatric cardiac operations. Long-term outcomes over time were assessed with the use of parametric hazard regression models., Results: Serious complications and/or high-intensity treatment occurred with 17%-24% of thrombi depending on location, most commonly in thrombi affecting the cardiac and cerebral circulation. Bleeding complications affected 13% of patients; associated factors included thrombolytics (OR 8.7, P < .001), greater daily dose of unfractionated heparin (OR 1.25 per 5 U/kg/day, P = .03), and extracorporeal support (OR 4.5, P = .007). Radiologic thrombus persistence was identified in 30% ± 3% at 12 months; associated factors included extracorporeal support (hazard ratio [HR] 1.9, P = .003), venous (HR 1.7, P = .003), and occlusive thrombi at presentation (HR 1.8, P = .001); greater oxygen saturation before surgery (HR 1.13/10%, P = .05) and thrombi in femoral veins (HR 1.9, P = .001) were associated with increased hazard of resolution. Freedom from postthrombotic syndrome was 83% ± 4% at 6 years, greater number of persistent vessel segment occlusions (HR 1.8/vessel, P = .001) and greater fibrinogen at diagnosis (HR 1.1 per g/L, P = .02) were associated with increased hazard., Conclusions: Thrombosis outcomes after pediatric cardiac surgery remain suboptimal. Given that more intensive treatment would likely increase the risk of bleeding, the focus should be on both thrombosis-prevention strategies, as well as in tailoring therapy according to a thrombosis outcome risk stratification approach., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The sessions of the symposium held in December 2014 allow us to capitalize on the shared knowledge and experience that arise from both cardiac anesthesia and cardiac intensive care. During this session, topics that crossed traditional boundaries of pediatric cardiac intensive care and pediatric cardiac anesthesia were presented and discussed. This article summarizes the five topics presented at the symposium., (© The Author(s) 2015.)

Symptomatic pulmonary thromboembolism (PTE) is rare in neonates, and the diagnosis is often made only postmortem. The true incidence is probably underestimated because of its varying presentations, ranging from mild respiratory distress to acute right-heart failure and cardiovascular collapse. We report a sudden cardiorespiratory collapse on day 10 of life in a preterm neonate who was subsequently diagnosed as having a saddle pulmonary embolus. The patient underwent an emergency surgical embolectomy as a salvage procedure. Considering the potentially lethal complications of PTE, neonatologists and pediatricians should maintain a high degree of suspicion in infants with sudden inexplicable deterioration in cardiorespiratory status. Surgical removal of the thrombus is an invasive procedure and potentially carries a high mortality rate. Two term neonatal survivors of surgical intervention have been reported in the medical literature so far. However, we believe that this is the first documented preterm neonatal survivor after surgical intervention for a massive saddle PTE., (Copyright © 2015 by the American Academy of Pediatrics.)

Objectives: The purpose of this review was to provide a systematic review of the literature regarding the use of extracorporeal life support (ECLS) in various specialized conditions, as part of the Pediatric Cardiac Intensive Care Society/Extracorporeal Life Support Organization Joint Statement on Mechanical Circulatory Support., Data Sources: MEDLINE and PubMed., Study Selection: Searches for published abstracts and articles were conducted using the following MeSH terms: extracorporeal life support, extracorporeal membrane oxygenation, or mechanical support, and pediatric or children., Data Extraction: Abstracts of all articles including case reports were reviewed; the full article was reviewed if the abstract indicated that it focused on extracorporeal life support for conditions other than primary respiratory disease or persistent pulmonary hypertension of the newborn and described outcomes such as survival to hospital discharge. Studies with potential overlapping patients were highlighted in the review process and summary results., Data Synthesis: Classification of recommendations and level of evidence are expressed in the American College of Cardiology Foundation/American Heart Association format., Conclusions: The majority of specialized situations where extracorporeal life support is used fall into the category of class II-III evidence. Class I indications for extracorporeal life support in the pediatric population include myocarditis and in the context of acute interventions in the cardiac catheterization laboratory.

Purpose: To validate a novel method of ultrasound dilution (COstatus(®); Transonic Systems, Ithaca, NY) for measuring cardiac output in paediatric patients after biventricular repair of congenital heart disease., Methods: Children undergoing biventricular repair of congenital heart disease were prospectively identified. Patients with significant intracardiac shunts were excluded. Postoperative cardiac output was measured by ultrasound dilution (COud) and concurrently calculated by the Fick equation (COrms) using measured oxygen consumption by respiratory mass spectrometry., Results: Thirty-five patients were studied generating 66 individual data sets. Subjects had a median (interquartile range) age of 147 days (11, 216), weight of 4.98 kg (3.78, 6.90) and body surface area of 0.28 m(2) (0.22, 0.34). Of the patients, 66% had peripheral arterial catheters and 34% had femoral cannulation; peripheral arterial lines accounted for 6/8 of unsuccessful studies due to inability to generate sufficient flow. The site of the central venous cannula did not impact the feasibility of completing the study. A mean bias of 0.00 L/min [2 standard deviation (SD) ± 0.76 L/min] between COud and COrms was found with a percentage error of 97%. When comparing cardiac index, bias increased to 0.13 L/min/m(2) (2SD ± 2.16 L/min/m(2))., Conclusions: Cardiac output by ultrasound dilution showed low bias with wide limits of agreement when compared to measurement derived by the Fick equation. Although measurements through central and peripheral arterial lines were completed with minimal difficulties in the majority of patients, the application of COstatus(®) in neonates with low body surface area may be limited.

From 2005 to 2011, 23 of 178 (12.9%) patients with venoarterial (VA) extracorporeal membrane oxygenation (ECMO) had left atrial (LA) decompression to help improve left ventricular (LV) function, LA/LV dilatation, and/or lung edema. LA decompression was achieved with LA cannulation (n = 16), surgically created adjustable atrial septal defect (n = 3), or balloon atrial septostomy (n = 4). Sixteen (70%) patients had LA decompression at the time of ECMO initiation and all had LA decompression within 12 hours of ECMO initiation. ECMO duration was 5.9 ± 4.5 days and 16 (70%) patients were successfully decannulated. Subsequent intensive care unit and hospital survival was achieved in 13 (57%) and 12 (52%) patients, respectively. Earlier timing of LA decompression appeared to be associated with a high probability of weaning from ECMO and reasonable LV functional recovery., (© 2012, Copyright the Authors. Artificial Organs © 2012, International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Background and Aims: Airway evaluation following infant cardiac surgery often reveals evidence of tracheobronchial narrowing. We studied the association between airway narrowing and extubation failure (EF) in this population., Methods: Prospective cohort study of infants (age ≤6 months) from March-September 2009. Flexible bronchoscopy (FB) evaluations were obtained using a standardised protocol after operative intervention. The primary endpoint was the development of extubation failure (EF; defined as the need for invasive mechanical ventilation ≤48 h after primary extubation) and several secondary endpoints., Results: Fifty-three patients were evaluated at a median age of 81 [interquartile range (IQR) 13-164] days and weight of 4.2 (IQR 3.2-6.0) kg; 13 (25 %) of the patients had single ventricle palliations and two subsequently underwent heart transplantation. Significant airway narrowing was noted in 15 of 30 [50 %, 95 % confidence interval (CI) 31-69 %] patients who underwent FB; ten of the 53 patients (19 %, 95 %CI 10-32 %) subsequently developed EF. Narrowed airway calibre on bronchoscopy had a sensitivity and specificity of 50 % (95 %CI 28-71 %) and 50 % (95 %CI 28-71 %), respectively, for EF. The single greatest predictor of EF by univariate analysis was the need for preoperative ventilation [odds ratio (OR) 6.5, 95 %CI 1.3-33.2, p = 0.03]. Patients with EF had a greater likelihood of intensive care readmission (OR 4.8, 95 %CI 1.1-21, p < 0.04) during the same hospital admission., Conclusions: Airway narrowing on FB is noted frequently after infant cardiac surgery. Overall assessment and presence of narrowing on bronchoscopy had poor sensitivity and specificity for EF in our cohort. Expert assessment of tracheobronchial narrowing on FB has poor to moderate inter-rater reliability.

Objectives: To describe the incidence of thrombotic complications across all 3 stages of single ventricle palliation and the association between thromboprophylaxis use and thrombotic risk., Study Design: Two separate cross-sectional studies were performed that included 195 patients born between 2003-2008 and 162 patients who underwent Fontan after 2000., Results: The incidence of thrombotic complications was 40% and 28% after initial palliation and superior cavopulmonary connection (SCPC), respectively; 5-year freedom from thrombotic complications after Fontan was 79%. Thromboprophylaxis was initiated for 70%, 46%, and 94% of patients after initial palliation, SCPC, and Fontan, respectively. Thromboprophylaxis with enoxaparin (vs no thromboprophylaxis) was associated with a reduction in risk of thrombotic complications after initial palliation (hazard ratio [HR] 0.5, P = .05) and SCPC (HR 0.2, P = .04). Thromboprophylaxis with warfarin was associated with a reduction in thrombotic complications after Fontan (HR 0.27, P = .05 vs acetylsalicylic acid; HR 0.18, P = .02 vs no thromboprophylaxis). Thrombotic complications were associated with increased mortality after initial palliation (HR 5.5, P < .001) and SCPC (HR 12.5, P < .001). Three patients experienced major bleeding complications without permanent sequelae (2 enoxaparin, 1 warfarin)., Conclusions: Given the negative impact of thrombotic complications on survival, the low risk of serious bleeding complications, and the association between thromboprophylaxis and lowered thrombotic complication risk across all 3 palliative stages, routine use of thromboprophylaxis from the initial palliation to the early post-Fontan period in this population may be indicated., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Background: The negative effects of long-term storage of allogeneic red blood cells (RBCs) on outcomes in adult cardiac surgery have been established, but evidence of a similar effect in pediatric cardiac surgery is limited., Methods: The weighted average duration of storage for RBC units used in 1,225 pediatric cardiac operations was determined. Operations were divided into high RBC use (more than 4 units or more than 150 mL/kg) or low RBC use. For both categories, associations between storage duration and surgical outcomes, adjusted for relevant patient characteristics, were evaluated., Results: High RBC use was associated with higher surgical complexity. Storage duration for patients who received low RBC volumes was not associated with surgical outcomes. For patients with high RBC transfusion volumes, longer storage duration (per day) was associated with higher odds of bleeding complications (odds ratio 1.029, p=0.07), renal insufficiency (odds ratio 1.085, p=0.001), higher inotrope score after surgery (12 to 24 hours +0.08, p=0.002; 24 to 48 hours +0.07, p<0.001), greater chest tube drainage (24 hours +1.5 mL/kg, p<0.001), longer postoperative hospitalization (+0.3 days p=0.02), and increased in-hospital mortality (odds ratio 1.054, p=0.03). Effects of RBC transfusions on postoperative bleeding were greatest for storage duration longer than 14 days., Conclusions: The freshest RBC units available should be used for pediatric cardiac operations expected to require more than 4 units or more than 150 mL/kg of allogeneic RBC transfusions, with no units more than 14 days old being transfused whenever possible., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Thrombosis, usually considered a serious but rare complication of pediatric cardiac surgery, has not been a major clinical and/or research focus in the past., Methods and Results: We noted 444 thrombi (66% occlusive, 60% symptomatic) in 171 of 1542 surgeries (11%). Factors associated with increased odds of thrombosis were age <31 days (odds ratio [OR], 2.0; P=0.002), baseline oxygen saturation <85% (OR, 2.0; P=0.001), previous thrombosis (OR, 2.6; P=0.001), heart transplantation (OR, 4.1; P<0.001), use of deep hypothermic circulatory arrest (OR, 1.9 P=0.01), longer cumulative time with central lines (OR, 1.2 per 5-day equivalent; P<0.001), and postoperative use of extracorporeal support (OR, 5.2; P<0.001). Serious complications of thrombosis occurred with 64 of 444 thrombi (14%) in 47 of 171 patients (28%), and were associated with thrombus location (intrathoracic, 45%; extrathoracic arterial, 19%; extrathoracic venous, 8%; P<0.001), symptomatic thrombi (OR, 8.0; P=0.02), and partially/fully occluding thrombi (OR, 14.3; P=0.001); indwelling access line in vessel (versus no access line) was associated with lower risk of serious complications (OR, 0.4; P=0.05). Thrombosis was associated with longer intensive care unit (+10.0 days; P<0.001) and hospital stay (+15.2 days; P<0.001); higher odds of cardiac arrest (OR, 4.9; P<0.001), catheter reintervention (OR, 3.3; P=0.002), and reoperation (OR, 2.5; P=0.003); and increased mortality (OR, 5.1; P<0.001). Long-term outcome assessment was possible for 316 thrombi in 129 patients. Of those, 197 (62%) had resolved at the last follow-up. Factors associated with increased odds of thrombus resolution were location (intrathoracic, 75%; extrathoracic arterial, 89%; extrathoracic venous, 60%; P<0.001), nonocclusive thrombi (OR, 2.2; P=0.01), older age at surgery (OR, 1.2 per year; P=0.04), higher white blood cell count (OR, 1.1/10(9) cells per 1 mL; P=0.002), and lower fibrinogen (OR, 1.4/g/L; P=0.02) after surgery., Conclusions: Thrombosis affects a high proportion of children undergoing cardiac surgery and is associated with suboptimal outcomes. Increased awareness and effective prevention and detection strategies are needed.

Purpose: Survival outcomes in children with heart disease after use of either non-emergent extracorporeal membrane oxygenation (ECMO) or cardiopulmonary resuscitation (CPR) onto ECMO (ECPR) are comparable. Concerns remain regarding the impact of CPR duration on survival and neurological outcome., Methods: Children with cardiac disease requiring ECMO were identified from our database. Demographic, operative and ECMO details were evaluated with respect to survival. In addition, resuscitation details were extracted for the recent subgroup requiring ECPR; these details were evaluated with respect to survival and neurological outcomes at midterm follow-up by univariate analysis and multivariable logistic regression., Results: There were 126 ECMO runs in 116 children; 61 (53%) received ECPR. Forty-eight (41%) children survived to discharge; survival in the most recent era was 48%. Thirty-seven children underwent ECPR in the most recent era with 14 (38%) surviving to discharge. Duration of cardiopulmonary resuscitation differed significantly between survivors and nonsurvivors (15 vs. 40 min, p = 0.009); children requiring ≥30 min of CPR had 79% reduced odds of hospital survival (OR = 0.21, 95% CI = 0.05-0.96, p = 0.04). Two children died after hospital discharge; with 33% having paediatric cerebral performance category scores ≤2. Poor neurological outcome was associated with longer duration of CPR (32 vs. 17.5 min, p = 0.03)., Conclusions: Despite comparable survival outcomes between ECPR and non-emergent ECMO in children with cardiac disease a significant association between CPR duration and outcome (survival and neurological) was noted in this population.

Background: Corticosteroids are commonly administered perioperatively in pediatric cardiac surgery to reduce cardiopulmonary bypass induced inflammation. However, their effects on outcomes and potential for adverse events are not well defined., Methods: A review was undertaken of cardiac operations between September 2004 and December 2007 carrying a comprehensive Aristotle score 10 or greater. A nonrandomized comparison was undertaken comparing those patients having received intraoperative methylprednisolone at anesthesia induction or in the bypass circuit prime with those who did not. To account for nonrandom assignment of steroid use, a propensity model was created to establish each patient's probability of having received steroids (∼150 variables evaluated, 17 in final model, c-stat 0.94, p < 0.001). Associations between postoperative outcomes and intraoperative steroid use were modeled in multivariable linear regression models adjusted for propensity score and relevant surgical characteristics., Results: In 221 identified cases, 134 (61%) patients received intraoperative steroids; of these, 44 (33%) also received preoperative doses. In propensity-adjusted regression models, intraoperative steroid use was associated with lower chest tube volume loss in the first 24 postoperative hours (-5.3 mL/kg, p < 0.001), and shorter durations of stay in intensive care (-2.3 days, p < 0.001) and hospital (-4.1 days, p < 0.001). Use of an additional preoperative dose resulted in further improvements, especially a reduction in duration of mechanical ventilation (-1.7 days versus no steroids, -1.2 days versus intraoperative steroids only, p = 0.002). Steroids were not associated with increased postoperative lactate, creatinine, or glucose levels, or odds of infection., Conclusions: Intraoperative steroid use is associated with improved postoperative outcomes for children undergoing high-risk cardiac surgery, with further benefits associated with a preoperative dose., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

This study aims to evaluate the impact of a change in extracorporeal membrane oxygenation (ECMO) technology on patient and circuit outcomes. A retrospective single-centre study of all ECMO runs from 1988 to 2006 was performed. Predictors of survival to hospital discharge (primary outcome measure) were evaluated in the entire cohort by univariate and multivariate analysis. A detailed subgroup univariate and multivariate analysis was performed in the cardiac and respiratory groups to identify predictors of survival to hospital discharge. A total of 275 patients underwent 294 extracorporeal support runs at a median (interquartile range) age of 40 (3-639) days and weight of 4.0 (3.1-10) kg. The primary indications for support were respiratory (41.8%), cardiac (45.6%) and sepsis (12.6%). Between the initial (Era 1) and most recent era (Era 3), cardiac support became the predominant ECMO indication (26 of 127 vs. 59 of 107; P<0.001). Survival to decannulation, intensive care and hospital discharge for the entire cohort and Era 3 patients were 50.0%, 48.9%, 44.4% and 71.7%, 55.6%, 52.6% (P<0.003), respectively. Treatment in Era 3 was associated with increased survival to intensive care discharge (P=0.02) for all ECMO patients. Cardiac survival was associated with treatment in Era 3 (P=0.04) and a lower complexity score (P<0.001). There was a significant reduction in mechanical circuit complications in the respiratory ECMO subgroup. A significant improvement in patient survival outcomes and reduction in mechanical circuit complications was noted in the current era. This improvement was associated with a change in ECMO technology.

Background: Risk factors for tricuspid regurgitation (TR) after adult orthotopic heart transplantation (OHT) have been reported, although there are no pediatric data., Methods: This study was a single-center retrospective analysis of patients

We describe the transcatheter closure of a patent ductus venosus in twin brothers with an ill-defined systemic illness and respiratory failure using the Amplatzer vascular plug. To our knowledge, this is the first description of the use of the Amplatzer vascular plug for ductus venosus closure.