Duct Stenting Versus Modified Blalock-Taussig Shunt in Neonates With Duct-Dependent Pulmonary Blood Flow: Associations With Clinical Outcomes in a Multicenter National Study.

BACKGROUND: Infants born with cardiac abnormalities causing dependence on the arterial duct for pulmonary blood flow are often palliated with a shunt usually between the subclavian artery and either pulmonary artery. A so-called modified Blalock-Taussig shunt allows progress through early life to an age and weight at which repair or further more stable palliation can be safely achieved. Modified Blalock-Taussig shunts continue to present concern for postprocedural instability and early mortality such that other alternatives continue to be explored. Duct stenting (DS) is emerging as one such alternative with potential for greater early stability and improved survival. METHODS: The purpose of this study was to compare postprocedural outcomes and survival to next-stage palliative or reparative surgery between patients undergoing a modified Blalock-Taussig shunt or a DS in infants with duct-dependent pulmonary blood flow. All patients undergoing cardiac surgery and congenital interventions in the United Kingdom are prospectively recruited to an externally validated national outcome audit. From this audit, participating UK centers identified infants <30 days of age undergoing either a Blalock-Taussig shunt or a DS for cardiac conditions with duct-dependent pulmonary blood flow between January 2012 and December 31, 2015. One hundred seventy-one patients underwent a modified Blalock-Taussig shunt, and in 83 patients, DS was attempted. Primary and secondary outcomes of survival and need for extracorporeal support were analyzed with multivariable logistic regression. Longer-term mortality before repair and reintervention were analyzed with Cox proportional hazards regression. All multivariable analyses accommodated a propensity score to balance patient characteristics between the groups. RESULTS: There was an early (to discharge) survival advantage for infants before next-stage surgery in the DS group (odds ratio, 4.24; 95% confidence interval, 1.37-13.14; P=0.012). There was also a difference in the need for postprocedural extracorporeal support in favor of the DS group (odds ratio, 0.22; 95% confidence interval, 0.05-1.05; P=0.058). Longer-term survival outcomes showed a reduced risk of death before repair in the DS group (hazard ratio, 0.25; 95% confidence interval, 0.07-0.85; P=0.026) but a slightly increased risk of reintervention (hazard ratio, 1.50; 95% confidence interval, 0.85-2.64; P=0.165). CONCLUSIONS: DS is emerging as a preferred alternative to a surgical shunt for neonatal palliation with evidence for greater postprocedural stability and improved patient survival to destination surgical treatment.

IVC Stent to Improve Ventricular Assist Device Filling Following Pediatric Cardiac Transplant.

Poor ventricular assist device filling is often seen in patients supported with the Berlin Heart Excor. Caval stenosis is an uncommon complication following the bicaval approach to orthotopic heart transplantation. We report the case of a five-year-old female patient post heart transplantation whose poor right ventricular assist device filling immediately resolved following management of caval stenosis.

Atrioventricular block: an unusual complication of Graves' disease.

We report the case of a 10-year-old girl treated with atenolol and carbimazole for tachycardia and hypertension associated with Graves' disease who developed symptomatic 2:1 heart block. 2:1 heart block resolved following cessation of atenolol, reduction in carbimazole dose and treatment of suspected tonsillitis. First-degree atrioventricular block persisted, but gradually normalised following improvement in thyroid status.

Attitudes and expectations of gastroenterology outpatients about the importance of diet and possible relationship to their symptoms.

OBJECTIVES: To evaluate gastroenterology outpatients' attitudes to the importance of diet and its relationship to their symptoms, as well as their expectations of dietary advice from health professionals. DESIGN: Prospective clinical audit. SETTING: Gastroenterology outpatient department of St George's Healthcare NHS Trust. PATIENTS: Two hundred and twenty-five patients, aged between 18 and 70 years met the inclusion criteria. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Participants' responses to a structured questionnaire. RESULTS: Sixty-nine per cent of participants felt their diet played an important role in their condition. Factors significantly associated with a positive dietary attitude included younger age (40.6 years vs 46.0 years, p<0.01), regularity of dietary pattern (108 vs 35, p<0.01), number of symptoms (4.6 vs 2.5, p<0.01), severity of gastrointestinal symptoms (2.3 vs 1.5, p<0.01), history of weight loss (34% vs 20.3%, p<0.05) and history of dietary advice (71.1% vs 33.3%, p<0.01). Sixty-eight per cent (68%) of participants were interested in receiving dietary advice, though only 36% expected to receive it. No differences were found for any comparisons based on average body mass index. CONCLUSION: The majority of gastroenterology outpatients view diet as playing an important role in their condition, particularly those who have more severe symptoms and those who have received dietary advice. Although a large proportion of patients are interested in receiving dietary advice, few expect to receive it in clinics. Further research is required to explore the reasons why, and to assess the confidence of health professionals in providing nutritional advice.