Transcatheter Versus Surgical Closure of Atrial Septal Defects in Children: A Value Comparison.

OBJECTIVES: The purpose of this study was to determine whether a transcatheter procedure or surgical closure offers a better value proposition for atrial septal defect (ASD) closure. BACKGROUND: Secundum ASDs are common congenital heart defects with both transcatheter and surgical treatment options. Although both options have been shown to have excellent results in children, the relative value of the 2 procedures is unclear. METHODS: Using data from the Pediatric Hospital Information System for 2004 to 2012, we compared the value of transcatheter versus surgical ASD closure for children ages 1 to 17 years, with value being defined as outcomes relative to costs. Total charges for procedure-related encounters were converted to costs using hospital-specific cost-to-charge ratios, and all costs were adjusted for inflation to reflect 2012 dollars. RESULTS: There were 4,606 transcatheter procedures and 3,159 surgeries at 35 children's hospitals. Those undergoing transcatheter closure were more likely to be older (5.6 years vs. 4.5 years, p < 0.0001). There was no mortality in either group. Children with a surgical procedure had a longer length of stay (4.0 days vs. 1.5 days, p < 0.0001), were more likely to have an infection (odds ratio: 3.73, p < 0.0001) or procedural complication (odds ratio: 6.66, p < 0.0001). Costs for transcatheter procedure encounters were lower than costs for surgical encounters (mean of $19,128 vs. $25,359, p < 0.0001). CONCLUSIONS: Both transcatheter and surgical ASD closure had excellent short-term outcomes, but transcatheter procedures had lower lengths of stay, rates of infection, and complications, resulting in lower overall costs. For children who are eligible, transcatheter ASD closure provides better short-term value than surgery.

Tissue Doppler Imaging-derived Diastolic Function Assessment in Children With Sickle Cell Disease and Its Relation With Ferritin.

Diastolic dysfunction has been shown to occur earlier than systolic dysfunction in iron overload states in adult patients with sickle cell disease (SCD). Tissue Doppler imaging (TDI)-derived E/E' has emerged as a noninvasive marker of diastolic function. We sought to determine diastolic function in children with SCD and study its relation with iron overload. A retrospective review of medical records of 225 pediatric patients with SCD who received an echocardiogram between January 2008 and December 2012 was performed. Echocardiographic measures including M-mode, spectral Doppler, and TDI-derived E/E' were compared with previously published data in healthy children. The left ventricular end-diastolic and end-systolic dimensions were significantly higher in SCD (P<0.0001) and the shortening fraction was similar (P=0.66). E/E' ratio was significantly higher in SCD at the mitral annulus, septum, and tricuspid annulus. In 54% of subjects, the septal E/E' was >8, indicating elevated left ventricular filling pressure. However, there was no significant correlation between ferritin level and E/E' ratios. Pediatric patients with SCD have a high prevalence of elevated estimated left ventricular filling pressure, but this does not correlate with ferritin levels.

Tissue Plasminogen Activator Use in Children: Bleeding Complications and Thrombus Resolution.

OBJECTIVE: To review our institutional experience with tissue plasminogen activator (tPA) to determine outcomes related to bleeding complications and thrombus resolution. STUDY DESIGN: We performed a retrospective review of all patients who received systemic tPA for thrombolysis. Data points included location of thrombus, initial and maximum tPA dose, and duration of tPA. The primary endpoint was bleeding complication. RESULTS: Between 2005 and 2014, 46 patients received systemic tPA for thrombolysis: 17 (37%) were patients with a primary cardiac diagnosis, there were 17 (37%) hematology/oncology patients, and 12 (26%) patients with noncardiac, nonhematology/oncology diagnoses. The indication for tPA was central venous thrombus (n = 23), pulmonary artery thrombus (n = 9), and cardiac or aortic thrombus (n = 14). Bleeding complications occurred in 15 patients (33%). Median initial tPA dose in the bleeding complication group was 0.10 mg/kg/h vs 0.03 mg/kg/h in the group without bleeding complication group (P = .01). Cardiac patients experienced more bleeding complications (P = .01). Multivariate analysis indicated that dose of tPA (P = .01) and diagnostic category (P < .01) were associated with bleeding complication. Complete thrombus resolution occurred in 21 patients, partial in 10 patients, and no resolution in 15 patients. Complete resolution of thrombus was not associated with diagnosis, thrombus location, tPA dose, or duration. CONCLUSIONS: Cardiac patients appear to be at highest risk of bleeding complication; bleeding complications were associated with higher doses of tPA, and cardiac patients were the cohort who received the highest doses of tPA. Higher tPA doses are associated with increased risk of bleeding complication but are not associated with successful thrombus resolution.

Association of Interstage Home Monitoring With Mortality, Readmissions, and Weight Gain: A Multicenter Study from the National Pediatric Cardiology Quality Improvement Collaborative.

BACKGROUND: Daily home monitoring of oxygen saturation and weight has been reported to improve outcomes for patients with single-ventricle heart disease during the period between stage I palliation and stage II palliation. However, these studies have been limited to single institutions and used historical control subjects. Our objective was to determine the association of various interstage home monitoring strategies with outcomes using a multicenter cohort with contemporary control subjects. METHODS AND RESULTS: We performed a retrospective cohort study using prospectively collected data from the National Pediatric Cardiology Quality Improvement Collaborative from 2008 to 2012. We compared interstage mortality, unscheduled readmissions, and change in weight-for-age Z score for various home monitoring strategies of oxygen saturation (n=494) or weight (n=472), adjusting for sex, syndrome, tricuspid regurgitation, arch obstruction, and shunt type. Overall interstage mortality was 8.1%, and 47% had ≥1 unscheduled readmission. We did not find any associations of home oxygen saturation or weight monitoring with mortality or readmission. Although there was no difference in weight-for-age Z score for daily (0.33±0.12) versus weekly (0.34±0.18, P=0.98) weight monitoring, daily home weight monitoring was superior to no home weight monitoring (-0.15±0.18; P<0.01). CONCLUSIONS: Home weight monitoring is associated with improved weight gain during the interstage period, but we did not find any benefits in other clinical outcomes for either home oxygen saturation monitoring or home weight monitoring.

Syncope in the Pediatric Emergency Department - Can We Predict Cardiac Disease Based on History Alone?

BACKGROUND: The American Heart Association recommends a "meticulous history" when evaluating patients with an initial episode of syncope. However, little is known about which historical features are most helpful in identifying children with undiagnosed cardiac syncope. OBJECTIVES: Our objectives were 1) to describe the cardiac disease burden in Emergency Department (ED) syncope presentations, and 2) to identify which historical features are associated with a cardiac diagnosis. METHODS: Using syncope presentations in our ED between May 1, 2009 and February 28, 2013, we 1) performed a cross-sectional study describing the burden of cardiac syncope, and 2) determined the sensitivity and specificity of four historical features identifying cardiac syncope. RESULTS: Of 3445 patients, 44.5% were male presenting at 11.5 ± 4.5 years of age. Of patients with a cardiac diagnosis (68, ~2%), only 3 (0.09%) were noted to have a previously undiagnosed cardiac cause of syncope: 2 with supraventricular tachycardia and 1 with myocarditis. Among the three cases and 100 randomly selected controls, the respective sensitivity and specificity of the historical features were 67% and 100% for syncope with exercise, 100% and 98% for syncope preceded by palpitations, and 67% and 70% for syncope without prodrome. The presence of at least two features yielded a sensitivity of 100% and specificity of 100%. CONCLUSIONS: Our study, which represents the largest published series of pediatric syncope presenting to the ED, confirms that newly diagnosed cardiac causes of syncope are rare. Using a few specific historical features on initial interview can help guide further work-up more precisely.

The Miniaturized Multiplane Micro-Transesophageal Echocardiographic Probe: A Comparative Evaluation of Its Accuracy and Image Quality.

BACKGROUND: The initial experience with the miniaturized multiplane micro-transesophageal echocardiographic probe (MTEE) reported high-quality diagnostic imaging in small infants. The aim of this study was to compare the diagnostic accuracy and image quality of the intraoperative MTEE with the pediatric multiplane transesophageal echocardiographic probe (PTEE). METHODS: Infants weighing <5 kg who underwent intraoperative transesophageal echocardiography were identified. Studies using the MTEE were matched 1:1 with those using the PTEE by cardiac diagnosis. The postoperative transesophageal echocardiograms, obtained using either probe, were reviewed for the presence of 11 cardiac abnormalities. Postoperative transesophageal echocardiograms were compared with predischarge transthoracic echocardiograms to assess accuracy. Using receiver operating characteristic curves, the areas under the curve for the MTEE and PTEE were compared. Two pediatric cardiologists scored six image quality metrics on equal numbers of studies obtained with the MTEE and the PTEE. Composite scores from both reviewers were used to compare image quality. RESULTS: The study included 110 transesophageal echocardiograms per probe type. The mean weight for the MTEE was lower than for the PTEE (3.15 ± 0.58 vs 3.70 ± 0.52 kg, P < .001). There was no significant difference in the diagnostic accuracy of the MTEE and PTEE using receiver operating characteristic curves. The numbers of residual anatomic lesions missed by the MTEE and PTEE were similar (19 vs 22, respectively). The composite image quality score was worse for the MTEE compared with the PTEE (81% vs 92%, respectively, P < .0001). CONCLUSIONS: Although the image quality of the MTEE is inferior compared with the PTEE, its diagnostic accuracy in infants weighing <5 kg is comparable.

Results of palliation with an initial pulmonary artery band in patients with single ventricle associated with unrestricted pulmonary blood flow.

OBJECTIVES: Pulmonary artery banding is the initial palliative surgery in patients with single ventricle cardiac anomalies presenting with unrestricted pulmonary blood flow. Reported mortality in those receiving pulmonary artery banding is high, and its application in patients with single ventricle anomalies and arch obstruction is controversial. We report current-era results after pulmonary artery banding in patients with single ventricle anomalies, including those with arch obstruction. METHODS: Between 2002 and 2012, 73 patients with single ventricle anomalies and unrestricted pulmonary blood flow underwent pulmonary artery banding, including 29 (40%) who received simultaneous arch repair. Competing risk analysis modeled events after pulmonary artery banding (death/transplantation, transition to the Glenn procedure) and subsequently after the Glenn procedure (death/transplantation, transition to the Fontan procedure) and examined risk factors affecting outcomes. RESULTS: Hospital mortality was 3 of 73 patients (4%). Before the Glenn procedure, 16 patients (22%) underwent 18 reoperations, including shunt (n = 7), Damus-Kaye-Stansel connection plus shunt (n = 5), pulmonary artery banding adjustment (n = 5), and transplantation (n = 1). On competing risk analysis, 2 years after pulmonary artery banding, 8% of patients have died or received transplantation, 88% have undergone the Glenn procedure, and 7% were alive without the Glenn procedure. Five years after the Glenn procedure, 9% have died, 71% have undergone the Fontan procedure, and 20% were alive awaiting the Fontan procedure. Overall survival 5 years after pulmonary artery banding was 86%. On multivariable analysis, risk factors for mortality were associated genetic/extracardiac anomalies (hazard ratio, 3.7; 95% confidence interval, 1.1-12.2; P = .03) and high-risk morphology (heterotaxy, unbalanced atrioventricular septal defect, and mitral atresia) (hazard ratio, 4.1; 95% confidence interval, 1.1-15.6; P = .04). CONCLUSIONS: Pulmonary artery banding is an acceptable initial palliative strategy of selected patients with single ventricle cardiac anomalies and unrestricted pulmonary blood flow, including those with concomitant arch obstruction. Short- and long-term outcomes are generally good, although results diverge with the worst outcomes noted in patients with heterotaxy, unbalanced atrioventricular septal defect, or associated extracardiac anomalies.

Improvement in Tricuspid Annular Plane Systolic Excursion with Pulmonary Hypertension Therapy in Pediatric Patients.

BACKGROUND: Tricuspid annular plane systolic excursion (TAPSE) has emerged as a novel and reliable measure of right ventricular (RV) function. The purpose of this study was to determine the effect of pulmonary hypertension (PH) therapy on TAPSE in pediatric patients and compare TAPSE to other quantitative measures of RV function. METHODS: A retrospective review of medical records and echocardiograms of patients in the PH clinic from January 2011 to August 2013 was done. Echocardiograms were analyzed prior to initiation or addition of a PH drug and at least 8 weeks later. Following quantitative measures of RV function were compared: TAPSE, TAPSE age-based z-score, RV fractional area change (RVFAC), tricuspid annular S', tricuspid inflow E/tricuspid annular E' velocity (TV E/E'), and RV myocardial performance index (RVMPI). RESULTS: Of the 37 patients included in this study (median age 0.6 years), 23 (62.2%) were treatment naive and others had a new PH drug added to their regimen at the time of the baseline echocardiogram. The median duration between the baseline and follow-up echocardiogram was 8 (2-25) months. There was a significant improvement in TAPSE and TAPSE age-based z-score on the follow-up echocardiogram. RVFAC, tricuspid S', TV E/E', and RVMPI did not show a statistically significant change. CONCLUSION: In contrast to the other echocardiographic markers of RV function, TAPSE, and TAPSE age-based z-score significantly improve after initiation or addition of PH therapy and can be used for serial noninvasive monitoring of RV function in pediatric PH patients.

Excessive postoperative bleeding and outcomes in neonates undergoing cardiopulmonary bypass.

BACKGROUND: Neonates undergoing cardiac surgery are especially prone to the hemostatic alterations of cardiopulmonary bypass (CPB) and are at high risk for post-CPB bleeding. An immature coagulation system, significant hemodilution from the CPB prime, long CPB times at low temperatures, and extensive suture lines increase neonates' susceptibility to bleeding after CPB. In this study, we examined the relationship between excessive bleeding in neonates after CPB and major postoperative adverse events. METHODS: We retrospectively reviewed the medical records of 169 neonates who underwent complex congenital heart surgery with CPB between January 1, 2010, and December 31, 2011. Perioperative data were collected and analyzed with specific focus on post-CPB bleeding as measured by 24-hour postoperative chest tube output (CTO), post-CPB transfusion requirements, and major postoperative adverse events, including renal dysfunction, dialysis, thrombosis, extracorporeal membrane oxygenation (ECMO), and in-hospital mortality. We used Spearman correlation to determine correlations between multiple perioperative variables and 24-hour CTO and postoperative blood product requirements. Also, we used logistic regression analysis to determine the association between excessive bleeding (defined as 24-hour CTO >75th percentile) and major postoperative adverse events. RESULTS: Significant correlations were found between 24-hour CTO and postoperative blood product transfusion with weight, Risk Adjustment for Congenital Heart Surgery (RACHS-1) score, CPB time, and lowest temperature. Logistic regression found that excessive bleeding after CPB was an independent predictor of postoperative dialysis (relative risk [RR] 12.0; confidence interval, 1.50-54.69; P = 0.02) and ECMO (RR 9.95; confidence interval, 3.07-28.47; P = 0.0008). RACHS-1 score was a significant predictor of in-hospital mortality (P = 0.03). CONCLUSIONS: Excessive postoperative bleeding in neonates after CPB is independently associated with increased adverse events, specifically the need for postoperative dialysis and ECMO support. Our findings in neonates are congruent with other recent research that also has found increasing transfusion requirements after pediatric CPB to be independently associated with an increase in major postoperative adverse events. Our results may aid clinicians in anticipating potential adverse events after neonatal bypass and in allocating the resources necessary to manage these events.

Late outcomes of infants supported by extracorporeal membrane oxygenation following the Norwood operation.

BACKGROUND: Hospital survival for infants who require extracorporeal membrane oxygenation (ECMO) following the Norwood operation is 30% to 60%. However, little is known about late outcomes of hospital survivors and their ability to progress through subsequent palliative stages. METHODS: Between 2002 and 2012, 38 (13.4%) of the 284 neonates with hypoplastic left heart syndrome or other single ventricle variants received ECMO support following Norwood. We examined factors affecting hospital death and compared postdischarge events between hospital survivors who received postoperative ECMO (n = 16 of 38) and a control of hospital survivors who did not receive ECMO (220 of 246). RESULTS: Unplanned cardiac reoperation was the only predictor of postoperative ECMO requirement. Overall, 22 (58%) of the 38 patients were weaned from ECMO support and 16 (42%) of the 38 survived to hospital discharge. The ECMO duration was a significant factor for hospital mortality (odds ratio = 1.52 per 1-day increase [1.03-2.24], P = .035). Following discharge, 15 (94%) of the 16 underwent Glenn and 1 (6%) of the 16 had interstage mortality. In the control group, 194 (88%) of the 220 underwent Glenn and 26 (12%) of the 220 had interstage mortality or received transplantation (P = .499). Following Glenn, 3 (20%) of the 15 patients had interstage mortality or received transplantation and 12 (80%) of the 15 proceeded to Fontan or were alive awaiting Fontan. In the control group, 23 (12%) of the 194 had interstage mortality or received transplantation and 171 (88%) proceeded to Fontan or were alive awaiting Fontan (P = .357). Overall, 81% of hospital survivors were alive 5 years following discharge in both ECMO and non-ECMO groups. CONCLUSIONS: ECMO support following Norwood is associated with high probability of hospital death. Nonetheless, interstage mortality, progression to subsequent palliative stages, intermediate survival, and freedom from heart transplantation are comparable to those in patients who did not require postoperative ECMO support.

Current outcomes of the Norwood operation in patients with single-ventricle malformations other than hypoplastic left heart syndrome.

BACKGROUND: Subsequent to increased experience with the Norwood operation in children with hypoplastic left heart syndrome (HLHS), its application has expanded to allow palliation of single-ventricle (SV) malformations other than HLHS. We describe current palliation outcomes in this group of SV patients. METHODS: Between 2002 and 2012, 65 of the 303 Norwood operations were performed in non-HLHS SV patients. Competing risk analysis modeled events after Norwood and after subsequent Glenn and examined risk factors affecting outcomes. RESULTS: Competing risk analysis showed that one year following Norwood, 24% of patients had died or received transplantation, 72% had undergone Glenn, and 4% were alive awaiting Glenn/Kawashima. Five years following Glenn, 9% of patients had died, 68% had undergone Fontan, and 23% were alive awaiting Fontan. Overall seven-year survival following Norwood was 68%. On multivariable analysis, mortality risk factors were unplanned cardiac reoperation (hazard ratio [HR]: 4.0 [1.5-10.6], P = .006), right dominant ventricle morphology (HR: 3.3 [1.3-8.3], P = .012), and postoperative extracorporeal membrane oxygenation (HR: 3.1 [1.1-9.0], P = .035). CONCLUSIONS: Operative death and interstage mortality continue to be problematic following Norwood palliation for non-HLHS SV variants. Outcomes seem comparable to those reported for HLHS, however they are influenced by underlying pathology; children with dominant left ventricle morphology (tricuspid atresia and double inlet left ventricle) have superior survival compared to those with dominant right ventricle morphology (mitral atresia, unbalanced atrioventricular septal defect, and most patients with atrial isomerism). Unplanned reoperations for technical imperfections diminish survival. Large multicenter studies might be warranted to better identify high-risk patients and provide guidance toward improving their survival.

Single ventricle palliation in low weight patients is associated with worse early and midterm outcomes.

BACKGROUND: While low weight is an established risk factor for operative mortality after single ventricle (SV) palliation, its influence on late outcomes is not well understood. We examined current-era effects of low weight at time of surgery on hospital mortality, progression through palliative stages, and survival. METHODS: Five hundred and thirty infants with SV underwent first-stage palliation (2002 to 2012). Competing risk analysis modeled events after initial surgery and after Glenn. Regression models examined the effect of low weight 2.5 kg or less (n = 77 of 530, 14.5%) on early and late outcomes. RESULTS: Initial palliation was Norwood (n = 284, 54%), modified Blalock-Taussig shunt (n = 173, 33%), and pulmonary artery band (n = 73, 14%). Competing risk analysis showed that at 6 months after initial palliation the proportion of patients who had died or received transplantation was 40% in patients 2.5 kg or less and 20% in patients greater than 2.5 kg (p < 0.001). Consequently, the proportion of patients who had progressed to Glenn was 33% in patients 2.5 kg or less and 59% in patients greater than 2.5 kg (p < 0.001). Subsequent to Glenn, progression toward Fontan was unaffected by initial weight. In addition to increased hospital mortality (odds ratio 1.86, 95% confidence interval [CI] 0.93% to 3.70%, p = 0.08); adjusted hazard analysis showed that weight 2.5 kg or less was associated with diminished late survival (hazard ratio 1.65, 95% CI 1.085% to 2.53%, p = 0.02) and that was evident for all palliation types and most SV morphologies. CONCLUSIONS: Low weight at time of first-stage SV palliation is associated with an increase in both hospital mortality and interstage attrition, with subsequently fewer patients progressing toward the Glenn operation. The increased death hazard in low weight SV patients persists for almost 1 year after initial palliation, suggesting the need for more vigilant monitoring and out-patient care in those high-risk patients.

Elevated tricuspid regurgitant velocity as a marker for pulmonary hypertension in children with sickle cell disease: less prevalent and predictive than previously thought?

Although elevated tricuspid regurgitant velocity (TRV), an echocardiographic marker for pulmonary hypertension, has previously been tied to mortality in adult patients with sickle cell disease, recent data demonstrated that it correlates poorly with catheterization findings. We describe the largest echocardiographic evaluation of pediatric patients with sickle cell disease to date, specifically the results of a protocol whereby a TRV≥250 cm/s prompted further evaluation. We investigated if elevated TRV would independently identify patients at risk for increased morbidity. A clinical echocardiographic database containing 630 patients with sickle cell disease was retrospectively reviewed; 120 patients (19%) met inclusion criteria and were compared 1:1 to randomly selected age-matched controls from the same database. By multivariate analysis, the elevated TRV cohort did not differ from controls in likelihood of acute chest episodes, hospitalization, or stroke. The study cohort's mean TRV in fact decreased to 242±33 cm/s at follow-up without a discernible and comprehensive intervention to explain the improvement. Three patients had catheterization-proven pulmonary hypertension. In conclusion, elevated TRV in children with sickle cell disease is less prevalent than previously thought and is not independently associated with increased short-term morbidity.

Novel electrocardiographic screening criterion for hypertrophic cardiomyopathy in children.

Electrocardiography is often advocated as a screening tool in children for hypertrophic cardiomyopathy (HC). We sought to establish an electrocardiographic screening tool to identify children with HC. We hypothesized that a pediatric-specific electrocardiographic criterion would perform better than the popular criteria used for screening children for left ventricular hypertrophy and HC. The earliest available electrocardiogram for children (n=108) with HC (ages 7 to 21 yrs) was reviewed. We sought to compare the diagnostic accuracy of 4 screening algorithms: (1) Sokolow-Lyon criterion (SV1+RV5/RV6>35 mm), (2) Cornell criterion (RaVL+SV3>28 mm in men, 20 mm in women), (3) total 12-lead voltage criterion (R wave to the nadir of Q/S wave>175 mm), and (4) pediatric-specific criterion (RaVL+SV2>23 mm). The same criteria were applied to a cohort of age-matched and gender-matched controls without cardiac disease. Statistically significant correlations were found between children with HC and positive screen using all 4 criteria. However, comparison of receiver operating characteristic demonstrated an area under the curve of 0.67 for Sokolow-Lyon criterion, 0.70 for Cornell criterion, 0.83 for total 12-lead criterion, and 0.82 for pediatric-specific criterion. Pediatric-specific criterion had superior sensitivity in gene-positive children and superior overall specificity than total 12-lead criterion. In conclusion, our study demonstrates that the pediatric-specific criterion employing leads RaVL+SV2 is more accurate in identifying children with HC in comparison with other popular screening criteria.

Relation of prenatal diagnosis with one-year survival rate for infants with congenital heart disease.

Prenatal diagnosis of congenital heart defects (CHDs) is increasingly common, but it is still unclear whether it translates to improved postoperative outcomes. We performed a retrospective cohort study of all infants (aged <1 year) who underwent surgery for CHDs from 2006 to 2011 at a single institution. Primary outcomes were in-hospital and 1-year mortality rates. Secondary outcomes were readmission within 30 days of discharge, postoperative length of intensive care unit and hospital stay, unplanned reoperation, and extracorporeal membrane oxygenation use. We used chi-square analyses, Wilcoxon rank-sum tests, Kaplan-Meier survival curves, and adjusted Cox proportional hazards models to compare outcomes. Of the 1,642 patients with CHDs, 539 (33%) were diagnosed prenatally. Patients with prenatal diagnoses were of a younger age and less weight at the time of surgery, had greater Risk Adjustment for Congenital Heart Surgery scores, and were more likely to be white, to have an identified syndrome, or to be born at term. Compared with those diagnosed postnatally, those diagnosed prenatally had a significantly higher unadjusted 1-year mortality rate (11% vs 5.5%, respectively, p = 0.03). Controlling for weight, surgical severity, race, age at surgery, prematurity, and the presence or absence of genetic syndrome, patients with prenatal diagnoses had significantly greater mortality at 1 year (adjusted hazard ratio 1.5, p = 0.03), as well as significantly longer intensive care unit and hospital stays. Infants with CHDs diagnosed prenatally had worse outcomes compared with those diagnosed postnatally. Prenatal diagnosis likely captures patients with more severe phenotypes within given surgical risk categories and even within diagnoses and thus may be an important prognostic factor when counseling families.

Cigarette smoking women of reproductive age who use oral contraceptives: results from the 2002 and 2004 behavioral risk factor surveillance systems.

BACKGROUND: Despite health warnings about the increased risk of cerebrovascular disease among women who smoke while using oral contraceptives (OCs), prior research suggests that OC use is still prevalent among women who smoke cigarettes. Our objective was to investigate the prevalence of OC use among cigarette smoking women of reproductive age in the United States. STUDY DESIGN: We extracted data from the 2002 and 2004 Behavioral Risk Factor Surveillance System surveys of 76,544 women between 18 and 44 years of age who reported using some form of contraception. OC use, or self-reported use of "the pill," was examined among those who currently smoke, either everyday or some days. Multivariable logistic regression models were used to compare OC use between smoking and nonsmoking women. RESULTS: One fourth (26.9%) of U.S. women who smoke compared with 34.6% of nonsmoking women reported currently using OCs. After adjusting for age, race/ethnicity, marital status, education level, binge drinking, and health care coverage, women who smoke were 0.6 (95% confidence interval [CI], 0.6-0.7) times as likely to use OCs as nonsmoking women. Among women aged 35 to 44 years, the odds of OC use among smokers was even further reduced (odds ratio [OR], 0.3; 95% CI, 0.3-0.4) compared with nonsmokers. CONCLUSION: Among U.S. women of reproductive age who use contraception, particularly among women aged 35 to 44 years, those who smoke cigarettes are significantly less likely to use OCs than those who do not.