Successful Implementation of Enhanced Recovery After Surgery (ERAS) in Paediatric Cardiac Surgery in Australia.

BACKGROUND & AIM: Fast-track or enhanced recovery after surgery (ERAS) is a care pathway for surgical patients based on a multidisciplinary team approach aimed at optimising recovery without increasing risk with protocols based on scientific evidence, which is monitored continuously to ensure compliance and improvement. These protocols have been shown to reduce the duration of postoperative mechanical ventilation and intensive care unit (ICU) length of stay (LOS) following paediatric cardiac surgery. We present the first structured implementation of ERAS in paediatric cardiac surgery in Australia. METHODS: All patients enrolled in the ERAS pathway between October 2019 and July 2023 were identified. Demographic and perioperative data were collected retrospectively from hospital records for patients operated before June 2021 and prospectively from June 2021. A control group (non-ERAS) was identified using propensity matching from patients who underwent similar procedures and were not enrolled in the ERAS pathway (prior to October 2019). Patients were matched for age, weight, and comprehensive Aristotle score. Outcomes of interest were duration of postoperative mechanical ventilation, ICU LOS, readmission to the ICU, hospital LOS, cardiac reintervention rate, postoperative complication rate, and number of 30-day readmissions. RESULTS: Of 1,084 patients who underwent cardiac surgery during the study period (October 2019-July 2023), 121 patients (11.2%) followed the ERAS pathway. The median age at the time of surgery was 4.8 years (interquartile range [IQR] 2.8-8.8 years). The most common procedure was the closure of atrial septal defect (n=58, 47.9%). The median cardiopulmonary bypass and cross-clamp times were 40 min (IQR 28-53.5 minutes) and 24.5 min (IQR 13-34 minutes) respectively. The majority were extubated in the operating theatre (n=108, 89.3%). The median ICU and hospital LOS were 4.5 hrs (IQR 4.1-5.6 hours) and 4 days (IQR 4-5 days) respectively. None of the patients required readmission to the ICU within 24 hrs of discharge from the ICU. Three (3) patients (2.5%) required reintervention. When compared with the non-ERAS group, the duration of postoperative mechanical ventilation, ICU and hospital LOS were significantly lower in the ERAS group. There was no significant difference in the ICU readmission rate, reintervention rate, complication rate, and number of 30-day readmissions between both groups. CONCLUSIONS: ERAS after paediatric cardiac surgery is feasible and safe in select patients with low preoperative risk. This pathway reduces the duration of postoperative mechanical ventilation, ICU and hospital LOS without increasing risks, enabling the optimisation of resources.

Early outcomes after post-cardiotomy extracorporeal membrane oxygenation in paediatric patients: a contemporary, binational cohort study.

OBJECTIVES: The aim of this study was to assess the early outcomes and risk factors of paediatric patients requiring extracorporeal membrane oxygenation after cardiac surgery (post-cardiotomy). METHODS: Retrospective binational cohort study from the Australia and New Zealand Congenital Outcomes Registry for Surgery database. All patients younger than 18 years of age who underwent a paediatric cardiac surgical procedure from 1 January 2013 to 31 December 2021 and required post-cardiotomy extracorporeal membrane oxygenation (PC-ECMO) in the same hospital admission were included in the study. RESULTS: Of the 12 290 patients included in the study, 376 patients required post-cardiotomy ECMO (3%). Amongst these patients, hospital mortality was 35.6% and two-thirds of patients experienced a major complication. Hypoplastic left heart syndrome was the most common diagnosis (17%). The Norwood procedure and modified Blalock-Taussig shunts had the highest incidence of requiring PC-ECMO (odds ratio of 10 and 6.8 respectively). Predictors of hospital mortality after PC-ECMO included single-ventricle physiology, intracranial haemorrhage and chylothorax. CONCLUSIONS: In the current era, one-third of patients who required PC-ECMO after paediatric cardiac surgery in Australia and New Zealand did not survive to hospital discharge. The Norwood procedure and isolated modified Blalock-Taussig shunt had the highest incidence of requiring PC-ECMO. Patients undergoing the Norwood procedure had the highest mortality (48%). Two-thirds of patients on PC-ECMO developed a major complication.

CardioCel® for repair of congenital heart defects: nationwide results of over 1000 implants.

OBJECTIVES: To assess the mid-term performance of CardioCel for the repair of congenital heart defects. METHODS: Data were retrospectively collected from databases and hospital records in 3 congenital cardiac surgery centres in Australia. Kaplan-Meier curves and log-rank tests were used to test for associations between patient age, gender, patch type and site of implantation. Multivariable Cox regression was used to test whether any specific implantation site was associated with reintervention risk, after adjusting for age group, gender and patch type. RESULTS: A total of 1184 CardioCel patches were implanted in 752 patients under the age of 18 years. Median age at implant was 12 months [interquartile range (IQR) 3.6-84]. Median follow-up was 2.1 years (IQR 0.6-4.6). Probability of freedom from CardioCel-related reintervention was 93% [95% confidence interval (CI) 91-95] at 1 year, 91% (95% CI 88-93) at 3 years and 88% (95% CI 85-91) at 5 years, respectively. On multivariable regression analysis, aortic valve repair had a higher incidence of reintervention [hazard ratio (HR) = 7.15, P = 0.008] compared to other sites. The probability of reintervention was higher in neonates (HR = 6.71, P = 0.0007), especially when used for augmentation of the pulmonary arteries (HR = 14.38, P = 0.029), as compared to other age groups. CONCLUSIONS: CardioCel can be used for the repair of a variety of congenital heart defects. In our study, in patients receiving a CardioCel implant, reinterventions were higher when CardioCel was used to augment the pulmonary arteries in neonates and for aortic valve repair as compared to other sites.

Utility of routine chest radiographs after chest drain removal in paediatric cardiac surgical patients-a retrospective analysis of 1076 patients.

OBJECTIVES: Chest drains are routinely placed in children following cardiac surgery. The purpose of this study was to determine the incidence of a clinically relevant pneumothorax and/or pleural effusion after drain removal and to ascertain if a chest radiograph can be safely avoided following chest drain removal. METHODS: This single-centre retrospective cohort study included all patients under 18 years of age who underwent cardiac surgery between January 2015 and December 2019 with the insertion of mediastinal and/or pleural drains. Exclusion criteria were chest drain/s in situ ≥14 days and mortality prior to removal of chest drain/s. A drain removal episode was defined as the removal of ≥1 drains during the same episode of analgesia ± sedation. All chest drains were removed using a standard protocol. Chest radiographs following chest drain removal were reviewed by 2 investigators. RESULTS: In all, 1076 patients were identified (median age: 292 days, median weight: 7.8 kg). There were 1587 drain removal episodes involving 2365 drains [mediastinal (n = 1347), right pleural (n = 598), left pleural (n = 420)]. Chest radiographs were performed after 1301 drain removal episodes [mediastinal (n = 1062); right pleural (n = 597); left pleural (n = 420)]. Chest radiographs were abnormal after 152 (12%) drain removal episodes [pneumothorax (n = 43), pleural effusion (n = 98), hydropneumothorax (n = 11)]. Symptoms/signs were present in 30 (2.3%) patients. Eleven (<1%) required medical management. One required reintubation and 2 required chest drain reinsertion. CONCLUSIONS: The incidence of clinically significant pneumothorax/pleural effusion following chest drain removal after paediatric cardiac surgery is low (<1%). Most patients did not require reinsertion of a chest drain. It is reasonable not to perform routine chest radiographs following chest drain removal in most paediatric cardiac surgical patients.

Mid- and long-term outcomes after surgical correction of subaortic stenosis: a 27-year experience.

OBJECTIVES: We reviewed the mid- and long-term surgical outcomes of patients with subaortic stenosis (SAS). METHODS: Patients operated for SAS from April 1990 to August 2016 were reviewed retrospectively. Patients with major associations such as aortic arch obstruction were excluded. Time to reintervention and predictors of recurrence were assessed using Kaplan-Meier analysis, log-rank test and uni/multivariable Cox regression. RESULTS: 120 patients at a median age of 4.7 years (interquartile range 2.9, 8.1) underwent primary operation (median peak preoperative left ventricular outflow tract gradient 52.5 mmHg, interquartile range 40, 70) involving fibrous tissue excision (n = 120) with septal myectomy (93%; n = 112) as the procedure of choice.At median follow-up of 13 years (interquartile range 7, 18), freedom from reintervention at 1, 3, 5 and 10 years was 99% (95% confidence interval 94%, 99%), 94% (87%, 97%), 93% (86%, 96%) and 90% (82%, 94%), respectively. Recurrence occurred in 18% (n = 20) with 15 patients undergoing reinterventions, 13 of whom required radical reoperation. Multivariable analysis revealed higher preoperative peak left ventricular outflow tract gradient (hazard risk 1.06, confidence interval 1.03, 1.09, P < 0.001), and presence of bicuspid aortic valve (hazard risk 14.13, confidence interval 3.32, 60.1, P < 0.001) as predictors for reintervention. Mild/moderate aortic regurgitation occurred in 49% (n = 55) of patients at the most recent follow-up. CONCLUSIONS: Reintervention for recurrent SAS is common, predicted by higher preoperative peak left ventricular outflow tract gradient, and presence of bicuspid aortic valve, and frequently involves a radical procedure. Aortic regurgitation is a major consequence of SAS, but its severity usually remains low. CLINICAL REGISTRATION NUMBER: SCHN HREC reference number 2019/ETH02729, approved on 09 July 2019.

A machine learning approach to predicting 30-day mortality following paediatric cardiac surgery: findings from the Australia New Zealand Congenital Outcomes Registry for Surgery (ANZCORS).

OBJECTIVES: We aim to develop the first risk prediction model for 30-day mortality for the Australian and New Zealand patient populations and examine whether machine learning (ML) algorithms outperform traditional statistical approaches. METHODS: Data from the Australia New Zealand Congenital Outcomes Registry for Surgery, which contains information on every paediatric cardiac surgical encounter in Australian and New Zealand for patients aged <18 years between January 2013 and December 2021, were analysed (n = 14 343). The outcome was mortality within the 30-day period following a surgical encounter, with ∼30% of the observations randomly selected to be used for validation of the final model. Three different ML methods were used, all of which employed five-fold cross-validation to prevent overfitting, with model performance judged primarily by the area under the receiver operating curve (AUC). RESULTS: Among the 14 343 30-day periods, there were 188 deaths (1.3%). In the validation data, the gradient-boosted tree obtained the best performance [AUC = 0.87, 95% confidence interval = (0.82, 0.92); calibration = 0.97, 95% confidence interval = (0.72, 1.27)], outperforming penalized logistic regression and artificial neural networks (AUC of 0.82 and 0.81, respectively). The strongest predictors of mortality in the gradient boosting trees were patient weight, STAT score, age and gender. CONCLUSIONS: Our risk prediction model outperformed logistic regression and achieved a level of discrimination comparable to the PRAiS2 and Society of Thoracic Surgery Congenital Heart Surgery Database mortality risk models (both which obtained AUC = 0.86). Non-linear ML methods can be used to construct accurate clinical risk prediction tools.

Development and validation of a machine learning-based tool to predict autism among children.

Autism is a lifelong condition for which intervention must occur as early as possible to improve social functioning. Thus, there is great interest in improving our ability to diagnose autism as early as possible. We take a novel approach to this challenge by combining machine learning with maternal and infant health administrative data to construct a prediction model capable of predicting autism disorder (defined as ICD10 84.0) in the general population. The sample included all mother-offspring pairs from the Australian state of New South Wales (NSW) between January 2003 and December 2005 (n = 262,650 offspring), linked across three health administrative data sets including the NSW perinatal data collection (PDC); the NSW admitted patient data collection (APDC) and the NSW mental health ambulatory data collection (MHADC). Our most successful model was able to predict autism disorder with an area under the receiver operating curve of 0.73, with the strongest risk factors for diagnoses found to include offspring gender, maternal age at birth, delivery analgesia, maternal prenatal tobacco disorders, and low 5-min APGAR score. Our findings indicate that the combination of machine learning and routinely collected admin data, with further refinement and increased accuracy than achieved by us, may play a role in the early detection of autism disorders.

Performance of CardioCel in Cardiac Surgery: A Systematic Review.

A systematic review was performed for evaluation of the performance of CardioCel® in cardiac surgery. The review included all studies published from January 2013 to December 2020. We conclude that CardioCel is a strong, flexible tissue substitute with good handling characteristics and a low incidence of thrombosis, aneurysm formation, infection, or structural degeneration. It can be used for a variety of intracardiac and extracardiac repairs of congenital heart defects in all age groups with good durability at mid-term follow-up. However, the use of CardioCel in certain positions requires caution. Information on the long-term performance of CardioCel is lacking.

Exploring the utility of synthetic data to extract more value from sensitive health data assets: A focused example in perinatal epidemiology.

BACKGROUND: Privacy, access and security concerns can hinder the availability of health data for research. The use of synthesised data in place of de-identified electronic health records (EHRs) presents an opportunity to conduct research while minimising privacy concerns. OBJECTIVES: To examine whether synthesised data can replicate two prenatal epidemiological associations: between prenatal smoking and lower birthweight, and between prenatal mood disorders and lower birthweight, using data synthesised from de-identified health administrative data collections. METHODS: We generated two synthetic datasets, using parametric and non-parametric data generating methods, and examined the synthetic data for evidence of privacy concerns. Next, univariable and multivariable logistic regression was utilised to estimate the associations in both synthetic datasets, with results then compared to the real data. RESULTS: Both synthesised datasets performed well in identifying the reduction in birthweight associated with prenatal smoking, while the non-parametric data underestimated the reduction in birthweight associated with prenatal mood disorders. Improbable relationships between some variables were identified in the parametric synthesised data, however, these can be addressed with simple rules during data synthesis. No duplicate rows (i.e., exact copies of de-identified data) were found in the parametric data, while only 0.6% of the rows in the non-parametric data were duplicated. CONCLUSIONS: Both synthesised datasets performed well in replicating the statistical properties of the original data while addressing privacy issues. Data synthesis methods provide an opportunity for researchers to utilise health data while managing privacy and security concerns.

Technique of Coronary Button Transfer Has no Impact on Neoaortic Root Size in Simple Transposition.

We studied the effect of various coronary transfer techniques (CTT) on neo-aortic root size after an arterial switch operation (ASO) in simple transposition by excluding the impact of recognized predisposing factors. One hundred and seventy-eight patients with simple transposition were reviewed retrospectively (January 2004-December 2018) and grouped as Punch Hole (n = 83/178), Nonpunch Hole (n = 65/178; Trapdoor or Standard) and Mixed (n = 30/178). Factors predicting the neo-aortic root z-scores- annulus, mid-sinus, and sinotubular junction (STJ) were analyzed by uni/multivariable linear regression. Follow-up was 6 years, Interquartile range (IQR) 3.4,10.6. Preoperative aortic (7.4 mm, IQR 6.9,8) and pulmonary annulus (7.5 mm, IQR 6.8,8.1) sizes were identical (P = 0.831). The changes in preoperative, postoperative, and latest median z-scores for neo-aortic annulus (-0.2, IQR -1.2,0.9; 0.0, IQR -0.9,0.9; 0.9, IQR -0.4,2.6; P < 0.001), mid-sinus (1.1, IQR-0.1,2; 2.6, IQR 1.6,3.7; 2.9, IQR 1.8,4.3; P < 0.001) and STJ (-0.1, IQR -0.8,1.1; 2.1, IQR 0.7,3; 2.4, IQR 1,3.5; P < 0.001) were significant. On multivariate analysis, preoperative pulmonary annulus z-score predicted the latest neo-aortic annulus z-score [Beta estimate (BE) = 0.32, 95% confidence interval (CI) = 0.03,0.62; P = 0.03] and STJ z-score (BE= 0.45, 95% CI= 0.20,0.70; P < 0.0001). CTT did not predict any of the latest neo-aortic z-scores (all P > 0.05). Mild plus neo-aortic regurgitation (neoAR) was not significantly different across CTT groups [punch hole 20% (n = 15/74), mixed 37% (n = 11/30), nonpunch hole 21% (n = 13/62); Fisher-exact P = 0.186], one patient required valve replacement for severe neoAR. The neo-aortic root enlarges significantly over time at all 3 levels following an ASO in simple transposition, however, this is not significantly influenced by the CTT utilized.

Academic performance in adolescent offspring of mothers with prenatal and perinatal psychiatric hospitalizations: A register-based, data linkage, cohort study.

BACKGROUND: This is the first study to investigate the longitudinal association between prenatal and perinatal psychiatric hospitalizations and academic achievements in adolescent offspring. METHODS: We conducted an administrative health data-based cohort study of 168, 528 mother-offspring pairs using linked data obtained from health and educational registries in New South Wales, Australia. Prenatal and perinatal maternal psychiatric diagnosis was measured by using ICD-10. The National Assessment Program for Literacy and Numeracy (NAPLAN) was used to assess the educational performance of the offspring. Logistic regression model was used to explore the association. Multivariate models were adjusted for maternal sociodemographic characteristics such as age at birth, marital status, educational status, and occupational status, maternal diabetes and chronic hypertension, maternal smoking during pregnancy, birth weight, and language spoken at home. RESULTS: The findings show that after adjusting for important covariates adolescent offspring of mothers with prenatal and perinatal psychiatric hospitalizations were more likely to perform below the national minimum standard in all domains of academic performance at age 14 years, when compared with the offspring of mothers without such hospitalizations, with the highest odds for numeracy (OR = 2.88; 95% CI: 2.50-3.31) followed by reading (OR = 2.08; 95% CI: 1.81-2.38), spelling (OR = 1.74; 95% CI: 1.51-2.01), and writing (OR = 1.56; 95% CI: 1.34-1.80). There was significant gender interaction such that males were more likely to experience lower rates of academic performance than females in all academic domains. Lower academic achievements were observed among offspring of mothers with all major groupings of psychiatric disorders, with a higher risk for severe psychiatric disorders followed by mental disorders due to substance use or medical conditions. CONCLUSION: In sum, maternal prenatal and perinatal psychiatric hospitalizations are associated with lower academic achievements in adolescent offspring, with a stronger effect on the academic performance of male offspring. Early intervention strategies that aim to enhance educational performance in the exposed offspring are needed.

Feeding Neonates and Infants Prior to Surgery for Congenital Heart Defects: Systematic Review and Meta-Analysis.

BACKGROUND: Necrotising enterocolitis (NEC) is a significant cause of mortality and morbidity in neonates requiring cardiac surgery. Feeding practices vary significantly across institutions and remain controversial. We conducted a systematic review of the literature and a meta-analysis to identify associations between feeding practices and necrotising enterocolitis. METHODS: This study was carried out in accordance with the PRISMA guidelines. A literature search was performed in November 2022 using the Cochrane Central Register, Embase, and Pubmed. Two investigators then independently retrieved eligible manuscripts considered suitable for inclusion. Data extracted included gestational age, birth weight, sex, nature of congenital heart lesion, type of operation performed, time on ventilator, ICU stay, hospital stay, post-operative feeding strategy, and complications. The methodological quality was assessed using the Downs and Black score for all randomised control trials and observational studies. RESULTS: The initial search yielded 92 studies. After removing duplicates, there were 85 abstracts remaining. After excluding ineligible studies, 8 studies were included for the meta-analysis. There was no significant risk of NEC associated with pre-operative feeding [OR = 1.22 (95% CI 0.77,1.92)] or umbilical artery catheter placement [OR = 0.91 (95% CI 0.44, 1.89)] and neither outcome exhibited heterogeneity [I2 = 8% and 0%, respectively]. There was a significant association between HLHS and NEC [OR = 2.56 (95% CI 1.56, 4.19)] as well as prematurity and NEC [OR 3.34 (95% CI 1.94, 5.75)] and neither outcome exhibited heterogeneity [I2 = 0% and 0%, respectively]. CONCLUSIONS: There was no association between NEC and pre-operative feeding status in neonates awaiting cardiac surgery. Pre-operative feeding status was not associated with prolonged hospital stay or need for tube assisted feeding at discharge. HLHS and prematurity were associated with increased incidence of NEC.

LIMA to LAD grafting returns patient survival to age-matched population: 20-year outcomes of MIDCAB surgery.

OBJECTIVES: Previous studies have demonstrated the safety and excellent short-term and mid-term survival after minimally invasive direct coronary artery bypass (MIDCAB). We reviewed the long-term outcomes up to 20 years, including overall survival and freedom from reintervention. METHODS: Consecutive patients who underwent MIDCAB between February 1997 and August 2020 were identified. Demographic details, operative information and long-term outcomes were obtained. The Australian National Death Index database was accessed to obtain long-term mortality data. RESULTS: A total of 271 patients underwent an MIDCAB procedure during the study period. There were no intraoperative deaths and only one 30-day mortality (0.4%). The mean length of follow-up was 9.82 ± 8.08 years. Overall survival at 5-, 10-, 15- and 20-year survival was 91.9%, 84.7%, 71.3% and 56.5%, respectively. Patients with single-vessel disease [left anterior descending artery (LAD) only] had significantly better survival compared to patients with multivessel disease (P = 0.0035). During long-term follow-up, there were no patients who required repeat revascularization of the LAD territory. Sixty-nine patients died with the cause of death in 15 patients (21.7%) being attributable to ischaemic heart disease. An analysis comparing the isolated LAD disease MIDCAB cohort survival with the expected survival among an age/gender/year matched sample of the Australian reference population, using the standardized mortality ratio, demonstrated that the rate of survival returned to that of the reference population (standardized mortality ratio = 0.94). CONCLUSIONS: MIDCAB is a safe and effective revascularization strategy which can be successfully performed in a carefully selected patient population with low morbidity and excellent long-term results. The survival of MIDCAB patients returns to that of their age/gender/year-matched counterparts within the normal population and hence should be offered as an alternative to coronary stenting when counselling patients with ischaemic heart disease.

Vocal cord dysfunction after pediatric cardiac surgery: A prospective implementation study.

Objective: To determine the incidence, outcomes, and evaluate diagnostic modalities for postoperative vocal cord dysfunction (VCD) following cardiothoracic surgery in children. Methods: A prospective mixed-methods study using principles of implementation science was completed. All patients undergoing surgery involving the aortic arch, ductus, or ligamentum arteriosum and vascular rings from September 2019 to December 2020 were enrolled. Patients underwent speech pathology assessment, laryngeal ultrasound, and flexible direct laryngoscopy. Results: Ninety-five patients were eligible for inclusion. The incidence of VCD ranged from 18% to 56% and varied according to procedure group. VCD occurred in 42% of neonates. Repair of hypoplastic aortic arch was associated with increased risk of VCD (57%; P = .002). There was no significant difference in duration of intubation, pediatric intensive care unit stay, or hospital stay. Forty percent children were able to achieve full oral feeding. Children with VCD were more likely to require nasogastric supplementary feeding at discharge (60% vs 36%; P = .044). Sixty-eight percent of patients demonstrated complete resolution of VCD at a median of 97 days postoperatively. Laryngeal ultrasound and speech pathology assessment combined had a sensitivity of 91% in comparison to flexible direct laryngoscopy. Conclusions: VCD occurred in one-third and resolved in two-thirds of patients at a median of 3 months following cardiac surgery. Aortic arch repair carried the highest risk of VCD. VCD adversely influenced feeding. Forty percent of patients achieved full oral feeding before discharge. VCD did not delay intensive care unit or hospital discharge. Speech pathology assessment and laryngeal ultrasound combined was reliable for diagnosis in most patients and was more patient friendly than flexible direct laryngoscopy.

The Australia and New Zealand Congenital Outcomes Registry for Surgery (ANZCORS): methodology and preliminary results.

BACKGROUND: Analysis of multi-institutional data and benchmarking is an accepted accreditation standard in cardiac surgery. Such a database does not exist for congenital cardiac surgery in Australia and New Zealand (ANZ). To fill this gap, the ANZ Congenital Outcomes Registry for Surgery (ANZCORS) was established in 2017. METHODS: Inclusion criteria included all cardiothoracic and extracorporeal membrane oxygenation (ECMO) procedures performed at five participating centres. Data was collected by data managers, validated by the surgical team, and securely transmitted to a central repository. RESULTS: Between 2015 and 2019, 9723 procedures were performed in 7003 patients. Cardiopulmonary bypass was utilized for 59% and 9% were ECMO procedures. Fifty-seven percent (n = 5531) of the procedures were performed in children younger than 1 year of age. Twenty-four percent of procedures (n = 2365) were performed in neonates (≤28 days) and 33% (n = 3166) were performed in children aged 29 days to 1 year (infants). The 30-day mortality for cardiac cases (n = 6572) was 1.3% and there was no statistical difference between the participating centres (P = 0.491). Sixty-nine percent of cases had no major post-operative complications (5121/7456). For cardiopulmonary bypass procedures (n = 5774), median stay in intensive care and hospital was 2 days (IQR 1, 4) and 9 days (IQR 5, 18), respectively. CONCLUSION: ANZCORS has facilitated pooled data analysis for paediatric cardiac surgery across ANZ for the first time. Overall mortality was low. Non-risk-adjusted 30-day mortality for individual procedures was similar in all units. The continued evaluation of surgical outcomes through ANZCORS will drive quality assessment in paediatric cardiac surgery across ANZ.

Prenatal tobacco and alcohol exposures and the risk of anxiety symptoms in young adulthood: A population-based cohort study.

BACKGROUND: Epidemiological studies have linked prenatal tobacco and alcohol exposures to internalizing behaviours in children and adolescents with inconsistent findings. Dearth of epidemiological studies have investigated the associations with the risk of experiencing symptoms of anxiety in young adulthood. METHODS: Study participants (N = 1190) were from the Raine Study, a population-based prospective birth cohort based in Perth, Western Australia. Data on prenatal tobacco and alcohol exposures were available for the first and third trimesters of pregnancy. Experiencing symptoms of anxiety in young adulthood at age 20 years was measured by a short form of the Depression Anxiety Stress Scale (DASS 21). Relative risk (RR) of experiencing symptoms of anxiety in young adulthood for prenatal tobacco and alcohol exposures were estimated with log binomial regression. RESULTS: After adjusting for potential confounders, we observed increased risks of experiencing symptoms of anxiety in young adults exposed to prenatal tobacco in the first trimester [RR = 1.52, 95% CI: 1.12-2.06, p-value < 0.01] and third trimester [RR = 1.53, 95% CI: 1.10-2.13, p-value  = 0.02]. However, we found insufficient statistical evidence for an association between first trimester [RR = 1.01, 95% CI: 0.76-1.22, p-value = 0.90] and third trimester [RR = 1.03, 95% CI: 0.80-1.34, p-value = 0.91] prenatal exposure to alcohol and the risk of experiencing symptoms of anxiety in young adults. There was a dose response association between prenatal tobacco exposure and increasing anxiety symptoms in offspring. CONCLUSION: The findings of this study suggest that an association between prenatal tobacco exposure and risk of anxiety symptoms remains apparent into young adulthood.

Comparison of homografts and bovine jugular vein conduits in the pulmonary position in patients <20 years of age.

OBJECTIVE: To compare the performance of homografts and bovine jugular vein (BJV) conduits in the pulmonary position. METHODS: All patients with congenital heart disease up to age 20 years who underwent pulmonary valve replacement with homografts or BJV at 3 centers in Australia were evaluated. There were 674 conduits, with 305 (45%) pulmonary homografts (PHs), 303 (45%) BJV conduits, and 66 (10%) aortic homografts (AHs). Endpoints were freedom from reintervention, structural valve degeneration (SVD), and infective endocarditis (IE). Propensity score matching was used to balance the comparison of PH and BJV conduits. RESULTS: The median follow-up was 6.4 years (interquartile range, IQR, 3.1-10.7 years). Freedom from reintervention at 5 and 10 years was 92% and 80%, respectively, for PH, 74% and 37% for BJV, and 75% and 47% for AH. BJV conduits had a higher risk of reintervention (P < .001) and SVD (P < .001) compared with PHs. These findings were confirmed with propensity score matching valid for conduit size >15 mm. AHs >15 mm had a higher risk of reintervention (P < .001) and SVD (P < .001) compared with PHs >15 mm. The performance of AHs and BJV conduits was similar across all sizes (reintervention, P = .94; SVD, P = .72). The incidence of IE was 1% for PH, 10% for BJV, and 1.5% for AH. CONCLUSIONS: In patients age <20 years with a conduit >15 mm, PHs outperformed BJV conduits and AHs in the pulmonary position. The performance of AH and BJV was comparable. Small conduits (≤15 mm) had similar performance across all conduit types.

Prenatal alcohol and tobacco exposures and the risk of cannabis use in offspring: Findings from a population-based cohort study.

BACKGROUND: There is a paucity of prospective longitudinal studies examining the associations between maternal use of alcohol and tobacco during pregnancy and the risk of cannabis use in offspring. The aim of this study was to examine the association between prenatal alcohol and tobacco exposures and offspring cannabis use. METHODS: Data were from the Raine Study, a longitudinal prospective birth cohort based in Western Australia. Cannabis use at 17 years of age was measured with a self-reported questionnaire developed to capture risky behaviors in adolescents. Associations between prenatal alcohol and tobacco exposures and the risk of cannabis use in offspring were examined using log-binomial regression models, computing relative risk (RR). We also computed the E-values (E) to estimate the extent of unmeasured confounding. RESULTS: After adjusting for potential confounders, we observed increased risks of cannabis use in offspring exposed to first trimester prenatal alcohol use (RR = 1.38, 95% CI: 1.09-1.75; E = 2.10, CI:1.40) and tobacco use (RR = 1.42, 95% CI: 1.08-1.86; E = 2.19, CI:1.37) as well as third trimester prenatal alcohol use (RR = 1.39, 95% CI: 1.09-1.79; E = 2.13, CI:1.40) and tobacco use (RR = 1.39, 95% CI: 1.09-1.79; E = 2.21, CI:1.34]. We also noted dose-response associations in which risk estimates in offspring increased with the level of exposures to prenatal alcohol and tobacco use. CONCLUSION: These findings provide epidemiological evidence for effects of prenatal alcohol and tobacco exposures on offspring cannabis use. Although these results should be confirmed by other studies, the present study adds to the mounting evidence suggesting that women should be encouraged to abstain from alcohol and tobacco during pregnancy.

The Ross/Ross-Konno procedure in infancy is a safe and durable solution for aortic stenosis.

OBJECTIVE: The objective of this study was to characterize early and midterm outcomes after the Ross/Ross-Konno procedure performed in infancy for severe aortic valve disease. METHODS: Between January 1995 and December 2018, 35 infants younger than 1 year (13 neonates) underwent a Ross/Ross-Konno procedure. Patients were followed up to a median of 4.1 years (interquartile range [IQR], 2.6-9.5). Primary outcome measures were survival, early morbidity, freedom from reintervention and long-term functional and echocardiographic status. RESULTS: Median age at operation was 49 days (IQR, 17-135) and weight was 4 kg (IQR, 3.4-5.2). Thirty-one (89%) had undergone a previous procedure, including balloon valvuloplasty in 26 (74%). Thirty (86%) required annular enlargement (Konno incision). Five required concomitant aortic arch surgery (2 neonates, 3 infants). There were no early deaths, and 1 late death at 18 months. Freedom from reoperation was 85% (95% confidence interval [CI], 68%-93%) at 1 year, 76% (95% CI, 54%-88%) at 5 years, and 62% (95% CI, 36%-79%) at 10 years. One modified Konno was performed at 5 years after a Ross in infancy. Ten right ventricle to pulmonary artery conduits have required reintervention (2 percutaneous pulmonary valve implantations). One child required a permanent pacemaker for complete heart block. At latest follow-up, 32 (94%) of 34 survivors were asymptomatic. There was no significant change in neoaortic Z-scores between 6 weeks and latest follow-up. CONCLUSIONS: The neonatal and infant Ross/Ross-Konno procedure can be performed with low mortality and achieves a stable left ventricular outflow tract. Significant early morbidity reflects the preoperative condition of the patients but definitive surgery of this type can be considered as a primary approach.