Developing and Validating Multi-Modal Models for Mortality Prediction in COVID-19 Patients: a Multi-center Retrospective Study.

The unprecedented global crisis brought about by the COVID-19 pandemic has sparked numerous efforts to create predictive models for the detection and prognostication of SARS-CoV-2 infections with the goal of helping health systems allocate resources. Machine learning models, in particular, hold promise for their ability to leverage patient clinical information and medical images for prediction. However, most of the published COVID-19 prediction models thus far have little clinical utility due to methodological flaws and lack of appropriate validation. In this paper, we describe our methodology to develop and validate multi-modal models for COVID-19 mortality prediction using multi-center patient data. The models for COVID-19 mortality prediction were developed using retrospective data from Madrid, Spain (N = 2547) and were externally validated in patient cohorts from a community hospital in New Jersey, USA (N = 242) and an academic center in Seoul, Republic of Korea (N = 336). The models we developed performed differently across various clinical settings, underscoring the need for a guided strategy when employing machine learning for clinical decision-making. We demonstrated that using features from both the structured electronic health records and chest X-ray imaging data resulted in better 30-day mortality prediction performance across all three datasets (areas under the receiver operating characteristic curves: 0.85 (95% confidence interval: 0.83-0.87), 0.76 (0.70-0.82), and 0.95 (0.92-0.98)). We discuss the rationale for the decisions made at every step in developing the models and have made our code available to the research community. We employed the best machine learning practices for clinical model development. Our goal is to create a toolkit that would assist investigators and organizations in building multi-modal models for prediction, classification, and/or optimization.

Fontan procedure: Early outcomes of 87 consecutive patients in a tertiary care center.

Al Absi and colleagues report their early results of the Fontan procedure in 87 consecutive patients between August 2008 and July 2017 in a tertiary care hospital. The use of the intra/extracardiac fenestration is a promising modification because it is unlikely to be occluded by surrounding tissue and may be associated with decreased pleural effusions, length of hospital stay, and incidence of postoperative arrhythmias.

Left innominate vein creation using left internal jugular vein tunneled to right internal jugular vein.

BACKGROUND: Left innominate vein occlusion is a known complication of pacemaker and central venous catheter placement. For dialysis-dependent patients with an arteriovenous fistula (AVF), this can prevent successful hemodialysis and may require surgical intervention. CASE REPORT: An 8-month-old male was diagnosed with hemolytic uremic syndrome and became dialysis-dependent at 11 months of age. After multiple vascular access and peritoneal dialysis complications, the patient had construction of a brachiobasalic AVF in his left arm at 13 years old. While waiting for the AVF to mature, an attempt to remove a previously placed left subclavian vein port-a-cath was unsuccessful and a follow-up imaging revealed that the vessel had become occluded. The fistula remained patent, but due to arm swelling and venous obstruction, his fistula was not accessible. Multiple attempts to percutaneously cross the left innominate vein were unsuccessful and the patient was referred for surgical intervention. At 15 years old, the patient was taken to the operating room for transposition of the left internal jugular vein (LIJ) to the right internal jugular vein (RIJ). The LIJ was transected under the mandible and anastomosed to the RIJ. Subsequently the patient underwent VWING insertion rather than venous transposition for constant site dialysis. Although he has required frequent transcatheter dilation of the LIJ-RIJ anastomosis, the patient was successfully dialyzed using this fistula for 5 years. The patient received a cadaveric renal transplant at 5 years 20 days. CONCLUSIONS: In cases of left innominate vein stenosis, transposing the LIJ can create a new left innominate vein that can alleviate venous hypertension and preserve fistula function. This procedure avoids sternotomy and only requires one anastomosis.

Oblique coronary artery prolongation in anomalous left coronary artery arising from the pulmonary artery: A case series.

BACKGROUND: Anomalous left coronary artery (LMCA) arising from the pulmonary artery (ALCAPA) is a life-threatening congenital birth defect. Prompt surgical correction by reimplantation of the LMCA into the aorta is the treatment of choice, however, unfavorable LCA location or length can make direct reimplantation difficult or even impossible without causing significant stretching or tension on the LMCA. This tension can lead to stenosis of the artery and coronary ischemia and must be avoided if possible. METHODS: A chart review from January 2010 to December 2018 of patients who had ALCAPA repair. Patients were excluded if direct reimplantation was possible. Herein, we describe four cases in which remote LMCA position necessitated the creation of a tubular prolongation of the LMCA. RESULTS: A generous coronary button from the pulmonary artery along with the oblique flap of aorta served as the prolongation of the left main coronary artery. This allowed for a tension-free anastomosis using native tissue with the ability to grow with the patient. The pulmonary artery and the aorta were then patched using pericardial tissue. All four patients had improvement in left ventricular function and degree of mitral regurgitation within weeks of surgery. No patient required extracorporeal membrane oxygenation support. Subsequent long-term angiographic follow-up has revealed excellent durability and patency of these coronary conduits. CONCLUSIONS: The variable nature of ALCAPA requires modification of the surgical approach on a patient by patient basis, and the above described technique adds an alternate and reliable long-term treatment option.

Adult congenital pulmonary valve insertion using a new bioprosthetic aortic valve: Inspiris.

We describe successful placement of the Inspiris Resilia aortic valve in the pulmonary position. This valve has advantages for immediate benefit and future percutaneous interventions, making it a promising prosthesis for adult congenital patients.

Severe tricuspid valve stenosis secondary to pacemaker leads presenting as ascites and liver dysfunction: a complex problem requiring a multidisciplinary therapeutic approach.

Tricuspid stenosis secondary to ventricular pacemaker leads is uncommon. We present a unique case of iatrogenic tricuspid stenosis secondary to fusion of the valve leaflets to transvenous implanted pacing leads. This occurred in an adult with childhood repaired Tetralogy of Fallot and high grade surgical heart block following multiple pacemaker procedures. The case was complicated by superior vena cava (SVC) and innominate vein stenosis secondary to implanted pacing leads, severe tricuspid valve (TV) stenosis, perforation of the heart by one of the implanted transvenous ventricular pacing leads, prolapse of the transvenous atrial pacing lead into the right ventricle, and unusual coronary sinus anatomy. We describe a multidisciplinary approach to management.

Mitral valve replacement with the pulmonary autograft in children: a word of caution.

A 4(1/2)-month-old patient who underwent mitral valve replacement for congenital mitral stenosis using a pulmonary autograft is reported. Failure of the autograft resulted in pulmonary hypertension, leading to pulmonary regurgitation in the reconstructed right ventricular outflow tract, then tricuspid regurgitation, refractory right heart failure, and death. Caution should be exercised in applying this procedure with children, particularly those at risk for pulmonary hypertension.

22q11.2 microduplication syndrome with associated esophageal atresia/tracheo-esophageal fistula and vascular ring.

This case report describes a patient with a 22q11.2 duplication. His features, which include VACTERL association with an esophageal atresia/tracheo-esophageal fistula and a vascular ring, expand the previously described phenotype for this duplication.

The internal mammary artery as a shunt in a noncyanotic infant with hemitruncus: surgical and anesthetic management.

The internal mammary artery (IMA) has been used as a systemic-to-pulmonary artery shunt in selected patients with congenital heart disease. Growth and development of hypoplastic pulmonary arteries have been described. We discuss the surgical and anesthetic management of an infant with an atretic-thrombosed right pulmonary artery originating from the ascending aorta in whom the IMA was used to create a systemic-to-pulmonary artery shunt after failure of a previous shunt and later successful pulmonary artery reconstruction. The IMA should be considered as an alternative conduit in patients requiring a systemic-to-pulmonary artery shunt for growth of pulmonary arteries.

Oblique coronary artery prolongation approach in anomalous left coronary artery from the pulmonary artery in a low-birth-weight neonate.

A 19-day-old newborn girl weighing 1.9-kg was born with anomalous origin of the left coronary artery (LCA) from the pulmonary artery (PA). Because of the small anatomic structures and long distance between the anomalous origin of the LCA high within the left posterior sinus of the main PA, a simple transfer of the anomalous LCA to the aorta was deemed impossible. A coronary button was created with an oblique flap of tissue cut from the posterior pulmonary arterial wall. An oblique flap was created from the anterior aortic wall. The two flaps were used to create a tubular prolongation that connected the LCA to the aorta. This created a tension-free anastomosis with potential for growth. The aorta and PA were then patched with pericardium. A left coronary angiogram three years after surgery demonstrated a patent coronary tube.

Risks of extracorporeal membrane oxygenation in patients with coronary artery anomalies.

Extracorporeal membrane oxygenation is widely used to support and rest the heart before or following repair of congenital cardiac lesions in children. The beneficial effects of extracorporeal membrane oxygenation for the failing myocardium are undisputed. It is often an automatic choice whenever the heart seems incapable of supporting the circulation. However, its use may prove detrimental in patients with coronary anomalies, as illustrated by the case reports presented here.

Extracorporeal membrane oxygenation in postcardiotomy patients: factors influencing outcome.

OBJECTIVE: Our objective was to assess the morbidity and mortality in children requiring extracorporeal membrane oxygenator support after cardiac surgery and to determine factors influencing outcome. METHODS: Between January 2003 and June 2008, 58 patients required extracorporeal membrane oxygenator support after cardiac surgery. A retrospective study was performed and factors influencing outcome were determined by logistic regression modeling with the probability of outcome based on a combination of multivariate predictors. RESULTS: Median age and weight were 12 days and 3.3 kg, respectively. Thirty-one patients had single ventricle repair and 27 had biventricular repair. Median duration of support with the oxygenator was 6 days. Thirty-nine (67%) patients were successfully weaned off the support, but only 24 (41%) survived to hospital discharge. Chief complications were renal failure (31%), neurologic complications (29%), and sepsis (16%). Multivariable logistic regression analysis identified 10 days or more of extracorporeal membrane oxygenation (odds ratio = 6.1), urine output less than 2 mL x kg(-1) x h(-1) in first 24 hours (odds ratio = 15), renal failure (odds ratio = 9.4), and pH less than 7.35 after 24 hours of extracorporeal membrane oxygenation (odds ratio = 82) as significant independent factors associated with failure to wean off extracorporeal membrane oxygenation. Factors associated with failure of hospital discharge despite successful decannulation were as follows: extracorporeal membrane oxygenator support time of 10 days or more, red blood cell transfusion of greater than 1000 mL/kg during the entire period of oxygenator support, and sepsis. Patients with single ventricle repair were at higher risk of hospital mortality. CONCLUSION: Longer duration of extracorporeal membrane oxygenator support, low pH and urine output in the first 24 hours, and renal failure are significant factors associated with mortality during extracorporeal membrane oxygenator support. Exposure to high amounts of blood transfusion during extracorporeal oxygenation, extended extracorporeal membrane oxygenator support, and sepsis increase risk of death after successful decannulation.

Femoral vein homograft for neoaortic reconstruction in Norwood stage 1 operation.

Femoral vein homografts are increasingly being used for arterial reconstruction in peripheral vascular surgery. We explored the suitability of using cryopreserved femoral vein homograft for neoaortic reconstruction in Norwood stage I operation for hypoplastic left heart syndrome.

Interrupted aortic arch with anomalous origin of left pulmonary artery from aorta.

We report a case of interrupted aortic arch and origin of the left pulmonary artery from the aorta with bilateral ductus arteriosus and discuss its possible embryological basis. To the best of our knowledge, this combination of anomalies has not been reported in the English medical literature.

Multiple papillary fibroelastomas of the heart.

We report the case of a 41-year-old woman who presented with extensive papillary fibroelastomas of the heart after multiple previous surgical procedures for hypertrophic cardiomyopathy. This case is significant because of the locally aggressive nature of the cardiac papillary fibroelastoma.

Late embolization of Amplatzer patent ductus arteriosus occlusion device with thoracic aorta embedment.

An 11.5-month-old child was found to have a widely patent ductus arteriosus 8 months after percutaneous Amplatzer device closure of the ductus. Angiography confirmed that the occlusion device had migrated to the descending thoracic aorta. The child underwent surgical removal of the device, which was firmly embedded in the aorta and could not be removed percutaneously.

Interrupted aortic arch and aortic atresia with circle of Willis-dependent coronary perfusion.

We present a case of type B interrupted aortic arch and aortic atresia. This combination is usually incompatible with life. However, the presence of an aberrant right subclavian artery and enough blood flow through the circle of Willis allowed perfusion of the coronary arteries through retrograde carotid and aortic blood flow. A two-ventricular repair was successfully undertaken.