Cardiac Critical Care Fellowship Training in the United States and Canada: Pediatric Cardiac Intensive Care Society-Endorsed Subcompetencies to the 2022 Entrustable Professional Activities.

OBJECTIVES: We aimed to define and map subcompetencies required for pediatric cardiac critical care (PCCC) fellowship education and training under the auspices of the Pediatric Cardiac Intensive Care Society (PCICS). We used the 2022 frameworks for PCCC fellowship learning objectives by Tabbutt et al and for entrustable professional activities (EPAs) by Werho et al and integrated new subcompetencies to the EPAs. This complementary update serves to provide a foundation for standardized trainee assessment tools for PCCC. DESIGN: A volunteer panel of ten PCICS members who are fellowship education program directors in cardiac critical care used a modified Delphi method to develop the update and additions to the EPA-based curriculum. In this process, the experts rated information independently, and repetitively after feedback, before reaching consensus. The agreed new EPAs were later reviewed and unanimously accepted by all PCICS program directors in PCCC in the United States and Canada and were endorsed by the PCICS in 2023. PROCEDURE AND MAIN RESULTS: The procedure for defining new subcompetencies to the established EPAs comprised six consecutive steps: 1) literature search; 2) selection of key subcompetencies and curricular components; 3) written questionnaire; 4) consensus meeting and critical evaluation; 5) approval by curriculum developers; and 6) PCICS presentation and endorsement. Overall, 110 subcompetencies from six core-competency domains were mapped to nine EPAs with defined levels of entrustment and examples of simple and complex cases. To facilitate clarity and develop a future assessment tool, three EPAs were subcategorized with subcompetencies mapped to the appropriate subcategory. The latter covering common procedures in the cardiac ICU. CONCLUSIONS: This represents the 2023 update to the PCCC fellowship education and training EPAs with the defining and mapping of 110 subcompetencies to the nine established 2022 EPAs. This goal of this update is to serve as the next step in the integration of EPAs into a standardized competency-based assessment framework for trainees in PCCC.

Plasma proteoglycan 4: a novel biomarker for acute lung injury after pediatric cardiac surgery.

Background: Identification of biological molecules related to post cardiopulmonary bypass (CPB) lung injury could help diagnose, predict and potentially impact patient's clinical course after cardiac surgery. Proteoglycan 4 (PRG4) initially identified as potential biomarker for patients with prolonged mechanical ventilation following CPB in a prior study. To further validate these findings, we sought to understand the association of lower plasma PRG4 with prolonged mechanical ventilation and worse lung compliance in a larger cohort of pediatric patients post CPB. Methods: Retrospective chart review study. Pediatric Cardiac Intensive Care Unit, Tertiary Hospital. Infants <1 year old with tetralogy of Fallot, ventricular septal defect, or atrioventricular septal defect who underwent surgical repair 2012-2020 and had stored plasma samples in our biorepository were screened for inclusion. Patients with mechanical ventilation before surgery were excluded. Patients were divided into quartiles based on postoperative duration of mechanical ventilation (control <25th percentile, study >75th percentile). Preoperative and 48-hour postoperative samples for each cohort (20 patients each) were tested for PRG4 level using enzyme-linked immunosorbent assay (ELISA) technique. Results: Study group had lower lung compliance, higher mean airway pressure and higher oxygen need postoperative when compared to control group. Plasma PRG4 levels before surgery and 48 hours postoperative were lower in study group compared to control group (P=0.0232 preoperative; P=0.0016 postoperative). Plasma PRG4 levels were compared preoperative to PRG4 levels postoperative in both group, there was no statistically significant difference (study group: P=0.0869; control group: P=0.6500). Conclusions: Lower levels of plasma PRG4 is associated with longer duration of mechanical ventilation, worse ventilator compliance and higher oxygen requirement after cardiac surgery in our patient population. Further validation of this finding in a larger and more diverse patient population is necessary prior to its application at the bedside.

Accelerated Protocols in Adolescent Idiopathic Scoliosis Surgery.

Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis. Treatment depends on the degree of curvature, skeletal maturity, and age of the patient. Once the curve reaches 50 degrees, posterior spinal fusion (PSF) is necessary to stabilize the spine and prevent further progression of the curve. PSF causes significant trauma to the tissues and often results in significant pain postoperatively. The purpose of this article is to provide the audience with a review of preoperative, intraoperative, and postoperative pain control with an accelerated protocol in patients with AIS undergoing PSF.

Perioperative multimodal analgesic injection for patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion surgery.

PURPOSE: This retrospective cohort study compared postoperative as-needed (PRN) opioid consumption pre and postimplementation of a perioperative multimodal analgesic injection composed of ropivacaine, epinephrine, ketorolac, and morphine in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Secondary outcomes include pain score measurements, time to ambulation, length of stay, blood loss, 90-day complication rate, operating room time, nonopioid medication usage, and total inpatient medication cost before and after the initiation of this practice. METHODS: Consecutive patients weighing ≥ 20 kg who underwent PSF for a primary diagnosis of AIS between January 2017 and December 2020 were included. Data from 2018 were excluded to account for standardization of the practice. Patients treated in 2017 only received PCA. Patients treated in 2019 and 2020 only received the injection. Excluded were patients who had any diagnoses other than AIS, allergies to any of the experimental medications, or who were nonambulatory. Data were analyzed utilizing the two-sample t-test or Chi-squared test as appropriate. RESULTS: Results of this study show that compared with 47 patients treated postoperatively with patient-controlled analgesia (PCA), 55 patients treated with a multimodal perioperative injection have significantly less consumption of PRN morphine equivalents (0.3 mEq/kg vs. 0.5 mEq/kg; p = 0.02). Furthermore, patients treated with a perioperative injection have significantly higher rates of ambulation on postoperative day 1 compared with those treated with PCA (70.9 vs. 40.4%; p = 0.0023). CONCLUSION: Administration of a perioperative injection is effective and should be considered in the perioperative protocol in patients undergoing PSF for AIS. LEVEL OF EVIDENCE: Therapeutic Level III.

Prospective, Randomized Ponseti Treatment for Clubfoot: Orthopaedic Surgeons Versus Physical Therapists.

BACKGROUND: Clubfoot is a common congenital foot deformity in children. The Ponseti method of serial casting has become the standard of care in clubfoot treatment. Clubfoot casting is performed in many centers by both orthopaedic surgeons and physical therapists (PTs); however, direct comparison of outcomes and complications of this treatment between these providers is limited. This study prospectively compared the outcomes of patients with clubfoot treated by these 2 groups of specialists. METHODS: Between January 2010 and December 2014, all patients under the age of 12 months with a diagnosis of clubfoot were included. Patients were randomized to an orthopaedic surgeon (MD) group or a PT group for weekly serial casting. Main outcome measures included the number of casts required to achieve correction, clinical recurrence of the deformity, and the need for additional surgical intervention. RESULTS: One hundred twenty-six infants were included in the study. Patient demographics and characteristics (sex, race, family history of clubfoot, laterality, and severity of deformity) were similar between treatment groups, with the only significant difference being the mean age of entry into the study (5.2 weeks in the MD group and 9.2 weeks in the PT group, P=0.01). Mean length of follow-up was 2.6 years. The number of casts required trended to a lower number in the MD group. There was no significant difference in the rates of clinical recurrence or additional surgical intervention between groups. CONCLUSIONS: Ponseti casting for treatment of clubfoot performed by orthopaedic surgeons and PTs results in equivalent outcomes without any difference in complications. Although the number of casts required trended to a lower number in the MD group, this likely did not result in any clinical significance, as the difference in cast number equaled <1 week's difference in the overall duration of serial casting. LEVEL OF EVIDENCE: Level I-therapeutic.

Will previous palliative surgery for congenital heart disease be detrimental to subsequent pig heart xenotransplantation?

INTRODUCTION: Pig heart xenotransplantation might act as a bridge in infants with complex congenital heart disease (CHD) until a deceased human donor heart becomes available. Infants develop antibodies to wild-type (WT, i.e., genetically-unmodified) pig cells, but rarely to cells in which expression of the 3 known carbohydrate xenoantigens has been deleted by genetic engineering (triple-knockout [TKO] pigs). Our objective was to test sera from children who had undergone palliative surgery for complex CHD (and who potentially might need a pig heart transplant) to determine whether they had serum cytotoxic antibodies against TKO pig cells. METHODS: Sera were obtained from children with CHD undergoing Glenn or Fontan operation (n = 14) and healthy adults (n = 8, as controls). All of the children had complex CHD and had undergone some form of cardiac surgery. Seven had received human blood transfusions and 3 bovine pericardial patch grafts. IgM and IgG binding to WT and TKO pig red blood cells (RBCs) and peripheral blood mononuclear cells (PBMCs) were measured by flow cytometry, and killing of PBMCs by a complement-dependent cytotoxicity assay. RESULTS: Almost all children and adults demonstrated relatively high IgM/IgG binding to WT RBCs, but minimal binding to TKO RBCs (p < 0.0001 vs WT), although IgG binding was greater in children than adults (p < 0.01). All sera showed IgM/IgG binding to WT PBMCs, but this was much lower to TKO PBMCs (p < 0.0001 vs WT) and was greater in children than in adults (p < 0.05). Binding to both WT and TKO PBMCs was greater than to RBCs. Mean serum cytotoxicity to WT PBMCs was 90% in both children and adults, whereas to TKO PBMCs it was only 20% and < 5%, respectively. The sera from 6/14 (43%) children were cytotoxic to TKO PBMCs, but no adult sera were cytotoxic. CONCLUSIONS: Although no children had high levels of antibodies to TKO RBCs, 13/14 demonstrated antibodies to TKO PBMCs, in 6 of these showed mild cytotoxicity. As no adults had cytotoxic antibodies to TKO PBMCs, the higher incidence in children may possibly be associated with their exposure to previous cardiac surgery and biological products. However, the numbers were too small to determine the influence of such past exposures. Before considering pig heart xenotransplantation for children with CHD, testing for antibody binding may be warranted.

Cardiac and Pulmonary Histopathology in Baboons Following Genetically-Engineered Pig Orthotopic Heart Transplantation.

BACKGROUND Although improving, survival after pig orthotopic heart transplantation (OHTx) in baboons has been mixed and largely poor. The causes for the high incidence of early failure remain uncertain. MATERIAL AND METHODS We have carried out pig OHTx in 4 baboons. Two died or were euthanized within hours, and 2 survived for 3 and 8 months, respectively. There was evidence of a significant 'cytokine storm' in the immediate post-OHTx period with the elevations in IL-6 correlating closely with the final outcome. RESULTS All 4 baboons demonstrated features suggestive of respiratory dysfunction, including increased airway resistance, hypoxia, and tachypnea. Histopathological observations of pulmonary infiltration by neutrophils and, notably, eosinophils within vessels and in the perivascular and peribronchiolar space, with minimal cardiac pathology, suggested a role for early lung acute inflammation. In one, features suggestive of transfusion-related acute lung injury were present. The 2 longer-term survivors died of (i) a cardiac dysrhythmia with cellular infiltration around the conducting tissue (at 3 months), and (ii) mixed cellular and antibody-mediated rejection (at 8 months). CONCLUSIONS These initial findings indicate a potential role of acute lung injury early after OHTx. If this response can be prevented, increased survival may result, providing an opportunity to evaluate the factors affecting long-term survival.

Journey to a new era: An innovative academic-practice partnership.

Successful academic-clinical partnerships are mutually beneficial for academic nursing and clinical organizations, supporting the long-term success of nursing programs while simultaneously improving patient outcomes. Advocated by the American Association of Colleges of Nursing in their 2016 report, Advancing Healthcare Transformation: New Era for Academic Nursing, this position paper provides six actions for transforming academic nursing. However, developing sustainable academic-practice models has proven challenging despite this roadmap, as research has not substantiated their benefits. This article describes an innovative academic-practice model that transitioned advanced practice registered nurses practicing at Le Bonheur Children's Hospital to full-time faculty, with a continued primary clinical practice role, in the College of Nursing at the University of Tennessee Health Science Center. We present the origin, development, and implementation of this academic-practice partnership model, offering recommendations for its replication by other universities and clinical agencies on this journey. Creating a sustainable model requires a shared vision, buy-in at all levels, frequent and transparent communication, planning that considers the individual policies of the partnering agencies, and persistence despite leadership changes. Two years into the partnership and remaining intact despite critical leadership changes within the clinical agency, the next phase of the relationship will permit us to document the model's impact on academic and clinical outcomes.

The Genetically Engineered Heart as a Bridge to Allotransplantation in Infants Just Around the Corner?

BACKGROUND: Mortality for infants on the heart transplant waitlist remains unacceptably high, and available mechanical circulatory support is suboptimal. Our goal is to demonstrate the feasibility of utilizing genetically engineered pig (GEP) heart as a bridge to allotransplantation by transplantation of a GEP heart in a baboon. METHODS: Four baboons underwent orthotopic cardiac transplantation from GEP donors. All donor pigs had galactosyl-1,3-galactose knocked out. Two donor pigs had human complement regulatory CD55 transgene and the other 2 had human complement regulatory CD46 and thrombomodulin. Induction immunosuppression included thymoglobulin, and anti-CD20. Maintenance immunosuppression was rapamycin, anti-CD-40, and methylprednisolone. One donor heart was preserved with University of Wisconsin solution and the other three with del Nido solution. RESULTS: All baboons weaned from cardiopulmonary bypass. B217 received a donor heart preserved with University of Wisconsin solution. Ventricular arrhythmias and depressed cardiac function resulted in early death. All recipients of del Nido preserved hearts easily weaned from cardiopulmonary bypass with minimal inotropic support. B15416 and B1917 survived for 90 days and 241 days, respectively. Histopathology in B15416 revealed no significant myocardial rejection but cellular infiltrate around Purkinje fibers. Histopathology in B1917 was consistent with severe rejection. B37367 had uneventful transplant but developed significant respiratory distress with cardiac arrest. CONCLUSIONS: Survival of B15416 and B1917 demonstrates the feasibility of pursuing additional research to document the ability to bridge an infant to cardiac allotransplant with a GEP heart.

Standardized Training for Physicians Practicing Pediatric Cardiac Critical Care.

OBJECTIVES: In the vast majority of Children's Hospitals, the critically ill patient can be found in one of three locations: the PICU, the neonatal ICU, and the cardiac ICU. Training, certification, and maintenance of certification for neonatology and critical care medicine are over seen by the Accreditation Council for Graduate Medical Education and American Board of Pediatrics. There is no standardization of training or oversight of certification and maintenance of certification for pediatric cardiac critical care. DATA SOURCES: The curricula from the twenty 4th year pediatric cardiac critical care training programs were collated, along with the learning objectives from the Pediatric Cardiac Intensive Care Society published "Curriculum for Pediatric Cardiac Critical Care Medicine." STUDY SELECTION: This initiative is endorsed by the Pediatric Cardiac Intensive Care Society as a first step toward Accreditation Council for Graduate Medical Education oversight of training and American Board of Pediatrics oversight of maintenance of certification. DATA EXTRACTION: A taskforce was established of cardiac intensivists, including the directors of all 4th year pediatric cardiac critical care training programs. DATA SYNTHESIS: Using modified Delphi methodology, learning objectives, rotational requirements, and institutional requirements for providing training were developed. CONCLUSIONS: In the current era of increasing specialized care in pediatric cardiac critical care, standardized training for pediatric cardiac critical care is paramount to optimizing outcomes.

Factors that Influence Acquisition of Lower Extremity Braces in the Pediatric Orthopaedic Population.

BACKGROUND: Lower extremity brace-wear compliance has been studied in pediatrics, but failure to acquire a prescribed brace has not been included. The purpose of this study was to evaluate brace acquisition as a component of brace-wear compliance. METHODS: Records of patients (0 to 21 y) prescribed lower extremity braces from 2017 to 2019 were reviewed. Diagnoses included cerebral palsy, spina bifida, short Achilles tendon, clubfoot, and other. Brace type was categorized as clubfoot foot abduction orthosis, ankle-foot orthosis, knee, hip, or custom/other braces. Brace prescription and acquisition dates were recorded. Insurance was classified as government, private, or uninsured. Patient demographics included age, sex, race, and calculated area deprivation index. RESULTS: Of the 1176 prescribed lower extremity braces, 1094 (93%) were acquired while 82 (7%) were not. The odds ratios (OR) of failure to acquire a prescribed brace in Black and Hispanic patients were 1.64 and 2.71 times that in White patients, respectively (95% confidence interval: 1.01-2.71, P=0.045; 1.23-5.6, P=0.015); in patients without insurance, the OR was 8.48 times that in privately insured patients (95% confidence interval: 1.93-31.1, P=0.007). The ORs of failure to acquire were 2.12 (P=0.003) in patients 4 years or more versus 0 to 3 years, 4.17 (P<0.0001) in cerebral palsy versus clubfoot, and 4.12 (P=0.01) in short Achilles tendon versus clubfoot. There was no significant association between sex or area deprivation index and failure of brace acquisition. CONCLUSIONS: In our cohort, 7% of prescribed braces were not acquired. Black or Hispanic race, lack of insurance, and older age were associated with failure to acquire prescribed braces. Braces prescribed for clubfoot were acquired more often than for cerebral palsy or short Achilles tendon. Brace-wear compliance is an established factor in treatment success and recurrence. This study identified risk factors for failed brace acquisition, a critical step for improving compliance. These results may help effect changes in the current system that may lead to more compliance with brace wear. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Assessment of physician training and prediction of workforce needs in paediatric cardiac intensive care in the United States.

OBJECTIVE: To assess the training and the future workforce needs of paediatric cardiac critical care faculty. DESIGN: REDCap surveys were sent May-August 2019 to medical directors and faculty at the 120 US centres participating in the Society of Thoracic Surgeons Congenital Heart Surgery Database. Faculty and directors were asked about personal training pathway and planned employment changes. Directors were additionally asked for current faculty numbers, expected job openings, presence of training programmes, and numbers of trainees. Predictive modelling of the workforce was performed using respondents' data. Patient volume was projected from US Census data and compared to projected provider availability. MEASUREMENTS AND MAIN RESULTS: Sixty-six per cent (79/120) of directors and 62% (294/477) of contacted faculty responded. Most respondents had training that incorporated critical care medicine with the majority completing training beyond categorical fellowship. Younger respondents and those in dedicated cardiac ICUs were more significantly likely to have advanced training or dual fellowships in cardiology and critical care medicine. An estimated 49-63 faculty enter the workforce annually from various training pathways. Based on modelling, these faculty will likely fill current and projected open positions over the next 5 years. CONCLUSIONS: Paediatric cardiac critical care training has evolved, such that the majority of faculty now have dual fellowship or advanced training. The projected number of incoming faculty will likely fill open positions within the next 5 years. Institutions with existing or anticipated training programmes should be cognisant of these data and prepare graduates for an increasingly competitive market.

Workforce demographics and unit structure in paediatric cardiac critical care in the United States.

OBJECTIVE: To assess current demographics and duties of physicians as well as the structure of paediatric cardiac critical care in the United States. DESIGN: REDCap surveys were sent by email from May till August 2019 to medical directors ("directors") of critical care units at the 120 United States centres submitting data to the Society of Thoracic Surgeons Congenital Heart Surgery Database and to associated faculty from centres that provided email lists. Faculty and directors were asked about personal attributes and clinical duties. Directors were additionally asked about unit structure. MEASUREMENTS AND MAIN RESULTS: Responses were received from 66% (79/120) of directors and 62% (294/477) of contacted faculty. Seventy-six percent of directors and 54% of faculty were male, however, faculty <40 years old were predominantly women. The majority of both groups were white. Median bed count (n = 20) was similar in ICUs and multi-disciplinary paediatric ICUs. The median service expectation for one clinical full-time equivalent was 14 weeks of clinical service (interquartile range 12, 16), with the majority of programmes (86%) providing in-house attending night coverage. Work hours were high during service and non-service weeks with both directors (37%) and faculty (45%). CONCLUSIONS: Racial and ethnic diversity is markedly deficient in the paediatric cardiac critical care workforce. Although the majority of faculty are male, females make up the majority of the workforce younger than 40 years old. Work hours across all age groups and unit types are high both on- and off-service, with most units providing attending in-house night coverage.

Tachyarrhythmia as a possible symptom of coronavirus in a neonate diagnosed with transposition of the great arteries.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic poses broad challenges to healthcare systems and providers. The manifestations of this disease are still being described in a variety of different contexts and patient populations. RESULTS: We report the case of a neonate who demonstrated COVID-19 after surgical correction of transposition of the great arteries. In addition, the patient demonstrated an evolving and persistent tachyarrhythmia consistent with neither the most likely postoperative complications nor typical COVID-19. DISCUSSION: The patient had negative preoperative testing for the virus and presented with profound oxygen desaturation and respiratory failure several days postoperatively. This raised concern for a complication of his arterial switch operation. It was found that one of the patient's caregivers was an asymptomatic carrier of COVID-19, and imaging ruled out intracardiac shunting. After initiating treatment for COVID-19, the patient's oxygen requirements and need for anti-arrhythmic agents improved. CONCLUSION: We propose that, despite negative preoperative testing, coronavirus infection may present as refractory tachyarrhythmia, and may be considered along with surgical complications as a cause for unexplained hypoxemia postoperatively.

Attitudes toward xenotransplantation: A survey of parents and pediatric cardiac providers.

BACKGROUND: Scientific advancements are occurring in cardiac xenotransplantation (XTx). However, there have been religious and social concerns surrounding this allotransplantation alternative. The purpose of this study was to explore the acceptance of XTx among stakeholders of the congenital heart disease (CHD) community. METHODS: A Likert-scale anonymous survey was distributed to physicians and nurses who care for children with CHD and parents of children with CHD. Psychosocial and clinical attitudes were compared across all groups to identify differences, and regression analysis was performed to identify factors associated with XTx acceptance. RESULTS: A total of 297 responded to the survey: 134 physicians, 62 nurses, and 101 parents. Potential acceptance of XTx if outcomes were similar to allotransplantation was high overall (75.3%), but different between the groups (physicians 86%; nurses 71%, parents 64%; P < .0001). Regression analysis showed respondents who reported religion would influence medical decision making (OR 0.48; 95%CI 0.24-0.97) and those who would not use a pig heart transplant as a bridge until a human heart became available were less likely to accept XTx (OR 0.09; 95%CI 0.04-0.21). Psychosocial concerns to XTx were minimal but were also associated with XTx acceptance particularly among parents (OR 0.17; 95%CI 0.03-0.80). CONCLUSIONS: Potential acceptance of XTx is high, assuming results are similar to allotransplantation. Religious beliefs and attitudes toward the use of XTx as a bridge to allotransplant may present barriers to XTx acceptance. Future research is needed to assess potential attitude differences in light of ethical, psychosocial, and religious objections to XTx.

The immune system in infants: Relevance to xenotransplantation.

Despite the improvement in surgical interventions in the treatment of congenital heart disease, many life-threatening lesions (eg, hypoplastic left heart syndrome) ultimately require transplantation. However, there is a great limitation in the availability of deceased human cardiac donors of a suitable size. Hearts from genetically engineered pigs may provide an alternative source. The relatively immature immune system in infants (eg, absence of anti-carbohydrate antibodies, reduced complement activation, reduced innate immune cell activity) should minimize the risk of early antibody-mediated rejection of a pig graft. Additionally, recipient thymectomy, performed almost routinely as a preliminary to orthotopic heart transplantation in this age-group, impairs the T-cell response. Because of the increasing availability of genetically engineered pigs (eg, triple-knockout pigs that do not express any of the three known carbohydrate antigens against which humans have natural antibodies) and the ability to diagnose congenital heart disease during fetal life, cardiac xenotransplantation could be preplanned to be carried out soon after birth. Because of these several advantages, prolonged graft survival and even the induction of tolerance, for example, following donor-specific pig thymus transplantation, are more likely to be achieved in infants than in adults. In this review, we summarize the factors in the infant immune system that would be advantageous in the success of cardiac xenotransplantation in this age-group.

Evaluation of Outcomes Before and After Implementation of a Standardized Postoperative Care Pathway in Pediatric Posterior Spinal Fusion Patients.

BACKGROUND: Standardized pathways decrease variability and improve outcomes and safety. PURPOSE: The article aims to evaluate outcomes of a standardized postoperative care pathway compared with individual surgeon preference. METHODS: A review of patients prestandardization and poststandardization was performed. Patients between the ages of 10-21 years with adolescent idiopathic scoliosis (ICD-9 code 737.30) admitted to the hospital for posterior spinal fusion (CPT code 22630) were included in the study. The prestandardization group (25 patients) was enrolled from April 1, 2010, through March 30, 2011, and the poststandardization group (25 patients) from April 1, 2014, to March 30, 2015. Exclusion criteria were renal disease, epilepsy, neurological disorder, or postoperative complications that led to change in routine care including ileus or fever greater than 102 °F. Data were analyzed using the Wilcoxon signed rank test, with significance set at p < .001. RESULTS: The length of stay (p = .0166), time to ambulation (p < .0001), patient-controlled analgesia use (p < .0001), and postoperative time to resumption of regular diet (p < .0001) were all significantly decreased in the poststandardization group. There were no complications or readmissions in either group. CONCLUSION: The standardized pathway resulted in shorter length of stay, decreased narcotic use, decreased time to regular diet, and decreased time to ambulation with no increase in complication rates.

Attitudes to Cardiac Xenotransplantation by Pediatric Heart Surgeons and Physicians.

BACKGROUND: Cardiac transplantation in early childhood is limited by scarcity of organ donors. Advances in cardiac xenotransplantation (XTx) research suggest that xenografts may one day represent an alternative to allografts. We sought to determine the attitudes among surgeons and cardiologists in the field of pediatric cardiac transplantation toward the potential use of XTx if this clinical option were to become a reality. METHODS: A Likert-scale anonymous survey addressing the use of XTx in pediatric patients was sent to members of the Congenital Heart Surgeons (CHS) Society and the Pediatric Heart Transplant Society. Results were described and compared between the two surgeon/physician groups. RESULTS: Ninety-two CHS and 42 pediatric transplant cardiologists (PTC) responded (N = 134). The potential acceptance of XTx was high in both groups, assuming risks and results were similar to those of cardiac allotransplantation (88% CHS vs 81% PTC; P = .07). When asked if they would recommend a xenograft, if the results were anticipated to be inferior to those of cardiac allotransplantation, as a bridge to a human heart, potential acceptance fell dramatically but remained higher among CHS than PTC (41% vs 17%, p 0.02). Approximately only one-third of CHS and half of PTC preferred primary cardiac XTx for hypoplastic left heart syndrome if there was no waitlist time and had similar outcomes to allotransplantation. CONCLUSIONS: Our findings suggest that potential acceptance of XTx by CHS and PTC would not be a major barrier if XTx demonstrated similar outcomes to allotransplantation. Acceptance by other congenital heart stakeholders remains to be investigated.

Anti-Pig Antibody in Infants: Can a Genetically Engineered Pig Heart Bridge to Allotransplantation?

BACKGROUND: Patients with congenital heart disease have high heart transplant waitlist mortality, and mechanical support is suboptimal. To evaluate feasibility of cardiac grafts from a genetically engineered triple-knockout pig as a bridge to allotransplantation, preformed anti-pig antibodies were measured in pediatric and adult patients. METHODS: Flow cytometry measured serum immunoglobulin M (IgM) or IgG binding to wild-type and triple-knockout red blood cells (RBCs), with binding to human O-negative RBCs as a negative control. Group 1 comprise 84 pediatric patients and 64 healthy adults' sera with no previous cardiac surgery. Group 2 comprised 25 infant's sera postcardiac surgery, including 10 after palliation for hypoplastic left heart syndrome. RESULTS: In group 1, IgM binding to wild-type RBCs occurred in 80% of sera and IgG binding occurred in in 91% of sera. Only 3% of sera showed IgM binding to triple-knockout RBCs, and 1 (<1%) was weakly positive for IgG binding. In group 2, all 25 infants demonstrated increased IgM and IgG binding to wild-type RBCs. One patient showed minimal IgM and another showed low IgG binding to triple-knockout RBCs. No infant after stage 1 Norwood demonstrated any IgG or IgM binding. CONCLUSIONS: Preformed anti-pig antibodies may not be a barrier to heart xenotransplantation in infants, even after cardiac surgery. With adequate immunosuppressive therapy, a triple-knockout pig heart transplant might function successfully as a bridge to allotransplantation.