Hospital Admissions for Abusive Head Trauma Before and During the COVID-19 Pandemic.

Importance: Several studies have demonstrated a decrease in the occurrence of child abuse in the US since the start of the COVID-19 pandemic. This finding has generated concern for missed cases due to the initial lockdowns and lack of childcare resources. Determining the association of the pandemic on hospitalizations for severe forms of abuse is essential to focus preventive efforts. Objective: To examine trends in abusive head trauma (AHT) before and during the COVID-19 pandemic. Design, Setting, and Participants: Retrospective, multicenter, repeated cross-sectional study, conducted January 1, 2016, through April 30, 2022, with data from tertiary care children's hospitals and contributors to the Pediatric Health Information System. Data were obtained for 2380 hospitalizations of children younger than 5 years with International Classification of Diseases, Tenth Revision, Clinical Modification codes for both abuse and head trauma. Main Outcomes and Measures: Monthly hospitalizations were analyzed using interrupted time-series analysis. Hospitalization severity (eg, intensive care unit stay) and clinical characteristics (subdural hemorrhages and retinal hemorrhages) were compared before and after the start of the pandemic. Results: We identified 2380 hospitalizations due to AHT (median age, 140 [IQR, 75.0-325.5] days) from 45 hospitals. The mean (SD) monthly incidence of AHT was 34.3 (5.8) before the COVID-19 pandemic compared with 25.6 (4.2) during COVID-19 (a 25.4% decrease). When the pre-COVID-19 and during COVID-19 periods were compared, there were no significant differences in severity or clinical characteristics. On interrupted time-series analysis, there was a significant decrease in the number of monthly hospitalizations (-8.1; 95% CI, -12.41 to -3.72; P < .001) in the first month of the pandemic. In the subgroup of children younger than 1 year, there was a significant decrease in monthly hospitalizations at the onset of the pandemic (-8.2; 95% CI, -12.02 to -4.43; P < .001) followed by a significant temporal increase across the COVID-19 period (P = .01). Conclusions and Relevance: The findings of this cross-sectional study suggest there was a significant decrease in monthly hospitalizations for AHT following the start of the pandemic in March 2020. Although there was no corresponding increase in hospitalization severity, the decrease during the pandemic may have been transient, as monthly hospitalizations for children younger than 1 year increased significantly over time during COVID-19, after the initial decrease.

In utero delivery of miRNA induces epigenetic alterations and corrects pulmonary pathology in congenital diaphragmatic hernia.

Structural fetal diseases, such as congenital diaphragmatic hernia (CDH) can be diagnosed prenatally. Neonates with CDH are healthy in utero as gas exchange is managed by the placenta, but impaired lung function results in critical illness from the time a baby takes its first breath. MicroRNA (miR) 200b and its downstream targets in the TGF-ß pathway are critically involved in lung branching morphogenesis. Here, we characterize the expression of miR200b and the TGF-ß pathway at different gestational times using a rat model of CDH. Fetal rats with CDH are deficient in miR200b at gestational day 18. We demonstrate that novel polymeric nanoparticles loaded with miR200b, delivered in utero via vitelline vein injection to fetal rats with CDH results in changes in the TGF-ß pathway as measured by qRT-PCR; these epigenetic changes improve lung size and lung morphology, and lead to favorable pulmonary vascular remodeling on histology. This is the first demonstration of in utero epigenetic therapy to improve lung growth and development in a pre-clinical model. With refinement, this technique could be applied to fetal cases of CDH or other forms of impaired lung development in a minimally invasive fashion.

Intra-amniotic Injection of Poly(lactic-co-glycolic Acid) Microparticles Loaded with Growth Factor: Effect on Tissue Coverage and Cellular Apoptosis in the Rat Model of Myelomeningocele.

BACKGROUND: Myelomeningocele (MMC) is a devastating congenital neurologic disorder that can lead to lifelong morbidity and has limited treatment options. This study investigates the use of poly(lactic-co-glycolic acid) (PLGA) microparticles (MPs) loaded with fibroblast growth factor (FGF) as a platform for in utero treatment of MMC. STUDY DESIGN: Intra-amniotic injections of PLGA MPs were performed on gestational day 17 (E17) in all-trans retinoic acid-induced MMC rat dams. MPs loaded with fluorescent dye (DiO) were evaluated 3 hours after injection to determine incidence of binding to the MMC defect. Fetuses were then treated with PBS or PLGA particles loaded with DiO, bovine serum albumin, or FGF and evaluated at term (E21). Fetuses with MMC defects were evaluated for gross and histologic evidence of soft tissue coverage. The effect of PLGA-FGF treatment on spinal cord cell death was evaluated using an in situ cell death kit. RESULTS: PLGA-DiO MPs had a binding incidence of 86% and 94% 3 hours after injection at E17 for doses of 0.1 mg and 1.2 mg, respectively. Incidence of soft tissue coverage at term was 19% (4 of 21), 22% (2 of 9), and 83% (5 of 6) for PLGA-DiO, PLGA-BSA, and PLGA-FGF, respectively. At E21, the percentage of spinal cord cells positive for in situ cell death was significantly higher in MMC controls compared with wild-type controls or MMC pups treated with PLGA-FGF. CONCLUSION: PLGA MPs are an innovative minimally invasive platform for induction of soft tissue coverage in the rat model of MMC and may reduce cellular apoptosis.

Engineering alginate microparticles for optimized accumulation in fetal rat myelomeningocele.

INTRODUCTION: Intraamniotic microparticle injection is a novel technique for the treatment of myelomeningocele (MMC) in which microparticles are delivered in-utero in a minimally invasive fashion to bind to and protect the exposed spinal cord. This technique could offer earlier intervention and greater access to prenatal treatment of MMC. Here we demonstrate progress on the engineering of the microparticles to promote binding to the MMC defect. We hypothesized that when the particle's surface charge was decreased and delivery concentration increased, particles would bind to the MMC defect more frequently and more specifically. METHODS: Alginate microparticles underwent surface modification to alter the particle charge. Dye-loaded alginate, alginate- dextran sulfate, and alginate- chitosan were injected on e17 into the amnion of a rat model of MMC and the incidence of successful binding and specificity of particle binding to the MMC defect were calculated. Specificity of binding was described using a defect-to-skin brightness ratio based on specimen imaging. Comparisons were made with chi-square, p< 0.05 marked significance. RESULTS: There was no difference in the incidence of successful binding at e17 with 0.6 mg/fetal kg between the three tested alginate particles. However, alginate- dextran sulfate bound most specifically to the defect (p< 0.05). Alginate-dextran sulfate also demonstrated more frequent binding at higher doses than lower doses (79% at 1.2 mg/kg vs 38% at 0.6 mg/kg and 24% at 0.8 mg/kg, p< 0.01 for both). Specificity was not sacrificed at higher dose injections: defect-to-skin brightness ratio of 5.4 at 1.2 mg/kg vs 1.8 at 0.6 mg/kg (p< 0.05) CONCLUSION: We demonstrate that the intraamniotic injection of alginate-dextran sulfate microparticles at high concentration bind more frequently and more specifically to MMC defects than the previously tested unmodified alginate microparticles.

Firework-related injuries treated at emergency departments in the United States during the COVID-19 pandemic in 2020 compared to 2018-2019.

BACKGROUND: Despite a national decrease in emergency department visits in the United States during the first 10 months of the pandemic, preliminary Consumer Product Safety Commission data indicate increased firework-related injuries. We hypothesized an increase in firework-related injuries during 2020 compared to years prior related to a corresponding increase in consumer firework sales. METHODS: The National Electronic Injury Surveillance System (NEISS) was queried from 2018 to 2020 for cases with product codes 1313 (firework injury) and narratives containing "fireworks". Population-based national estimates were calculated using US Census data, then compared across the three years of study inclusion. Patient demographic and available injury information was also tracked and compared across the three years. Firework sales data obtained from the American Pyrotechnics Association were determined for the same time period to examine trends in consumption. RESULTS: There were 935 firework-related injuries reported to the NEISS from 2018 to 2020, 47% of which occurred during 2020. National estimates for monthly injuries per million were 1.6 times greater in 2020 compared to 2019 (p < 0.0001) with no difference between 2018 and 2019 (p = 0.38). The same results were found when the month of July was excluded. Firework consumption in 2020 was 1.5 times greater than 2019 or 2018, with a 55% increase in consumer fireworks and 22% decrease in professional fireworks sales. CONCLUSIONS: Firework-related injures saw a substantial increase in 2020 compared to the two years prior, corroborated by a proportional increase in consumer firework sales. Increased incidence of firework-related injuries was detected even with the exclusion of the month of July, suggesting that the COVID-19 pandemic may have impacted firework epidemiology more broadly than US Independence Day celebrations.

Institutional Variation in Gastrostomy Tube Placement After Duodenal Atresia Repair in Children With Trisomy 21.

OBJECTIVES: To compare institutional practice patterns for gastrostomy tube placement in neonates with duodenal atresia (DA) and trisomy 21. METHODS: A retrospective review of the Pediatric Health Information System (PHIS) from 2015 to 2018 identified infants <10 days old with ICD-10 diagnostic codes for DA and trisomy 21, in addition to procedure codes for an intestinal bypass or duodenoduodenostomy. This cohort was then queried for gastrostomy tube procedure codes and diagnostic codes for associated co-morbidities. RESULTS: Two hundred and nine infants were identified with DA, trisomy 21, and an intestinal bypass. Fifty-seven (27%) underwent gastrostomy placement. Baseline characteristics of those with and without gastrostomy tubes were similar. Patients from 16 hospitals that placed no gastrostomy tubes (No-G-tube-Hospitals) were compared to children from 30 hospitals that placed at least one gastrostomy tube (G-tube-Hospitals). Open atresia repairs occurred more frequently at G-tube-Hospitals, but patients were otherwise similar. There was no difference in readmission at 12 months for gastrostomy placement between children from No-G-tube-Hospitals and those from G-tube-Hospitals that did not undergo gastrostomy during their index admission. CONCLUSIONS: One-third of institutions in this study did not place gastrostomy tubes during index admissions for neonates with trisomy 21 and DA, yet this did not negatively impact the length of stay or incidence of subsequent gastrostomy placement as a result. Future research is needed to determine factors that predispose patients to failure without gastrostomy, as well as best practices for post-operative management in these patients to reduce unnecessary tube placement.

A narrative review of in utero gene therapy: advances, challenges, and future considerations.

The field of in utero gene therapy (IUGT) represents a crossroad of technologic advancements and medical ethical boundaries. Several strategies have been developed for IUGT focusing on either modifying endogenous genes, replacing missing genes, or modifying gene transcription products. The list of candidate diseases such as hemoglobinopathies, cystic fibrosis, lysosomal storage disorders continues to grow with new strategies being developed as our understanding of their respective underlying molecular pathogenesis increases. Treatment in utero has several distinct advantages to postnatal treatment. Biologic and physiologic phenomena enable the delivery of a higher effective dose, generation of immune tolerance, and the prevention of phenotypic onset for genetic diseases. Therapeutic technology for IUGT including CRISPR-Cas9 systems, zinc finger nucleases (ZFN), and peptide nucleic acids (PNAs) has already shown promise in animal models and early postnatal clinical trials. While the ability to detect fetal diagnoses has dramatically improved with developments in ultrasound and next-generation sequencing, treatment options remain experimental, with several translational gaps remaining prior to implementation in the clinical realm. Complicating this issue, the potential diseases targeted by this approach are often debilitating and would otherwise prove fatal if not treated in some manner. The leap from small animals to large animals, and subsequently, to humans will require further vigorous testing of safety and efficacy.

Diffusion weighted imaging as a biomarker of retinoic acid induced myelomeningocele.

Neural tube defects are a common congenital anomaly involving incomplete closure of the spinal cord. Myelomeningocele (MMC) is a severe form in which there is complete exposure of neural tissue with a lack of skin, soft tissue, or bony covering to protect the spinal cord. The all-trans retinoic acid (ATRA) induced rat model of (MMC) is a reproducible, cost-effective means of studying this disease; however, there are limited modalities to objectively quantify disease severity, or potential benefits from experimental therapies. We sought to determine the feasibility of detecting differences between MMC and wild type (WT) rat fetuses using diffusion magnetic resonance imaging techniques (MRI). Rat dams were gavage-fed ATRA to produce MMC defects in fetuses, which were surgically delivered prior to term. Average diffusion coefficient (ADC) and fractional anisotropy (FA) maps were obtained for each fetus. Brain volumes and two anatomically defined brain length measurements (D1 and D2) were significantly decreased in MMC compared to WT. Mean ADC signal was significantly increased in MMC compared to WT, but no difference was found for FA signal. In summary, ADC and brain measurements were significantly different between WT and MMC rat fetuses. ADC could be a useful complementary imaging biomarker to current histopathologic analysis of MMC models, and potentially expedite therapeutic research for this disease.

Trends in fundoplication volume for pediatric gastroesophageal reflux disease.

INTRODUCTION: Fundoplication for gastro-esophageal reflux disease (GERD) has been commonly performed by pediatric surgeons, however there are no recent data documenting fundoplication trends. Changes in fundoplication volume impact pediatric surgical training and may reflect changes in care for children with severe GERD. MATERIALS & METHODS: The Pediatric Health Information System (PHIS) was queried from 2010-2019 for children with ICD-9/ICD-10 codes for GERD, fundoplication, and gastrostomy. Institutional surgical volume and patient demographics were examined over time. A secondary analysis using the Accreditation Council for Graduate Medical Education case logs for pediatric surgery fellows was performed across the same years to assess effects upon surgical volume for trainees. RESULTS: Mean institutional fundoplication case volume decreased from 50 in 2010 to 17 in 2019. Trends were similar between institutions with and without fellowship programs when corrected by total operative volume. Patient characteristics were relatively unchanged between 2010 and 2019. Fundoplication volume reported in fellow case logs decreased from 46 in 2010 to 26 in 2019, mirroring national data. CONCLUSIONS: Institutional volume for fundoplication in children with GERD has seen a 3-fold decrease over the last decade, mirrored by an almost 2-fold decrease in case volume reported by pediatric surgery fellows.

Laparoscopy is increasingly used for pediatric inguinal hernia repair.

INTRODUCTION: Inguinal hernia repairs (IHR) are commonly performed by pediatric surgeons in the United States. The operative approach depends on surgeon preference with no definitive prospective studies comparing laparoscopic inguinal hernia repair (LIHR) versus traditional inguinal hernia repair (TIHR). We aim to assess current practice, hypothesizing that laparoscopy is increasingly used for pediatric IHR. MATERIAL & METHODS: The Children's Hospital Association (CHA) Pediatric Health Information System was queried for IHRs performed between 01/01/2009 and 12/31/2018. Demographics, procedure type, hernia laterality, and cost were obtained. Patients were grouped by procedure type (laparoscopic/traditional). RESULTS: 125,249 IHRs were performed at 32 CHA hospitals during the ten-year study period. 115,782 (92.4%) were TIHR and 9467 (7.6%) LIHR. Use of laparoscopy increased 5-fold from 3% to 15% over the study period. When comparing laparoscopic to traditional IHR groups, there were more females (28.3% vs 12.6%), African-Americans (19.7% vs 14.4%), government-insured (50% vs 45.2%), younger patients (4.2 vs 4.4 years), bilateral IHRs (11.4% vs 7.9%), and higher adjusted total hospital cost ($3,791 vs $2995) in the laparoscopic group (p<0.0001, all comparisons). CONCLUSIONS: Laparoscopy for pediatric IHR is increasing at CHA hospitals where nearly 1 in 6 children currently undergoes a laparoscopic repair. The long-term outcomes with laparoscopic repair are worthy of future study.

Nanoparticles for delivery of agents to fetal lungs.

Fetal treatment of congenital lung disease, such as cystic fibrosis, surfactant protein syndromes, and congenital diaphragmatic hernia, has been made possible by improvements in prenatal diagnostic and interventional technology. Delivery of therapeutic agents to fetal lungs in nanoparticles improves cellular uptake. The efficacy and safety of nanoparticle-based fetal lung therapy depends on targeting of necessary cell populations. This study aimed to determine the relative distribution of nanoparticles of a variety of compositions and sizes in the lungs of fetal mice delivered through intravenous and intra-amniotic routes. Intravenous delivery of particles was more effective than intra-amniotic delivery for epithelial, endothelial and hematopoietic cells in the fetal lung. The most effective targeting of lung tissue was with 250nm Poly-Amine-co-Ester (PACE) particles accumulating in 50% and 44% of epithelial and endothelial cells. This study demonstrated that route of delivery and particle composition impacts relative cellular uptake in fetal lung, which will inform future studies in particle-based fetal therapy.

The parental journey of fetal care: a systematic review and metasynthesis.

OBJECTIVE: This study aimed to synthesize the qualitative literature on parental experiences of fetal care to reflect events that happened across the continuum of care and to better understand parents' positive and negative experiences with care delivery. DATA SOURCES: Eligible studies published until June 2020 were retrieved from MEDLINE, Embase, Cochrane Central Register of Controlled Trials, EBSCO CINAHL, Web of Science, and ProQuest. STUDY ELIGIBILITY CRITERIA: Studies must have been: (1) published in English in a peer-reviewed journal or in ProQuest, (2) available in full text, (3) contained a qualitative component, and (4) focused on expectant parents' experiences of tertiary, coordinated, multidisciplinary prenatal diagnosis and care related to a fetal anomaly. STUDY APPRAISAL AND SYNTHESIS METHODS: Researchers used the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. A metastudy and an interpretive description approach was taken to synthesize the events that happened across the continuum of care and the themes associated with a positive care experience. RESULTS: The metasynthesis included 13 studies and 217 patients from 11 different multidisciplinary fetal diagnosis and intervention practices across North America and Europe. We identified key events that influenced parental experience of fetal care across the continuum. The themes associated with a positive care experience are parents (1) gaining understanding and feeling understood, (2) realizing agency and control, and (3) finding hope and meaning. We identified aspects of healthcare delivery that served as barriers or facilitators to these positive experiences. CONCLUSION: Understanding the commonalities of the parental experience of fetal care across diverse settings creates a foundation for improving care and better meeting the needs of parents undergoing a painful and life-defining event. Although health outcomes are not always positive, a positive experience of care is possible and can assist parents to cope with their grief, manage their expectations, and engage in their care. The findings of this study illustrate the ways in which healthcare delivery can facilitate or obstruct a positive care experience.

Establishing a National Rate of Rectal Biopsy Positivity in the Diagnosis of Hirschsprung Disease.

OBJECTIVES: Although rectal biopsy has long been established as the criterion standard for the diagnosis of Hirschsprung disease, little to no information exists regarding nationwide rates of rectal biopsy positivity or interinstitutional variability. We sought to determine the national rate of rectal biopsy positivity and factors contributing to institutional variability. METHODS: A retrospective review of the Children's Hospital Association's (CHA) Pediatric Health Information System from 2009 to 2018 identified infants <100 days old with ICD-9/ICD-10 procedural codes for rectal biopsy in addition to codes for pull-through procedures within 500 days of life as a proxy for positive biopsy. A subgroup analysis of only patients biopsied at institutions with positive biopsy rates 1 standard deviation above or below the mean positive biopsy rate (deemed high and low outliers) was performed to better delineate these populations. RESULTS: A total of 7225 children underwent rectal biopsies between 2009 and 2018 at 52 Children's Hospital Association Hospitals. Mean positive biopsy rate for individual institutions was 21.5% (standard deviation ±â€Š6.4%). Linear regression to predict the effect of hospital surgical volume on positive biopsy rate demonstrated no volume outcome relationship (R2 = 0.049). Patients at high outlier hospitals for biopsy positivity were found to travel significantly further to the hospital (232.5 vs 123.1 miles, P < 0.0001) when compared to patients presenting at low outlier hospitals. CONCLUSIONS: There appears to be little interinstitutional variability in the rate of surgery following rectal biopsy for presumed Hirschsprung and no significant relationship to surgical volume. About 1 in every 4 infants undergoing biopsy proceeds to surgery.

Model for End-Stage Liver Disease Sodium as a Predictor of Surgical Risk in Cirrhotic Patients With Ascites.

BACKGROUND: The Model for End-Stage Liver Disease Sodium (MELD-Na) incorporates hyponatremia into the MELD score and has been shown to correlate with surgical outcomes. The pathophysiology of hyponatremia parallels that of ascites, which purports greater surgical risk. This study investigates whether MELD-Na accurately predicts morbidity and mortality in patients with ascites undergoing general surgery procedures. MATERIALS AND METHODS: We used the National Surgical Quality Improvement Program database (2005-2014) to examine the adjusted risk of morbidity and mortality of cirrhotic patients with and without ascites undergoing inguinal or ventral hernia repair, cholecystectomy, and lysis of adhesions for bowel obstruction. Patients were stratified by the MELD-Na score and ascites. Outcomes were compared between patients with and without ascites for each stratum using low MELD-Na and no ascites group as a reference. RESULTS: A total of 30,391 patients were analyzed. Within each MELD-Na stratum, patients with ascites had an increased risk of complications compared with the reference group (low MELD-Na and no ascites): low MELD-Na with ascites odds ratio (OR) 4.33 (95% confidence interval [CI] 1.96-9.59), moderate MELD-Na no ascites OR 1.70 (95% CI 1.52-1.9), moderate MELD-Na with ascites OR 3.69 (95% CI 2.49-5.46), high MELD-Na no ascites OR 3.51 (95% CI 3.07-4.01), and high MELD-Na ascites OR 7.18 (95% CI 5.33-9.67). Similarly, mortality risk was increased in patients with ascites compared with the reference: moderate MELD-Na no ascites OR 3.55 (95% CI 2.22-5.67), moderate MELD-Na ascites OR 13.80 (95% CI 5.65-33.71), high MELD-Na no ascites OR 8.34 (95% CI 5.15-13.51), and high MELD-Na ascites OR 43.97 (95% CI 23.76-81.39). CONCLUSIONS: MELD-Na underestimates morbidity and mortality risk for general surgery patients with ascites.

Preoperative Venoarterial Extracorporeal Membrane Oxygenation Slashes Risk Score in Advanced Structural Heart Disease.

BACKGROUND: Cardiac surgery for structural heart disease has poor outcomes in the presence of cardiogenic shock or advanced heart failure. We applied venoarterial extracorporeal membrane oxygenation (ECMO) to restore end-organ function and resuscitate patients before high-risk cardiac operation. METHODS: Twelve patients with cardiogenic shock and end-organ failure were evaluated for cardiac surgery. The average Society of Thoracic Surgeons mortality risk was 24% ± 13%. Patients were peripherally cannulated on ECMO for 7 ± 4 days, before undergoing operation for prosthetic mitral stenosis (n = 4), ruptured papillary muscle (n = 4), ischemic ventricular septal defect (n = 3), or severe aortic stenosis (n = 1). RESULTS: Mean age was 61 ± 8 years. Comorbidities included acute renal failure (n = 11), inotrope requirement (n = 10), intraaortic balloon pump (n = 8), severe acidosis (n = 6), high-dose vasopressor requirement (n = 8), and cardiac arrest (n = 1). With ECMO support, vasopressor requirement, central venous pressure, creatinine, lactate, pH, pulmonary hypertension, and The Society of Thoracic Surgeons mortality risk and EuroSCORE (European System for Cardiac Operative Risk Evaluation) II all improved significantly. Care was withdrawn in 1 patient on ECMO with initially unknown anoxic brain injury. No patients required dialysis at discharge. Complications included 1 permanent stroke. All operative patients survived to hospital discharge. Average length of follow-up was 420 days, with 2 patient deaths at 76 and 230 days and 6 patients surviving over 1 year. CONCLUSIONS: ECMO can be used as a bridge to heart valve or septal defect surgery in severely decompensated patients. Through recovery of end-organ function, ECMO may allow surgical correction of structural heart disease in patients considered inoperable or convert a salvage situation to an elective operation.

Programmatic and Surgeon Specialization Improves Mortality in Isolated Coronary Bypass Grafting.

BACKGROUND: Throughout surgery, specialization in a procedure has been shown to improve outcomes. Currently, there is no evidence for or against subspecialization in coronary surgery. Tasked with the goal of improving outcomes after isolated coronary artery bypass grafting (CABG), our institution sought to determine whether the development of a subspecialized coronary surgery program would improve morbidity and mortality. METHODS: All isolated CABG operations at a single institution were retrospectively examined in two distinct periods, 2002 to 2013 and 2013 to 2016, before and after the implementation of a subspecialized coronary surgery program. Improved policies included leadership and subspecialization of a program director, standardization of surgical technique and postoperative care, and monthly multidisciplinary quality review. Outcomes were collected and compared. RESULTS: Between 2002 and 2013, 3,256 CABG operations were done by 16 surgeons, the most frequent surgeon doing 33%. Between 2013 and 2016, 1,283 operations were done by 10 surgeons, 70% by the coronary program director. CABGs done in the specialized era had shorter bypass and clamps times and increased use of bilateral internal mammary arteries. Blood transfusion and complication rates, including permanent stroke and prolonged ventilation, were significantly decreased after implementation of the coronary program. Likewise, overall operative mortality (2.67% vs 1.48%, p = 0.02) was significantly reduced. CONCLUSIONS: Subspecialization in CABG and dedicated coronary surgery programs may lead to faster operations, increased use of bilateral internal mammary arteries, fewer complications, and improved survival after isolated CABG.

Transmitral Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy.

BACKGROUND: Intrinsic abnormalities of the mitral valve are common in patients with hypertrophic cardiomyopathy and may need to be addressed at operation. METHODS: Consecutive patients undergoing transmitral septal myectomy were retrospectively reviewed. The ventricular septum was exposed through a left atriotomy, and the anterior leaflet of the mitral valve was detached from its annulus. An extended myectomy was performed to the base of the papillary muscles. After myectomy, the anterior leaflet was reattached and concomitant mitral valve repair or replacement was performed. In some cases, we performed a modified anterolateral commissural closure suture, which served to reposition the lateral aspect of the anterior leaflet out of the left ventricular outflow tract ("curtain stitch"). RESULTS: Twenty patients who underwent this procedure were identified (70% women; mean age 63 years). Mitral regurgitation was moderate in 55% and severe in 40%. Preoperative peak left ventricular outflow tract gradient was 92 ± 43 mm Hg. Mitral valve repair (n = 11) or replacement (n = 9) was performed. Predischarge transthoracic echocardiography demonstrated a left ventricular outflow tract gradient of 10 ± 5 mm Hg. There was no operative mortality. Follow-up was 100% complete and averaged 22 ± 25 months. No patient required reoperation, and there was no recurrence of left ventricular outflow tract obstruction or mitral regurgitation greater than mild. CONCLUSIONS: Potential advantages of transmitral myectomy include a panoramic view of the septum and mitral subvalvular apparatus and the ability to simultaneously address mitral valve pathology. Consideration should be given to using the transmitral approach to septal myectomy as the preferred approach for the surgical treatment of hypertrophic cardiomyopathy.