Use of carotid and axillary artery approach for stenting the patent ductus arteriosus in infants with ductal-dependent pulmonary blood flow: A multicenter study from the congenital catheterization research collaborative.

BACKGROUND: Carotid artery (CA) and axillary artery (AA) access are increasingly used for transcatheter stenting of the patent ductus arteriosus (PDA), although reports are limited. METHODS: The Congenital Catheterization Research Collaborative (CCRC) reviewed multicenter data from infants who underwent PDA stenting via the CA or AA approach from 2008 to 2017, and compared outcomes to those of infants undergoing PDA stenting via the femoral artery (FA) approach. Post-procedure ultrasound (US) imaging was reviewed. RESULTS: Forty-nine infants underwent PDA stenting from the CA (n = 43) or AA (n = 6) approach, compared with 55 infants who underwent PDA stenting from the FA approach. The PDA was the sole pulmonary blood flow (PBF) source in 61% of infants in the CA/AA cohort, compared with 33% of the FA cohort (p < .01). Ductal tortuosity for CA/AA cohort was Type I (straight) in 10 (20%), Type II (one turn) in 17 (35%), and Type III (multiple turns) in 22 (45%) infants and reflected a greater degree of tortuosity when compared to the FA cohort (p < .01). In 17 infants with CA/AA approach, the "flip technique" was used, and was associated with shorter procedure times for highly tortuous PDA (Type III) patients. Rates of procedural complications were similar across access sites. Most common complications were access site injury (thrombus or bleeding) and stent malposition. No complications were specifically related to the "flip technique." CONCLUSIONS: Use of CA and AA approach for PDA stenting was found to be more commonly employed in sole source PBF and highly tortuous PDAs. Procedural modifications such as the "flip technique" may lead to shorter procedure times. CA and AA approaches are associated with a similar burden of procedural or late complications. Post-procedural surveillance of the CA and AA is suggested, given the incidence of vascular findings on US.

Changes in Anesthetic and Postoperative Sedation-Analgesia Practice Associated With Early Extubation Following Infant Cardiac Surgery: Experience From the Pediatric Heart Network Collaborative Learning Study.

OBJECTIVES: The Pediatric Heart Network sponsored the multicenter Collaborative Learning Study that implemented a clinical practice guideline to facilitate early extubation in infants after repair of isolated coarctation of the aorta and tetralogy of Fallot. We sought to compare the anesthetic practice in the operating room and sedation-analgesia management in the ICU before and after the implementation of the guideline that resulted in early extubation. DESIGN: Secondary analysis of data from a multicenter study from January 2013 to April 2015. Predefined variables of anesthetic, sedative, and analgesia exposure were compared before and after guideline implementation. Propensity score weighted logistic regression analysis was used to determine the independent effect of intraoperative dexmedetomidine administration on early extubation. SETTING: Five children's hospitals. PATIENTS: A total of 240 study subjects who underwent repair of coarctation of the aorta or tetralogy of Fallot (119 preguideline implementation and 121 postguideline implementation). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Clinical practice guideline implementation was accompanied by a decrease in the median total intraoperative dose of opioids (49.7 vs 24.0 µg/kg of fentanyl equivalents, p < 0.001) and benzodiazepines (1.0 vs 0.4 mg/kg of midazolam equivalents, p < 0.001), but no change in median volatile anesthetic agent exposure (1.3 vs 1.5 minimum alveolar concentration hr, p = 0.25). Intraoperative dexmedetomidine administration was associated with early extubation (odds ratio 2.5, 95% CI, 1.02-5.99, p = 0.04) when adjusted for other covariates. In the ICU, more patients received dexmedetomidine (43% vs 75%), but concomitant benzodiazepine exposure decreased in both the frequency (66% vs 57%, p < 0.001) and cumulative median dose (0.5 vs 0.3 mg/kg of ME, p = 0.003) postguideline implementation. CONCLUSIONS: The implementation of an early extubation clinical practice guideline resulted in a reduction in the dose of opioids and benzodiazepines without a change in volatile anesthetic agent used in the operating room. Intraoperative dexmedetomidine administration was independently associated with early extubation. The total benzodiazepine exposure decreased in the early postoperative period.

SCAI/CCAS/SPA expert consensus statement for anesthesia and sedation practice: Recommendations for patients undergoing diagnostic and therapeutic procedures in the pediatric and congenital cardiac catheterization laboratory.

Current practice of sedation and anesthesia for patients undergoing pediatric congenital cardiac catheterization laboratory (PCCCL) procedures is known to vary among institutions, a multi-society expert panel with representatives from the Congenital Heart Disease Council of the Society for Cardiovascular Angiography and Interventions (SCAI), the Society for Pediatric Anesthesia (SPA) and the Congenital Cardiac Anesthesia Society (CCAS) was convened to evaluate the types of sedation and personnel necessary for procedures performed in the PCCCL. The goal of this panel was to provide practitioners and institutions performing these procedures with guidance consistent with national standards and to provide clinicians and institutions with consensus-based recommendations and the supporting references to encourage their application in quality improvement programs. Recommendations can neither encompass all clinical circumstances nor replace the judgment of individual clinicians in the management of each patient. The science of medicine is rooted in evidence, and the art of medicine is based on the application of this evidence to the individual patient. This expert consensus statement has adhered to these principles for optimal management of patients requiring sedation and anesthesia. What follows are recommendations for patient monitoring in the PCCCL regardless of whether minimal or no sedation is being used or general anesthesia is being provided by an anesthesiologist. © 2016 Wiley Periodicals Inc.

SCAI/CCAS/SPA Expert Consensus Statement for Anesthesia and Sedation Practice: Recommendations for Patients Undergoing Diagnostic and Therapeutic Procedures in the Pediatric and Congenital Cardiac Catheterization Laboratory.

Current practice of sedation and anesthesia for patients undergoing pediatric and congenital cardiac catheterization laboratory (PCCCL) procedures is known to vary among institutions, a multi-society expert panel with representatives from the Congenital Heart Disease Council of the Society for Cardiovascular Angiography and Interventions, the Society for Pediatric Anesthesia and the Congenital Cardiac Anesthesia Society was convened to evaluate the types of sedation and personnel necessary for procedures performed in the PCCCL. The goal of this panel was to provide practitioners and institutions performing these procedures with guidance consistent with national standards and to provide clinicians and institutions with consensus-based recommendations and the supporting references to encourage their application in quality improvement programs. Recommendations can neither encompass all clinical circumstances nor replace the judgment of individual clinicians in the management of each patient. The science of medicine is rooted in evidence, and the art of medicine is based on the application of this evidence to the individual patient. This expert consensus statement has adhered to these principles for optimal management of patients requiring sedation and anesthesia. What follows are recommendations for patient monitoring in the PCCCL regardless of whether minimal or no sedation is being used or general anesthesia is being provided by an anesthesiologist.

Longitudinal Echocardiographic Evaluation of an Unusual Presentation of X-Linked Myxomatous Valvular Dystrophy Caused by Filamin A Mutation.

Polyvalvar myxomatous valve degeneration is a clinical pathology rarely encountered during cardiac anesthesia, but, when present, most commonly occurs in the context of a connective tissue disorder. Filamin A mutations have begun to be recognized as a source of progressive myxomatous mitral and tricuspid valve degeneration. These lesions can be diagnosed by echo, but their clinical presentation can be equivocal. We present a patient with significant echocardiographic findings of mitral and tricuspid valvar regurgitation, aortic dilatation, and intraoperative findings of aortic ectasia. In our case, a detailed family history led to a preoperative echocardiogram revealing myxomatous mitral and tricuspid valve degeneration with significant regurgitation and aortic dilatation. Genetic evaluation led to the diagnosis of a Filamin A mutation. Pre- and postrepair echocardiographic assessments of valvar function played a key role in the management of this patient. Continued surveillance of his aortic dilation and evaluation of postrepair valve function warrants close follow-up with a high likelihood for further surgical intervention.

Excessive postoperative bleeding and outcomes in neonates undergoing cardiopulmonary bypass.

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

Newly released data from the revised U.S. birth certificate, 2011.

OBJECTIVES: This report is the first release of multistate data for selected items exclusive to the 2003 revision of the U.S. Standard Certificate of Live Birth. Included is information for prepregnancy body mass index, smoking and quitting smoking in the 3 months prior to pregnancy, receipt of food from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) during pregnancy, pregnancy resulting from infertility treatment, source of payment for delivery, and maternal morbidities. METHODS: Descriptive statistics are presented for 100% of 2011 births to residents of the 36 states, the District of Columbia (D.C.), and Puerto Rico that had implemented the revised birth certificate by January 1, 2011. This reporting area is not a random sample, and results are not generalizable to the United States as a whole. RESULTS: The 3,267,934 births to residents of the 36-state and D.C. reporting area represented 83% of all 2011 U.S. births. Levels of prepregnancy obesity ranged from 18.0% in Utah to 28.6% in South Carolina. Hispanic women were the least likely to smoke in the 3 months prior to pregnancy and were the most likely to quit smoking prior to pregnancy. Women under age 20 were more than twice as likely to receive WIC food during pregnancy as women aged 35 and over in nearly all states and D.C. The percentage of births resulting from infertility treatment ranged from 0.3% in New Mexico to over 3.5% in Maryland and Utah. The percentage of deliveries covered by Medicaid ranged from 28.8% in North Dakota to 64.2% in Louisiana.

Assessing the quality of medical and health data from the 2003 birth certificate revision: results from two states.

OBJECTIVES: A primary goal of the 2003 revision of the U.S. Standard Certificate of Live Birth was to improve data quality, in part by improving data sources, definitions, and instructions. This report evaluates the quality of selected medical and health data from the 2003 revision of the birth certificate by comparing birth certificate data with information abstracted from hospital medical records. METHODS: A random sample of records for 600 births that occurred in 2010-2011 in State A, and a convenience sample of 495 births that occurred in State B in 2009 were reviewed. Birth certificate and hospital medical record data were compared for these categories: pregnancy history, prenatal care, gestational age, birthweight, pregnancy risk factors, obstetric procedures, onset of labor, source of payment, characteristics of labor and delivery, fetal presentation, method of delivery, abnormal conditions of the newborn, infant living, and infant breastfed. Levels of missing data, exact agreement, kappa scores, sensitivity, and false discovery rates are presented, where applicable. RESULTS: Exact agreement or sensitivity, was high for a number of items for both states (e.g., number of cesarean deliveries, cephalic presentation, cesarean delivery, and birthweight within 500 grams), but exact agreement or sensitivity was low or extremely low for both states for several items (e.g., total number of prenatal visits, previous preterm birth, meconium staining, and fetal intolerance of labor) (Figure 1). Levels of agreement or sensitivity for most items (e.g., prenatal care beginning in first trimester and source of payment-private insurance) were substantial or moderate. Data quality varied by state, and often, varied widely by hospital.

Births: final data for 2010.

OBJECTIVES: This report presents 2010 data on U.S. births according to a wide variety of characteristics. Data are presented for maternal characteristics including age, live-birth order, race and Hispanic origin, marital status, attendant at birth, method of delivery, and infant characteristics (period of gestation, birthweight, and plurality). Birth and fertility rates by age, live-birth order, race and Hispanic origin, and marital status also are presented. Selected data by mother's state of residence are shown, as well as birth rates by age and race of father. Trends in fertility patterns and maternal and infant characteristics are described and interpreted. METHODS: Descriptive tabulations of data reported on the birth certificates of the 4.0 million births that occurred in 2010 are presented. Denominators for population-based rates are postcensal estimates derived from the U.S. 2010 census. RESULTS: The number of births declined to 3,999,386 in 2010, 3 percent less than in 2009. The general fertility rate also declined 3 percent, to 64.1 per 1,000 women aged 15-44. The teen birth rate fell 10 percent to 34.2 per 1,000. Birth rates for women in each 5-year age group from 20 through 39 years declined, but the rate for women aged 40-44 continued to rise. The total fertility rate (estimated number of births over a woman's lifetime) was down 4 percent to 1,931 per 1,000 women. The number, rate, and percentage of births to unmarried women declined. The cesarean deliver rate was down for the first year since 1996 to 32.8 percent. The preterm birth rate declines for the fourth year in a row to 11.99 percent; the low birthweight rate was stable at 8.15 percent. The twin birth rate declined slightly to 33.1 per 1,000 births; the triplet and higer-order multipe birth rate dropped 10 percent to 137.6 per 100,000.

Fetal and perinatal mortality, United States, 2006.

OBJECTIVES: This report presents 2006 fetal and perinatal mortality data by maternal age, marital status, race, Hispanic origin, and state of residence, as well as by fetal birthweight, gestational age, plurality, and sex. Trends in fetal and perinatal mortality are also examined. METHODS: Descriptive tabulations of data are presented and interpreted. RESULTS: There were 25,972 reported fetal deaths at 20 weeks of gestation or more in the United States in 2006. The U.S. fetal mortality rate was 6.05 fetal deaths at 20 weeks of gestation or more per 1,000 live births, 3% lower than in 2005 (6.22). From 2005 to 2006, fetal mortality declined 3% for fetal deaths at 20-27 weeks of gestation, while the rate at 28 weeks or more did not decline significantly. This contrasts with the long-term trend of declines in fetal mortality at 28 weeks or more and stability at 20-27 weeks of gestation. Fetal mortality rates declined significantly for non-Hispanic black women from 2005 to 2006; however, rates for other racial and ethnic groups were essentially unchanged. In 2006, the fetal mortality rate for non-Hispanic black women (10.73) was more than twice the rate for non-Hispanic white (4.81) and Asian or Pacific Islander (4.89) women. The rate for American Indian or Alaska Native women (6.04) was 26% higher, and the rate for Hispanic women (5.29) was 10% higher, than the rate for non-Hispanic white women. Fetal mortality rates were higher than average for teenagers, women aged 35 and over, unmarried women, and women with multiple pregnancies.

Births: final data for 2009.

OBJECTIVES: This report presents 2009 data on U.S. births according to a wide variety of characteristics. Data are presented for maternal characteristics including age, live-birth order, race and Hispanic origin, marital status, hypertension during pregnancy, attendant at birth, method of delivery, and infant characteristics (period of gestation, birthweight, and plurality). Birth and fertility rates by age, live-birth order, race and Hispanic origin, and marital status also are presented. Selected data by mother's state of residence are shown, as well as birth rates by age and race of father. Trends in fertility patterns and maternal and infant characteristics are described and interpreted. METHODS: Descriptive tabulations of data reported on the birth certificates of the 4.13 million births that occurred in 2009 are presented. Denominators for population-based rates are postcensal estimates derived from the U.S. 2000 census. RESULTS: The number of births declined to 4,130,665 in 2009, 3 percent less than in 2008. The general fertility rate declined 3 percent to 66.7 per 1,000 women aged 15-44 years. The teenage birth rate fell 6 percent to 39.1 per 1,000. Birth rates for women in each 5-year age group from 20 through 39 years declined, but the rate for women 40-44 years continued to rise. The total fertility rate (estimated number of births over a woman's lifetime) was down 4 percent to 2,007.0 per 1,000 women. The number and rate of births to unmarried women declined, whereas the percentage of nonmarital births increased slightly to 41.0. The cesarean delivery rate rose again, to 32.9 percent. The preterm birth rate declined to 12.18 percent; the low birthweight rate was stable at 8.16 percent. The twin birth rate increased to 33.2 per 1,000; the triplet and higher-order multiple birth rate rose 4 percent to 153.5 per 100,000.

The impact of aprotinin on postoperative renal dysfunction in neonates undergoing cardiopulmonary bypass: a retrospective analysis.

BACKGROUND: Recent concern about the safety of aprotinin administration to adults has led to its suspension from worldwide markets. However, few studies have examined its safety in pediatric patients. Studies in children evaluating aprotinin's safety have been hindered by the heterogeneity of pediatric patients and the inconsistency of clinical protocols. In this investigation, we retrospectively reviewed 200 neonatal cardiac surgical cases performed at our institution to examine the safety of aprotinin, focusing on postoperative renal dysfunction, using a consistent aprotinin dosing protocol. METHODS: Two-hundred consecutive neonates scheduled for palliative or corrective congenital cardiac surgery requiring cardiopulmonary bypass (CPB) from January 1, 2005 through February 28, 2007 were included in this retrospective investigation. Preoperative, intraoperative and postoperative data were collected and analyzed. Markers of safety included 72-h postoperative renal dysfunction, need for dialysis (peritoneal or hemodialysis), thrombosis and in-hospital mortality. RESULTS: Neonates were divided into those who received aprotinin (aprotinin group; n = 156) and those who did not (no aprotinin group; n = 44). Twenty-four and 72-h postoperative serum creatinine levels were significantly greater than baseline levels in both groups. The degree of change in creatinine levels was highly significant and similar between the two groups. A larger percentage of neonates in the aprotinin group developed renal dysfunction, although this difference was not statistically significant. Stepwise logistic regression, assessing the impact on renal dysfunction of all variables that indicated significance between neonates who did or did not receive aprotinin and between neonates who did or did not develop renal dysfunction, identified CPB time and age as significant predictors of postoperative renal dysfunction. All neonates who developed postoperative renal dysfunction had a CPB time of more than 100 min regardless of the use of aprotinin. Additionally, using this subset, similar percentages of renal dysfunction occurred in both groups. A second multivariable regression analysis to simultaneously account for the predictors of CPB time, age and aprotinin administration found CPB time to be the only significant predictor of renal dysfunction. Incidences of postoperative dialysis, postoperative thrombosis and in-hospital mortality were not statistically significantly different between the aprotinin and the no aprotinin groups. CONCLUSION: The occurrence of postoperative renal dysfunction in neonates was more significantly predicted by the duration of CPB than by the intraoperative administration of aprotinin. CPB times of more than 100 min appeared to be a critical marker for the development of postoperative renal dysfunction. Randomized prospective trials are needed to confirm the validity of our retrospective findings.

Clinical measures of heparin's effect and thrombin inhibitor levels in pediatric patients with congenital heart disease.

In this investigation, we examined the relationship among three thrombin inhibitors, antithrombin III (ATIII), heparin cofactor II (HCII), and alpha-2-macroglobulin (alpha2M), and several clinical tests of heparin's effect in pediatric patients with congenital heart disease undergoing cardiopulmonary bypass. One hundred eighteen children were stratified into six age groups: <1 mo, 1-3 mo, 3-6 mo, 6-12 mo, 12-24 mo, and >10 yr. Baseline ATIII, HCII, and alpha2M values were measured. Baseline celite- and kaolin-activated clotting times (ACT) were also measured and repeated 3 min after a standard heparin dose of 400 U/kg. Differences in ACT values before and after heparin administration and a heparin dose-response relationship were calculated for each patient. Kaolin-activated ACT tests showed less variation after heparin administration than celite-activated tests. In contrast to what has been demonstrated in adults, ATIII showed no positive correlation with the clinical tests of heparin's effect nor did the other thrombin inhibitors. Additionally, patients <1 mo old had unexpectedly low levels of alpha2M accompanying their expected low levels of ATIII and HCII. Our findings raise concerns about the ability of heparin to adequately anticoagulate these neonates during cardiopulmonary bypass and, consequently, challenge the accuracy of ACT prolongation to truly reflect the extent of their anticoagulation.