Advancement of a standardised enteral feeding protocol in functional single ventricle patients following stage I palliation using cerebro-somatic near-infrared spectroscopy.

INTRODUCTION: Infants with single ventricle following stage I palliation are at risk for poor nutrition and growth failure. We hypothesise a standardised enteral feeding protocol for these infants that will result in a more rapid attainment of nutritional goals without an increased incidence of gastrointestinal co-morbidities. MATERIALS AND METHODS: Single-centre cardiac ICU, prospective case series with historical comparisons. Feeding cohort consisted of consecutive patients with a single ventricle admitted to cardiac ICU over 18 months following stage I palliation (n = 33). Data were compared with a control cohort and admitted to the cardiac ICU over 18 months before feeding protocol implementation (n = 30). Feeding protocol patients were randomised: (1) protocol with cerebro-somatic near-infrared spectroscopy feeding advancement criteria (n = 17) or (2) protocol without cerebro-somatic near-infrared spectroscopy feeding advancement criteria (n = 16). RESULTS: Median time to achieve goal enteral volume was significantly higher in the control compared to feeding cohort. There were no significant differences in enteral feeds being held for feeding intolerance or necrotising enterocolitis between cohorts. Feeding cohort had significant improvements in discharge nutritional status (weight, difference admit to discharge weight, weight-for-age z score, volume, and caloric enteral nutrition) and late mortality compared to the control cohort. No infants in the feeding group with cerebro-somatic near-infrared spectroscopy developed necrotising enterocolitis versus 4/16 (25%) in the feeding cohort without cerebro-somatic near-infrared spectroscopy (p = 0.04). CONCLUSIONS: A feeding protocol is a safe and effective means of initiating and advancing enteral nutrition in infants following stage I palliation and resulted in improved nutrition delivery, weight gain, and nourishment status at discharge without increased incidence of gastrointestinal co-morbidities.

The effect of angiotensin-converting enzyme inhibitors on the rate of ascending aorta dilation in patients with bicuspid aortic valve.

BACKGROUND: Bicuspid aortic valve (BAV), the most common congenital heart defect, is associated with progressive aortic dilation and increased risk of dissection and rupture. The use of an angiotensin-converting enzyme (ACE) inhibitor has recently proven effective in slowing the rate of aortic dilation in other aortopathies, suggesting it may also be useful in managing BAV. We sought to determine whether ACE inhibitors effectively reduce the rate of aortic dilation in adolescents and young adults with BAV. METHODS: A retrospective cohort study was undertaken. Subjects receiving ACE inhibitor therapy were compared with controls with BAV and matched for the degree of aortic regurgitation. The rate of change in ascending aorta diameter was compared between the two groups. RESULTS: Among the 141 subjects identified in the patient records, 103 were receiving no medication and 38 were taking ACE inhibitors. Over a mean follow-up of 37 months, the ascending aorta Z-score increased slightly among those receiving ACE inhibitor +4.5 ± 1.6 to +4.7 ± 1.6. The rate of change was no different than those subjects not receiving ACE inhibitors, P = .64. CONCLUSION: In an adolescent and young adult population with an isolated BAV, there is no proven benefit to ACE inhibitor use with regard to slowing rate of ascending aortic dilation.

Cost analysis of percutaneous pulmonary valve replacement.

Percutaneous pulmonary valve implantation is currently being used to treat right ventricular outflow tract obstruction or insufficiency in congenital heart disease. Presumably this alternative to surgical conduit replacement may result in cost savings owing to shorter hospital stays; however, a formal cost comparison has not been undertaken. Total hospital costs of percutaneous pulmonary valve implantation were compared to costs of surgical conduit replacement. Midterm cost-savings analysis was then modeled over 5 years using initial costs and reintervention rates. Need for surgical or transcatheter reintervention was derived from published data (5-year freedom from reintervention was assumed to be 53% for percutaneous pulmonary valves and 90% for surgical conduits). Cost of Melody valve and delivery device ($30,500) was higher than the conduit cost ($8,700), but total procedural costs were nearly identical at just less $50,000 for each procedure. When considering the increased need for reintervention in patients with Melody valves, surgical conduit revision results in moderate cost savings at 5 years after the initial procedure ($19,928 per patient). In conclusion, Melody valve implantation compares reasonably well to surgical conduit revision despite the added midterm costs, but ongoing analysis including the impact of nonsurgical options on quality-of-life measurements and improvement of reintervention rates for percutaneously placed valves needs to be considered.

Detection of a coronary artery anomaly after a sudden cardiac arrest in a 17 Year-old with D-transposition of the great arteries status post arterial switch operation: a case report.

Long-term follow-up and testing for patients who have undergone congenital heart surgery is an evolving field. We report the case of a 17-year-old patient who had an arterial switch operation as an infant for d-transposition of the great vessels and suffered sudden cardiac arrest while participating in a cross-country event. Previous evaluations, including a cardiac catheterization and stress testing, did not indicate any identifiable abnormalities. After the arrest, a computed tomography angiogram of his chest showed an abnormal takeoff of the reimplanted left coronary artery.