Immunisation deferral practices surrounding congenital heart surgery.

BACKGROUND: Perioperative immunisation administration surrounding congenital heart surgery is controversial. Delayed immunisation administration results in children being at risk of vaccine-preventable illnesses and is associated with failure to complete immunisation schedules. Among children with CHD, many of whom are medically fragile, vaccine-preventable illnesses can be devastating. Limited research shows perioperative immunisation may be safe and effective. METHODS: We surveyed Pediatric Acute Care Cardiology Collaborative member centres and explored perioperative immunisation practices. We analysed responses using descriptive statistics. RESULTS: Complete responses were submitted by 35/46 (76%) centres. Immunisations were deferred for any period prior to surgery by 23 (66%) centres and after surgery by 31 (89%) centres. Among those who deferred post-operative immunisation, 20 (65%) required deferral only for patients whose operations required cardiopulmonary bypass. Duration of deferral in the pre- and post-operative periods was variable. Many centres included exceptions to their policy for specific vaccine-preventable illnesses. Almost all (34, 97%) centres administer routine childhood immunisation to patients who remain admitted for prolonged periods. CONCLUSIONS: Most centres defer routine childhood immunisation for some period before and after congenital heart surgery. Centre specific practices vary. Immunisation deferral confers risk to patients and may not be warranted in this population. Further research would be necessary to understand the immunologic impact of these practices.

Assessing enrollment of eligible infants in the national pediatric cardiology quality improvement collaborative (NPC-QIC) through linkage to the pediatric cardiac critical care consortium (PC4) registry.

BACKGROUND: The National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) lacks a rigorous enrollment audit process, unlike other collaborative networks. Most centers require individual families to consent to participate. It is unknown whether there is variation across centers or biases in enrollment. METHODS: We used the Pediatric Cardiac Critical Care Consortium (PC4) registry to assess enrollment rates in NPC-QIC for those centers participating in both registries using indirect identifiers (date of birth, date of admission, gender, and center) to match patient records. All infants born 1/1/2018-12/31/2020 and admitted 30 days of life were eligible. In PC4, all infants with a fundamental diagnosis of hypoplastic left heart or variant or who underwent a surgical or hybrid Norwood or variant were eligible. Standard descriptive statistics were used to describe the cohort and center match rates were plotted on a funnel chart. RESULTS: Of 898 eligible NPC-QIC patients, 841 were linked to 1,114 eligible PC4 patients (match rate 75.5%) in 32 centers. Match rates were lower in patients of Hispanic/Latino ethnicity (66.1%, p = 0.005), and those with any specified chromosomal abnormality (57.4%, p = 0.002), noncardiac abnormality (67.8%, p = 0.005), or any specified syndrome (66.5%, p = 0.001). Match rates were lower for patients who transferred to another hospital or died prior to discharge. Match rates varied from 0 to 100% across centers. CONCLUSIONS: It is feasible to match patients between the NPC-QIC and PC4 registries. Variation in match rates suggests opportunities for improvement in NPC-QIC patient enrollment.

Effect of Cardiopulmonary Bypass on SARS-CoV-2 Vaccination Antibody Levels.

Background Adults undergoing heart surgery are particularly vulnerable to respiratory complications, including COVID-19. Immunization can significantly reduce this risk; however, the effect of cardiopulmonary bypass (CPB) on immunization status is unknown. We sought to evaluate the effect of CPB on COVID-19 vaccination antibody concentration after cardiac surgery. Methods and Results This prospective observational clinical trial evaluated adult participants undergoing cardiac surgery requiring CPB at a single institution. All participants received a full primary COVID-19 vaccination series before CPB. SARS-CoV-2 spike protein-specific antibody concentrations were measured before CPB (pre-CPB measurement), 24 hours following CPB (postoperative day 1 measurement), and approximately 1 month following their procedure. Relationships between demographic or surgical variables and change in antibody concentration were assessed via linear regression. A total of 77 participants were enrolled in the study and underwent surgery. Among all participants, mean antibody concentration was significantly decreased on postoperative day 1, relative to pre-CPB levels (-2091 AU/mL, P<0.001). Antibody concentration increased between postoperative day 1and 1 month post CPB measurement (2465 AU/mL, P=0.015). Importantly, no significant difference was observed between pre-CPB and 1 month post CPB concentrations (P=0.983). Two participants (2.63%) developed symptomatic COVID-19 pneumonia postoperatively; 1 case of postoperative COVID-19 pneumonia resulted in mortality (1.3%). Conclusions COVID-19 vaccine antibody concentrations were significantly reduced in the short-term following CPB but returned to pre-CPB levels within 1 month. One case of postoperative COVID 19 pneumonia-specific mortality was observed. These findings suggest the need for heightened precautions in the perioperative period for cardiac surgery patients.

Prenatal care coordination, racial and socioeconomic inequities, and pre- and post-operative outcomes in hypoplastic left heart syndrome.

OBJECTIVE: We sought to identify associations between prenatal care coordination (PNC) and outcomes in hypoplastic left heart syndrome (HLHS). STUDY DESIGN: We hypothesized that suboptimal PNC is associated with worse pre-operative status. HLHS patients from 2016 through 2019 were identified using a multicenter registry. Optimal PNC was defined as (1) a completed interdisciplinary conference and (2) closed-loop communication with the obstetric team. Associations between PNC and outcomes were identified. RESULTS: Of 1441 patients, 1242 (86%) had prenatal diagnosis. Among those with a prenatal diagnosis, PNC was achieved in only 845 (68%). Suboptimal PNC was associated with adverse events (50% vs 40%, p < 0.001), inotrope need (19% vs 13%, p = 0.007), mechanical ventilation (22% vs 16%, p = 0.016), and parenteral feeding (60% vs 46%, p < 0.001). African-American race and non-commercial insurance were associated with a lower likelihood of optimal PNC (p = 0.006 and p < 0.001, respectively). CONCLUSION: Improving PNC and overcoming racial and socioeconomic barriers are important targets to improve HLHS perinatal care.

Standard volume infusion unmasked diastolic dysfunction in pediatric heart transplant recipients during surveillance cardiac catheterization, but without echocardiographic correlates.

BACKGROUND: Adult experience evaluating left ventricular diastolic function (LVDFx) includes volume administration during catheterization while obtaining pulmonary capillary wedge pressures (PCWP) or left ventricular end diastolic pressures (LVEDP). Catheterization is inherently challenging in pediatric patients, making echocardiographic assessment ideal. Pediatric echocardiographic studies predicting LVDFx have variable hemodynamic and hydration conditions and have produced inconsistent results. We evaluated the association between simultaneous echocardiographic and catheterization assessment of LVDFx, using a fluid bolus for optimal loading conditions. METHODS: Prospective cohort study of pediatric heart transplant recipients receiving echocardiogram simultaneous with routine cardiac catheterization. Mitral valve inflow velocities, septal and lateral wall tissue Doppler indices, and PCWP and/or LVEDP were obtained and repeated following a 10 ml/kg bolus. Echocardiographic parameters were evaluated for an association with changes in PCWP or LVEDP following the bolus. Abnormal LVDFx was defined as PCWP or LVEDP ≥12 mm Hg. RESULTS: Twenty-nine patients underwent catheterization. Median pre-bolus PCWP and LVEDP were 11.0 mm Hg and 10.0 mm Hg, respectively. After bolus, median PCWP and LVEDP increased to 14.0 mm Hg (p < .001) and 13 mm Hg (p < .001), respectively. Of 21 patients with normal pre-bolus catheterization hemodynamics, 14 (66.7%) increased to abnormal following fluid bolus. Using area under an ROC, no echocardiographic parameter of LVDFx, or their ratios, were associated with predetermined abnormal LVEDP and/or PCWP. CONCLUSION: After bolus, our cohort demonstrated significant increases in LVEDP and/or PCWP, unmasking diastolic dysfunction. Fluid challenges should be considered in pediatric patients undergoing cardiac catheterization with suspected diastolic dysfunction. Echocardiographic measurements were unable to discriminate between normal and abnormal LVEDP and/or PCWP.

Acceptability of an interstage home monitoring mobile application for caregivers of children with single ventricle physiology: Toward technology-integrated family management.

PURPOSE: Infants with single ventricle physiology experience numerous vulnerable transitions, and the interstage period for shunt-dependent children represents the time of highest risk for morbidity and mortality. Data exchange, physiological monitoring, and communication between clinicians and caregivers through interstage home monitoring are critical. The purpose of this study is to report on the acceptability of a technology-enhanced home monitoring mobile application for interstage family management of children with single ventricle physiology. DESIGN AND METHODS: This study employed a qualitative descriptive study design and recruited caregivers that were part of a broader quality improvement project where they were beta users of a mobile health application specifically developed for the interstage home monitoring time period. RESULTS: Eleven caregivers were enrolled in this study that was a part of the early phases of beta testing the mobile application from a human-centered design perspective. In general, the participants had a favorable sentiment toward the technology-integrated family management aspects that the mobile application allowed for during the interstage process. The acceptability findings can be organized through the following themes: time needed for mobile application, family as integrated members of care team, connectedness and confidence, and resolving technical issues. CONCLUSIONS: Evaluation of the feasibility and acceptability of this technology from the perspective of family/caregivers is a critical component of human-centered design. The integration of technology-facilitated communication shows immense promise for patient populations undergoing vulnerable transitions in care. Future study is needed to determine the role mobile applications have in improved clinical outcomes, enhanced provider clinical-decision support, and family engagement in care.

Association Between Pulsatility Index and the Development of Necrotizing Enterocolitis in Infants with Congenital Heart Disease.

Infants with congenital heart disease are known to have higher rates of necrotizing enterocolitis (NEC) which is associated with poorer outcomes. Although the etiology is recognized as distinct from the premature neonatal population, there is not a universal consensus regarding etiology or specific risk factors. In this retrospective single-institution case-control study, we assessed whether aortic pulsatility index (PI) as detected via ultrasound might be associated with NEC in neonates undergoing cardiac surgical repair within the first month of life. The study identified 30 participants who developed NEC and 50 matched controls. Baseline demographic and surgical characteristics were similar between groups. Patients who developed NEC had higher mortality (26% vs 4%, p < 0.01). Standard PI and the modified pulsatility values were calculated manually and underwent logistic regression. The median log PI of the NEC cohort was higher compared to the lowest control PI (0.68 vs 0.48, p = 0.03); the median log PI of the NEC cohort was significantly lower than the highest PI of the control cohort (0.61 vs 0.98, p = 0.05). The modified pulsatility index demonstrated similar trends with the median log MODPI of the NEC cohort being significantly greater than that of the control cohort (3.9 vs. 3.1, p = 0.01). Infants with congenital heart disease who develop NEC have a higher PI and MODPI when compared to the lowest control PI. This suggests that infants with a higher baseline PI may be at increased risk for developing NEC.

Safety and efficacy of a home nasogastric monitoring program for premature infants.

BACKGROUND: A novel home monitoring program, in which premature infants are cared for at home with a nasogastric tube in place prior to achievement of full oral feeding, was evaluated. The program combines a digital, fully EMR-integrated, virtual daily rounding platform with direct provider video and telephone contact. METHODS: A case-control study was performed evaluating infants < 34 weeks' gestation who were followed in our program. A historical control group, was created by matching 2 : 1 based on gestational age±6 days, retroactively. RESULT: 15 patients discharged in the program were compared with 30 controls. The home cohort gained an average of 30 g/day compared with the in-hospital group at 27g/day (p = 0.325). The home group required a mean of 5.9±2.9 days to full oral feeding once discharged, not different from the control group at 5.4±3.7 days (p = 0.606). The percentage of oral feeds for the home cohort, however, increased at a rate of 12.2%before discharge compared to rising 57%at home (p < 0.001). The control group spent an additional 8.1±3.9 days in the hospital after reaching criteria. There were no reported adverse events or readmissions. CONCLUSION: Premature infants can safely advance oral feeds using a home monitoring program. While at home, infants gained weight similarly to their inpatient controls, yet gained full oral skills at a significantly faster rate compared to when they were in the hospital.

Use of a Digital Monitoring Platform to Improve Outcomes in Infants With a Single Ventricle.

BACKGROUND: Despite advances, infants with single ventricle heart disease continue to have high morbidity and mortality in the first year of life. Home monitoring programs (HMPs) have reduced mortality and have grown to use integrative digital platforms. The objective was to evaluate how implementation of a digital HMP platform affects nutritional outcomes in infants undergoing staged single ventricle palliation. METHODS: We conducted a retrospective, multicenter, observational study of all infants who required a neonatal operation as part of staged single ventricle palliation between 2013 and 2018. Patients were excluded if less than 35 weeks' gestation or underwent biventricular repair in the first year of life. Implementation of a digital monitoring platform that allows for secure monitoring of nasogastric feed advancement and oxygen saturation occurred in 2016, creating the two groups in a similar surgical era. RESULTS: There were 38 patients who fell under a standard HMP compared to 31 utilizing the digital platform. There was no difference in baseline demographics, anatomy, or preoperative factors between the groups. Use of a digital platform was associated with reduced postoperative length of stay (30.1 vs 33.1 days, P = .04). More children in the digital platform monitoring group were able to achieve oral feeding at one year of age (90% vs 68%, P = .03). A total of 25% of infants went home with a nasogastric tube, all but one transitioning to full oral feeds. CONCLUSIONS: Use of a digital, fully electronic medical record (EMR)-integrated, comprehensive HMP was associated with shorter postoperative length of stay in neonates undergoing staged single ventricle palliation and allowed for higher rates of full oral feeding.

Preventing and Mitigating SARS-CoV-2 Transmission - Four Overnight Camps, Maine, June-August 2020.

The World Health Organization declared coronavirus disease 2019 (COVID-19) a pandemic on March 11, 2020.* Shortly thereafter, closures of 124,000 U.S. public and private schools affected at least 55.1 million students through the end of the 2019-20 school year.† During the summer of 2020, approximately 82% of 8,947 U.S. overnight camps did not operate.§ In Maine, only approximately 20% of 100 overnight camps opened.¶ An overnight camp in Georgia recently reported SARS-CoV-2, the virus that causes COVID-19, transmission among campers and staff members when nonpharmaceutical interventions (NPIs) were not strictly followed (1); however, NPIs have been successfully used to mitigate SARS-CoV-2 transmission among military basic trainees (2). During June-August 2020, four overnight camps in Maine implemented several NPIs to prevent and mitigate the transmission of SARS-CoV-2, including prearrival quarantine, pre- and postarrival testing and symptom screening, cohorting, use of face coverings, physical distancing, enhanced hygiene measures, cleaning and disinfecting, and maximal outdoor programming. During the camp sessions, testing and symptom screening enabled early and rapid identification and isolation of attendees with COVID-19. Among the 1,022 attendees (staff members and campers) from 41 states, one territory, and six international locations, 1,010 were tested before arrival; 12 attendees who had completed a period of isolation after receiving a diagnosis of COVID-19 2 months before arrival were not tested. Four (0.4%) asymptomatic attendees received positive SARS-CoV-2 test results before arrival; these persons delayed their arrival, completed 10 days of isolation at home, remained asymptomatic, and did not receive any further testing before arrival or for the duration of camp attendance. Approximately 1 week after camp arrival, all 1,006 attendees without a previous diagnosis of COVID-19 were tested, and three asymptomatic cases were identified. Following isolation of these persons and quarantine of their contacts, no secondary transmission of SARS-CoV-2 occurred. These findings can inform similar multilayered public health strategies to prevent and mitigate the introduction and transmission of SARS-CoV-2 among children, adolescents, and adults in congregate settings, such as overnight camps, residential schools, and colleges.

Temperature instability in infants with trisomy 21 in the neonatal intensive care unit.

BACKGROUND: Temperature instability has been observed in infants with trisomy 21 (T21) in the neonatal intensive care unit (NICU) but has not been described in the literature. METHODS: All infants with T21 in the NICU 2011-2017 with at least 2 days of temperatures when ≥36 weeks PMA and not receiving external thermoregulation, and 2:1 matched controls were included. Prevalence and number of temperatures < 36 and >38 °C and infection workups were compared. RESULTS: Hypothermia and hyperthermia were more common among T21 infants (n = 61) vs. controls: hypothermia 30% vs. 11% (p < 0.01); hyperthermia 16% vs. 8% (p = 0.13). Infants with T21 were more likely to have infection workups at the time of temperature instability (16% vs. 6%) but only one of ten workups was diagnostic of infection. CONCLUSIONS: Temperature instability without infection is common among infants with T21 in the NICU.

Cardiopulmonary Bypass and Infant Vaccination Titers.

BACKGROUND: Infants with congenital heart disease remain vulnerable to potentially preventable pathogens. Although immunization can significantly reduce this risk, it is unknown how immunization status can be affected by cardiac surgery with cardiopulmonary bypass (CPB). The objective was to evaluate the effect of CPB on infant vaccination status after cardiac surgery. METHODS: We conducted a prospective observational study of patients between 2 and 14 months of age who had received at least their first round of infant vaccinations and who required cardiac surgery with CPB. Antibody titers were measured before CPB and again the following morning. Demographic and surgical variables were assessed via regression methods for their effects on the change in titers. RESULTS: Among the 98 patients followed, there was no demonstrated difference between the pre- and postoperative values in regard to diphtheria, tetanus, polio 1, polio 3, or Haemophilus influenzae titers. Bordetella (1.03 vs 0.84, P < .001), and hepatitis B (log 2.10 vs 1.89, P = .001) titers did reduce after CPB but did not fall below the immunized threshold. Changes in antibody titers were not associated with time between immunization and surgery, age or weight at surgery, blood products administered, number of previous doses, time on CPB, or heterotaxy diagnosis for most of the vaccines. CONCLUSIONS: Infant vaccine antibody titers were minimally affected by CPB and not associated with any easily modifiable surgical variables. Although antibody titers are only 1 marker of immunity, deviation from the recommended vaccination schedule may be unnecessary for children requiring congenital heart surgery.

Prevalence of Culture-Negative Fever in Infants With Down Syndrome Undergoing Cardiac Surgery.

BACKGROUND: Children with Down syndrome (DS) often have congenital heart disease that requires surgical repair in the first year. Anecdotally, we have noted that patients with DS seem to have a higher rate of culture-negative postoperative fever. The objective was to evaluate the prevalence of postoperative fever and recovery among patients with DS undergoing cardiac surgery. METHODS: We conducted a retrospective, case-control study of all patients at our institution less than one year of age with DS undergoing surgical repair of an atrioventricular septal defect or ventricular septal defect between 2010 and 2016. The control group was patients with no chromosomal anomalies who were age and surgery matched to the DS group. Temperatures were recorded for the first 72 hours postoperatively, with duration and degree of fever being assessed using the area under the curve. RESULTS: Patients with DS (n = 34) had a significantly higher prevalence of fever than the control group (59% vs 24%, P = .003), longer ventilator time, and longer length of stay. Among the DS group, those who developed fever tended to be older at the time of surgery (146 ± 63 vs 103 ± 45 days, P = .04). The DS group with fever had similar cardiopulmonary bypass times, intensive care unit and total lengths of stay, ventilator days, and hospital costs compared to patients with DS without fever. CONCLUSIONS: Patients with DS have a higher incidence of culture-negative fever within the first 72 hours. The presence of fever in these patients, however, does not affect their overall postoperative course.

Trajectory of right ventricular indices is an early predictor of outcomes in hypoplastic left heart syndrome.

BACKGROUND: Children with hypoplastic left heart syndrome (HLHS) have risk for mortality and/or transplantation. Previous studies have associated right ventricular (RV) indices in a single echocardiogram with survival, but none have related serial measurements to outcomes. This study sought to determine whether the trajectory of RV indices in the first year of life was associated with transplant-free survival to stage 3 palliation (S3P). METHODS: HLHS patients at a single center who underwent stage 1 palliation (S1P) between 2000 and 2015 were reviewed. Echocardiographic indices of RV size and function were obtained before and following S1P and stage 2 palliation (S2P). The association between these indices and transplant-free survival to S3P was examined. RESULTS: There were 61 patients enrolled in the study with 51 undergoing S2P, 20 S3P, and 18 awaiting S3P. In the stage 1 perioperative period, indexed RV end-systolic area increased in patients who died or needed transplant following S2P, and changed little in those surviving to S3P (3.37 vs -0.04 cm2 /m2 , P = .017). Increased indexed RV end-systolic area was associated with worse transplant-free survival. (OR = 0.815, P = .042). In the interstage period, indexed RV end-diastolic area increased less in those surviving to S3P (3.6 vs 9.2, P = .03). CONCLUSION: Change in indexed RV end-systolic area through the stage 1 perioperative period was associated with transplant-free survival to S3P. Neither the prestage nor poststage 1 indexed RV end-systolic area was associated with transplant-free survival to S3P. Patients with death or transplant before S3P had a greater increase in indexed RV end-diastolic area during the interstage period. This suggests earlier serial changes in RV size which may provide prognostic information beyond RV indices in a single study.

The effect of congenital diaphragmatic hernia on the development of left-sided heart structures.

INTRODUCTION: Patients with congenital diaphragmatic hernias often have concomitant congenital heart disease (CHD), with small left-sided cardiac structures as a frequent finding. The goal of this study is to evaluate which left-sided heart structures are affected in neonates with congenital diaphragmatic hernias. METHODS: Retrospective review of neonates between May 2007 and April 2015 with a diagnosis of a congenital diaphragmatic hernia was performed. Clinical and echocardiographic data were extracted from the electronic medical record and indexed to body surface area and compared to normative values. Univariable regression models assessed for associations between different variables and length of stay. RESULTS: Data of 52 patients showed decreased mean z scores for the LVIDd (-3.16), LVIDs (-3.05), aortic annulus (-1.68), aortic sinuses (-2.11), transverse arch (-3.11), and sinotubular junction (-1.47) with preservation of the aorta at the diaphragm compared to age-matched normative data with similar body surface areas. Regression analysis showed a percent reduction in length of stay per 1 mm size increase for LVIDd (8%), aortic annulus (27%), aortic sinuses (18%), sinotubular junctions (20%), and transverse arches (25%). CONCLUSIONS: Patients with congenital diaphragmatic hernias have significantly smaller left-sided heart structures compared to age-matched normative data. Aortic preservation at the diaphragm provides evidence for a mass effect aetiology with increased right-to-left shunting at the fetal ductus resulting in decreased size. Additionally, length of stay appears to be prolonged with decreasing size of several of these structures. These data provide quantitative evidence of smaller left-sided heart structures in patients with congenital diaphragmatic hernias.

The effect of right ventricular function on survival and morbidity following stage 2 palliation: An analysis of the single ventricle reconstruction trial public data set.

OBJECTIVE: Limited information is known on how right ventricular function affects outcomes after stage 2 palliation. We evaluated the impact of different right ventricular indices prior to stage 2 palliation on morbidity and mortality. DESIGN: Retrospective study design. SETTING: Pediatric Heart Network Single Ventricle Reconstruction Trial Public Data Set. PATIENT: Any variant of stage 1 palliation and all anatomic hypoplastic left heart syndrome variants in the trial were evaluated. Echocardiograms prior to stage 2 palliation were analyzed and compared between those who failed and those who survived. INTERVENTION: None. OUTCOME MEASURES: Mortality was defined as death, listed for transplant, or transplanted after stage 2 palliation. Morbidity was evaluated as hospital length of stay and duration of intubation. RESULTS: A total of 283 patients met criteria for analysis. Of those, only 18 patients failed stage 2. Right ventricular fractional area change was less in those who failed (30% vs 34%, P = .039) and right ventricular indexed end-diastolic volume and end-systolic volume were larger in those who failed (142.74 mL/ BSA1.3 vs 111.29 mL/BSA1.3 , P = .023, 88.45 mL/ BSA1.3 vs 62.75 mL/ BSA1.3 , P = .025, respectively). Larger right ventricular indexed end-diastolic and systolic volumes were associated with failure (OR 1.17 [1.01-1.35] P = .021, OR 1.25 [1.03-1.52] P = .021, respectively). Every 10% increase in RV ejection fraction had a 63% decrease in length of stay and a 68% decrease in duration of intubation (P = .014, and P = .039, respectively). CONCLUSION: Patients with decreased right ventricular fractional area change and larger right ventricular indexed end-diastolic and systolic volumes were more likely to fail stage 2 palliation. Those with preserved right ventricular function had a shorter hospital length of stay and duration of intubation. Echocardiographic measurements of right ventricular indices during the interstage period can be utilized to determine the prognosis following stage 2 palliation.

Effects of Gestational Age on Early Survivability in Neonates With Hypoplastic Left Heart Syndrome.

Prematurity increases pre- and postoperative mortality in children with congenital heart disease. There are no large, multicentered, studies that have evaluated this relation specifically in neonates with hypoplastic left heart syndrome (HLHS). We sought to determine the impact of gestational age (GA) on survival to Stage 1 palliation surgery and hospital discharge in infants with HLHS. We reviewed data from 1,913 neonates with HLHS born at or transferred to a Vermont Oxford Network expanded member hospital in the United States from 2009 to 2014. Demographic, diagnostic, and surgical codes, and outcome data within the Vermont Oxford Network database were used to determine the effect of GA and birth weight on survival to Stage 1 palliation surgery and hospital discharge. Risk models were developed controlling for common confounders to determine the relative risk of GA on the observed outcomes. These data demonstrate that, when compared with 39-week infants, those born at earlier GA were less likely to survive until surgery; <34 weeks adjusted risk ratio (ARR) for survival: 0.47 (95% confidence interval 0.37 to 0.60), 34 to 35 weeks ARR 0.73 (0.62 to 0.87), and 36 to 37 weeks ARR 0.88 (0.83 to 0.94). Higher GA also positively correlated with survival to hospital discharge, although there was no difference in 34 to 35-week infants and 36 to 37-week infants. In conclusion, these data show that GA was an independent risk factor for survival to Stage 1 palliation surgery and survival to hospital discharge. However, there is no significant difference in survival to hospital discharge between infants born in 34 to 37 weeks gestation.

Predictive Factors for Central Line-Associated Bloodstream Infections in Pediatric Cardiac Surgery Patients With Chylothorax.

OBJECTIVES: To assess the prevalence of central line-associated bloodstream infections in pediatric patients with and without chylothorax after cardiac surgery and identify risk factors that predict those patients at highest risk for developing a central line-associated bloodstream infection. DESIGN: Retrospective single-center cohort study. SETTING: A PICU located within a tertiary-care academic pediatric hospital. PATIENTS: All pediatric patients admitted to the PICU after cardiac surgery between 2008 and 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified 1,191 pediatric cardiac surgery patients in the study time frame, of which 66 (5.5%) had chylothorax. Patients with chylothorax were more likely to have a central line-associated bloodstream infection (23% vs 3.8%; p < 0.001). Patients with both chylothorax and central line-associated bloodstream infection had longer durations of central venous catheter, higher Risk Adjustment Congenital Heart Surgery score, longer PICU stay, and higher mortality compared with patients with chylothorax who did not have a central line-associated bloodstream infection. Multivariable analysis identified higher Risk Adjustment Congenital Heart Surgery score, longer duration of central venous catheter, and higher chest tube output at 24 hours after initiating treatment for chylothorax to be predictive of increased central line-associated bloodstream infection risk in patients with chylothorax. CONCLUSIONS: The prevalence of central line-associated bloodstream infection is higher in pediatric patients with chylothorax after heart surgery. In patients with chylothorax, complexity of surgery, central venous catheter duration, and chest tube output are associated with increased risk for developing a central line-associated bloodstream infection. Using this knowledge will allow us to identify patients at increased risk for central line-associated bloodstream infections and to focus extra prevention efforts on them.