Joyce T. Johnson

National variation in the use of tracheostomy in patients with congenital heart disease

Objectives: The postsurgical care of children with congenital heart disease may be complicated by the need for cardiorespiratory support, including tracheostomy. The variation of the use of tracheostomy across multiple pediatric cardiac surgical centers has not been defined. We describe multicenter variation in the use of tracheostomy in children undergoing congenital heart surgery. Design: We retrospectively analyzed a multicenter cohort. Setting: Pediatric Health Information Systems database retrospective cohort. Patients: Children less than 18 years who underwent both tracheostomy and cardiac surgery (1/04–6/14). Interventions: Univariate and multivariate statistics were performed, stratifying by high (≥ 75th percentile) and low (⩽ 25th percentile) tracheostomy volume and adjusting for patient characteristics in multivariate models. Measurements and Main Results: Out of 123,510 hospitalizations involving cardiac surgery, 1,292 tracheostomies (1.2%) were performed (46 hospitals). The rate of tracheostomy placement ranged from 0.3% to 2.5% with no difference in the rate of tracheostomy placement between high and low tracheostomy use centers (p = 0.8). The median time to tracheostomy was 63 days (interquartile range, 36–100), and there was no difference between high- and low-tracheostomy centers. High-tracheostomy centers had

Admission to dedicated pediatric cardiac intensive care units is associated with decreased resource use in neonatal cardiac surgery

420,000 lower hospital charges than low-volume centers (p = 0.03). Tracheostomy day greater than the median (63 d), Risk Adjustment for Congenital Heart Surgery-1 score 6, and extracorporeal membrane oxygenation were significantly associated with adjusted increased odds of mortality. Later hospital day of tracheostomy was associated with a

Acute and midterm results following perventricular device closure of muscular ventricular septal defects: A multicenter PICES investigation

13,000/d increase in total hospital charges (p < 0.001). Conclusions: Variation in the usage of tracheostomy in infants and children undergoing congenital heart surgery exists across the country. High-tracheostomy centers had lower hospital charges. Late tracheostomy placement, higher congenital heart disease surgical risk, and extracorporeal membrane oxygenation use are independent predictors of in-hospital mortality in this population.

Brom Aortoplasty for Supravalvular Aortic Stenosis

Objective: Neonates undergoing congenital heart surgery require highly specialized, resource‐intensive care. Location of care and degree of specialization can vary between and within institutions. Using a multi‐institutional cohort, we sought to determine whether location of admission is associated with an increase in health care costs, resource use and mortality. Methods: We retrospectively analyzed admission for neonates (<30 days) undergoing congenital heart surgery between 2004 and 2013 by using the Pediatric Health Information Systems database (44 childrens hospitals). Multivariate generalized estimating equations adjusted for center‐ and patient‐specific risk factors and stratified by age at admission were performed to examine the association of admission intensive care unit (ICU) with total hospital costs, mortality, and length of stay. Results: Of 19,984 neonates (60% male) identified, 39% were initially admitted to a cardiac ICU (CICU), 48% to a neonatal ICU (NICU), and 13% to a pediatric ICU. In adjusted models, admission to a CICU versus NICU was associated with a

Cardiovascular and general health status of adults with Trisomy 21

20,440 reduction in total hospital cost for infants aged 2 to 7 days at admission (P = .007) and a

DOES LOCATION OF ADMISSION AFFECT RESOURCE UTILIZATION AND OUTCOME AFTER NEONATAL CARDIAC SURGERY? A MULTI-CENTER STUDY

23,700 reduction in total cost for infants aged 8 to 14 days at admission (P = .01). Initial admission to a CICU or pediatric ICU versus NICU at <15 days of age was associated with shorter hospital and ICU length of stay and fewer days of mechanical ventilation. There was no difference in adjusted mortality by admission location. Conclusions: Admission to an ICU specializing in cardiac care is associated with significantly decreased hospital costs and more efficient resource use for neonates requiring cardiac surgery.

GASTROINTESTINAL COMPLICATIONS IN PATIENTS WITH A FONTAN CIRCUIT

To describe acute and mid‐term results of hybrid perventricular device closure of muscular ventricular septal defects (mVSDs).

Lifetime Cardiac Reinterventions Following the Fontan Procedure

Background: Controversy remains regarding the optimal surgical approach for children with supravalvular aortic stenosis (SVAS). Methods: Since 1997 we have used Brom three-patch aortoplasty for patients with SVAS. We prefer computed tomography (CT) imaging for preoperative evaluation rather than cardiac catheterization as it avoids the well-known morbidity of general anesthesia. The purpose of this study was to present our intermediate-term results of this strategy. Results: Twenty consecutive patients with SVAS were treated with Brom aortoplasty. Mean age was 3.7 ± 5.9 years (median, 1.5 years). Twelve patients had Williams syndrome. Ten patients had preoperative advanced medical imaging (seven CT, three magnetic resonance imaging) and did not have cardiac catheterization. Mean times for cardiopulmonary bypass and cross-clamp were 172 ± 29 minutes and 110 ± 21 minutes, respectively. Ten patients had simultaneous pulmonary artery stenosis patching. Median length of stay was seven days. There was no operative or late mortality. Mean follow-up was 6 ± 5 years. There were no reoperations on the aortic root. Fifteen patients had mild or less aortic insufficiency (AI) and two had moderate AI. One patient who had infant balloon dilation of the aortic valve and postoperative subacute bacterial endocarditis had moderate-to-severe AI and aortic stenosis (AS). One patient had moderate residual SVAS; all others had no AS. No patients had late coronary insufficiency. Conclusion: Brom aortoplasty promotes restoration of normal aortic root geometry and relief of coronary ostial stenosis, which is important in preventing myocardial ischemia. Computed tomography imaging is our preferred diagnostic modality. Intermediate-term outcomes are excellent with no recurrent SVAS, coronary events, or reoperations on the aortic valve.

The Effect of Image Review before Patient Discharge on Study Completeness and Sonographer Job Satisfaction in a Pediatric Echocardiographic Laboratory

BACKGROUND Patients with Trisomy 21 are now living well into adulthood. Little data exists to assist the cardiologist in the care of these patients. We sought to examine the cardiac and general health status of adults with Trisomy 21 undergoing cardiac evaluation. METHODS & RESULTS A retrospective review of all affected adults >21years followed at 2 tertiary care institutions was performed. Of 193 patients identified, median age was 31 (range 21.1-60.5) years. Cardiac surgery was performed in childhood in 127 with 30 patients who did not undergo surgery developing Eisenmenger syndrome. The remaining 36 patients did not warrant early surgical intervention. Six patients were lost to follow-up. Significant cardiac residua were present in 117 (62%). Arrhythmias were present in 53 (28%) with 15 having atrial fibrillation (8%). Non-cardiac comorbidities were common and included sleep apnea, pulmonary hypertension, thyroid dysfunction, thromboses and recurrent infections. Hospitalization in adulthood occurred in 58 patients (51%); pneumonia and cardiac related surgeries being the most common reasons for hospitalization. Average age of death (n=23) was 39.8±8.5years. Transition of care to an adult provider was uncommon occurring in 54 (27%) patients. On multivariate analysis, presence of younger age and absence of pulmonary hypertension were the sole predictors of survival for the group as a whole, as well as those patients without Eisenmenger syndrome. CONCLUSIONS Adults with Trisomy 21 have frequent cardiac and non-cardiac co-morbidities. Cardiologists caring for these patients should be familiar with the adult acquired medical problems these patients encounter.

Admission to a Dedicated Cardiac Intensive Care Unit Is Associated With Decreased Resource Use for Infants With Prenatally Diagnosed Congenital Heart Disease

Neonatal cardiac surgeries are resource intensive with high costs and significant hospital lengths of stay (LOS). Location of inital admission unit may impact resource use and outcomes. Understanding this relationship may allow modifications to improve efficiency. We compared resource use, costs,