Faculty Bibliography

OBJECTIVES/OBJECTIVE:To discover distinct clusters of morphologic features within the spectrum of complete atrioventricular septal defect (cAVSD) among children who underwent biventricular repair (BVR), and determine their association with post-repair mortality and left atrioventricular valve (LAVV) reintervention. METHODS:From 1/1/2012 to 7/1/2024, 685 children with cAVSD enrolled across 34 Congenital Heart Surgeons' Society hospitals underwent BVR and had core laboratory analysis of a preintervention echocardiogram. Morphologic clusters were identified by unsupervised staggered interaction distance clustering. Median follow-up for mortality and LAVV reintervention was 4.1 and 3.3 years, with 10% of each followed >8.4 and >7.7 years, respectively. RESULTS:versus 12 in D, 13 in C, and 14 in A. Mortality at 1 and 8 years was 5.5% and 9.1% in B, 5.4% and 6.9% in D, 4.6% and 9.7% in C, and 4.5% and 11% in A. LAVV reintervention at 1 and 8 years was 8.4% and 14% in B, 7.4% and 15% in D, 9.3% and 14% in C, and 6.7 and 15% in A. CONCLUSIONS:Preintervention echocardiographic features identify 4 morphologic clusters of cAVSD. Associations with survival and LAVV reintervention after BVR provide knowledge that may guide decision-making in surgical management of "borderline" hearts.

OBJECTIVE/UNASSIGNED:The arterial switch operation (ASO) is the standard repair for d-transposition of the greater arteries, although coronary reimplantation remains technically complex and carries the risk of both early and late complications. Coronary ostial plasty for late stenosis has been described using various patch materials, each with its own advantages and limitations. However, the optimal patch material remains unclear. METHODS/UNASSIGNED:We report 2 cases of symptomatic late left main coronary artery (LMCA) stenosis after ASO in young adults with complex coronary artery. Both patients underwent coronary ostial plasty in which a femoral artery homograft patch was used. The patients' preoperative presentation, imaging findings, operative details, and postoperative course are reviewed. RESULTS/UNASSIGNED:Case 1 was a 22-year-old man with a single coronary artery arising from the right anterior sinus and >75% LMCA ostial stenosis. Case 2 was a 25-year-old young man with interarterial LMCA atresia and collateralization from a dominant right coronary artery. In both cases, surgical repair involved extending the aortotomy into the LMCA and performing ostial plasty using a femoral artery homograft patch. Both patients had uneventful recoveries and remain asymptomatic with excellent functional status. CONCLUSIONS/UNASSIGNED:Late coronary artery stenosis is a recognized complication after ASO, particularly in patients with complex coronary anatomy. Although multiple patch materials have been used for ostial plasty, each has drawbacks. Femoral artery homograft may represent a promising alternative in these challenging anatomical settings.

BACKGROUND/UNASSIGNED:Polytetrafluoroethylene (PTFE), traditionally used for construction of Blalock-Taussig-Thomas (BTT) shunt, is associated with complications such as perioperative bleeding, thrombosis, and stenosis. Saphenous vein homografts (SVHs) are theoretically more hemostatic and less thrombogenic. METHODS/UNASSIGNED:A retrospective chart review was conducted of all infants who underwent BTT shunt placement between January 2015 and May 2023 to compare the use of blood and blood products in the operating room and within the first 24 hours after cardiac intensive care unit admission. Morbidity (unplanned reoperations, extracorporeal membrane oxygenation requirement, or dialysis) was also compared. RESULTS/UNASSIGNED:= .004) with SVH. There were no group differences in rate of shunt thrombosis or need for percutaneous intervention. Interstage mortality (8% vs 13%) and morbidity (8% vs 10%) were similar, as were hemodynamic data before shunt takedown. CONCLUSIONS/UNASSIGNED:SVH as BTT shunt is associated with significantly less perioperative bleeding compared with PTFE, with no differences in risk of thrombosis or need for percutaneous intervention.

The use of prostaglandin infusion to maintain patency of the ductus arteriosus in patients with critical coarctation of the aorta (CoA) to support systemic circulation is the standard of care. However, pulmonary overcirculation resulting from a patent ductus arteriosus in patients with critical CoA is not well described in the literature. We report two cases of critical CoA that required invasive measures to control pulmonary blood flow before surgical repair of the CoA. Both patients had signs of decreased oxygen delivery, hyperlactatemia, and systemic to pulmonary flow via the ductus arteriosus. One patient required surgical pulmonary artery banding and the second patient underwent pulmonary flow restrictor device placement for the control of pulmonary blood flow. A rapid improvement in oxygen delivery and normalization of lactate levels were observed after control of pulmonary overcirculation. Both patients underwent successful surgical repair of the coarctation A and were discharged home.

Extracorporeal life support (ECLS) therapy is increasingly being used to support children with refractory cardiorespiratory failure, but its use is occasionally associated with complications.1 Neonatal aortic dissection in association with ECLS is rare and the clinical sequelae of aortic dissection in neonates are poorly understood. We report a case of extensive type B aortic dissection in a neonate receiving ECLS therapy for refractory cardiogenic shock secondary to tachycardia-induced cardiomyopathy and Wolf Parkinson White (WPW) syndrome. The patient was noted to have aortic dissection along with multiple abdominal organ ischemic injury a day after ECLS arterial cannula position adjustment. The patient was rapidly decannulated from ECLS and the aortic dissection was managed conservatively with good outcome. We discuss our approach and rationale behind conservative management of this rarely reported complication associated with ECLS therapy and discuss available literature.

BACKGROUND:Despite documented associations between social determinants of health and outcomes post-congenital heart surgery, clinical risk models typically exclude these factors. OBJECTIVES/OBJECTIVE:The study sought to characterize associations between social determinants and operative and longitudinal mortality as well as assess impacts on risk model performance. METHODS:Demographic and clinical data were obtained for all congenital heart surgeries (2006-2021) from locally held Congenital Heart Surgery Collaborative for Longitudinal Outcomes and Utilization of Resources Society of Thoracic Surgeons Congenital Heart Surgery Database data. Neighborhood-level American Community Survey and composite sociodemographic measures were linked by zip code. Model prediction, discrimination, and impact on quality assessment were assessed before and after inclusion of social determinants in models based on the 2020 Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model. RESULTS:Of 14,173 total index operations across New York State, 12,321 cases, representing 10,271 patients at 8 centers, had zip codes for linkage. A total of 327 (2.7%) patients died in the hospital or before 30 days, and 314 children died by December 31, 2021 (total n = 641; 6.2%). Multiple measures of social determinants of health explained as much or more variability in operative and longitudinal mortality than clinical comorbidities or prior cardiac surgery. Inclusion of social determinants minimally improved models' predictive performance (operative: 0.834-0.844; longitudinal 0.808-0.811), but significantly improved model discrimination; 10.0% more survivors and 4.8% more mortalities were appropriately risk classified with inclusion. Wide variation in reclassification was observed by site, resulting in changes in the center performance classification category for 2 of 8 centers. CONCLUSIONS:Although indiscriminate inclusion of social determinants in clinical risk modeling can conceal inequities, thoughtful consideration can help centers understand their performance across populations and guide efforts to improve health equity.