ABSTRACT
Background Surgical strategies to achieve biventricular (BiV) repair in children with borderline left ventricle (LV) continue to evolve. We report our innovative strategy of LV recruitment utilizing systemic to pulmonary artery shunt upsizing along with fenestrated atrial septation (FAS). Case The case is a 22mo old with hypoplastic left heart variant with type A aortic arch interruption and bilateral SVC. The LV, aortic and mitral valve were hypoplastic not meeting criteria for BiV repair. He underwent stage 1 palliation (Norwood with 4mm BTT shunt). Frequent COVID infections and over-circulation led to BiV dysfunction and cardiogenic shock requiring ECMO support for 4 days. At 5 months of age cardiac catheterization (CC) revealed good hemodynamic parameters for a stage 2 Glenn. An MRI also revealed growth of the left ventricle. Decision-making A decision was made to engage in a staged LV recruitment process to achieve BiV repair. We elected to avoid a volume offloading procedure in the form of a Glenn. To optimize continued volume loading on the LV, Stage 2 palliation consisted of upsizing to a 5mm BTT shunt with 4mm FAS. MRI at 22 months showed an LV volume of 60ml/m2 associated with CC hemodynamics showing LA pressure of 13mmHg, and LV end-diastolic pressure of 12mmHg. He underwent BiV repair with takedown of DKS, with primary anastomosis of the aorta and the pulmonary artery to their respective circulations. The postoperative echocardiogram illustrated a gradient of 5mmHg and 3mmHg through the mitral and aortic valve respectively. The pt was placed on a beta blocker and discharged on day 5 following BiV conversion. This strategy provides increased pulmonary blood flow with increased bloodflow across the mitral valve and inflow into the LV. In so doing may enhance the rate of LV growth. Furthermore, this strategy avoids the bidirectional Glenn (BDG), a volume offloading operation. Conclusion Shunt upsizing with FAS is well tolerated. It has the potential advantage for fewer operations to achieve BiV circulation due to rapid LV growth in comparison to other staged LV recruitment strategies involving the BDG.Copyright © 2023 American College of Cardiology Foundation
ABSTRACT
Background: During the initial surge of the COVID-19 pandemic in the spring and summer of 2020, pediatric heart centers were forced to rapidly alter the way patient care was provided in order to minimize interruption to patient care as well as exposure to the virus. In this study, we used a survey-based approach to characterize the changes that occurred in pediatric cardiology practices across the country during and just following the initial peak of COVID-19. Methods: In this survey based descriptive study we characterize changes that occurred within pediatric cardiology practices across the United States and describe provider experience and attitudes towards these changes during the pandemic. decision making during this period. This survey was emailed to an existing list serve of American Academy of Pediatrics Section on Cardiology and Cardiothoracic Surgery (AAP:SOCCS) members. Recipients of the survey included pediatric cardiologists, cardiothoracic surgeons, and fellows-intraining. The questionnaire was initially distributed in June 2020 and was active through August 2020. Results: Surveys were returned by 79 participants across 28 states. Areas of practice of respondents included general cardiology, non-invasive imaging, electrophysiology, heart failure/transplant, interventional cardiology, and adults with congenital heart disease. Common changes that were implemented included decreased numbers of procedures, limiting visitors, and shifting towards telemedicine encounters. There was a high level of satisfaction among providers with telemedicine encounters and a variety of platforms were utilized. Echocardiography was less likely to be performed during the pandemic as compared to prior to the pandemic in nearly all clinical scenarios presented. More than half of respondents expressed concerns about financial stability with regards to personal or practice situation but most were not frequently concerned about their personal safety. Conclusion: Pediatric cardiology practice across the country was heavily impacted by COVID-19 and required many adaptations including minimization of non-essential procedures and increasing use of telemedicine. Providers were generally satisfied with telemedicine and utilized several platforms. Financial concerns were common;however, most participants were not frequently concerned about personal safety. Inter-institutional collaboration could be useful in creating standardized protocols based on shared experiences that could be rapidly implemented in future public health crises. Experience with Telemedicine. A) Barriers to implementing telemedicine. B) Provider rated effectiveness of telemedicine. C) Home monitoring devices used as part of telemedicine program. D) Provider satisfaction vs perceived patient satisfaction with telemedicine encounters. Likelihood of Performing Echocardiography Prior to and During COVID-19 Pandemic. Participants were asked to rate the likelihood for each scenario as always, frequently, occasionally, or never. Responses were converted to a 5-point scale. Pre- and post- responses were analyzed using Wilcoxon signed-rank test. Significant decreases in likelihood of echocardiography were found in nearly all situations.