Venovenous extracorporeal membrane oxygenation and late ductal stenting for infant with transposition of the great arteries, pulmonary stenosis and SARS, -CoV-2 pneumonia

Introduction: The SARS-CoV-2 pandemic has affected medical decision-making in all practice areas, including the pediatric cardiac intensive care unit (CICU), sometimes necessitating the use of innovative management strategies. Venovenous extracorporeal membrane oxygenation (VV-ECMO) and, particularly, late ductal stenting are infrequently applied interventions in the CICU. Here we present a critically ill infant with d-transposition of the great arteries (d-TGA), ventricular septal defect (VSD), pulmonary stenosis (PS), and patent ductus arteriosus (PDA), in which VV-ECMO and late ductal stenting were utilized successfully in the setting of active SARS-CoV-2 infection to treat worsening PS and pulmonary venous desaturation, thereby delaying surgical intervention and its associated risks during active infection. Case Description: A 3 month old male with d-TGA, VSD, and PS, initially managed with a balloon atrial septostomy at birth, was admitted to the CICU after presenting with respiratory distress and hypoxemia. He was found to be SARS-CoV-2 positive, requiring only nasal cannula initially. Admission echocardiogram demonstrated known d-TGA, VSD, severe pulmonary stenosis (peak gradient 95-110mmHg), unrestrictive atrial communication, and preserved systolic function. A tiny, hemodynamically insignificant PDA was also noted. While admitted, the patient exhibited intermittent, severe desaturations requiring escalating respiratory support. He was started on a prostaglandin infusion with aim to promote additional pulmonary blood flow through the PDA, thereby limiting the severity and frequency of desaturations. However, the patient ultimately became severely hypoxemic, despite multiple interventions to improve oxygenation. Echocardiogram at this time demonstrated preserved ventricular function, so the decision was made to escalate to VVECMO therapy. Following ECMO cannulation, the patient's hypoxemia quickly resolved, and he remained hemodynamically stable. Given the persistence of his PDA and the desire to avoid the risks of cardiac surgery in the setting of acute COVID infection, percutaneous intervention to augment pulmonary blood flow was attempted. Despite its diminutive size, his PDA was able to be successfully cannulated and stented the day after ECMO initiation. He was able to be quickly weaned from ECMO support and was decannulated the following day. He was subsequently extubated and ultimately discharged home with planning for definitive surgical intervention underway. Discussion(s): Here we present an interesting case of an infant with d-TGA, VSD, PS, and PDA in which VV-ECMO and PDA stenting were successfully applied to treat acute hypoxemia in the setting of SARS-CoV-2 infection and severe pulmonary stenosis. These therapies may be considered in appropriate patients for whom the risks of cardiac surgery are significant.

Impact of coronavirus disease 2019 on adult patients with congenital heart disease

Background: COVID-19 is responsible for a worldwide pandemic, causing more than 18,000 deaths to date in Portugal. Data already exists regarding the increased risk of adverse events in patients with cardiovascular diseases, however the impact of SARS-CoV-2 infection in patients (P) with congenital heart disease (CHD) is still under investigation. Purpose(s): To study the impact of COVID-19 in a adult patients with CHD Methods: Adult patients seen at the CHD outpatient's clinic at a tertiary centre, who became infected with SARS-CoV-2 infection up to December 2021 were included. Assessment of patients' symptoms, need for hospitalization and admission in an intensive care unit was assessed based on medical records. Result(s): We identified seventy-nine patients (pts) with COVID-19 infection. Symptoms were present in 67 (84%). The median age was 44 (15) years, 52% were females. Eight P (10%) had complex cyanotic disease;seven Tetralogy of Fallot;five (6%) transposition of great arteries;eight (10%) right ventricle obstacle;two (3%) atrioventricular canal defect;sixteen (20%) atrial septal defect;nine (11%) ventricular septal defect;eight (10%) aortic coarctation;two (3%) had Eisenmenger syndrome. 49% of P had previous surgery or percutaneous procedure. 63% of P were at New York Heart Association (NYHA) class of I and 30% at NYHA II. Mild symptoms were reported by 56 P (71%). Ten adults (7,9%) experienced moderate symptoms (dyspnea and hypoxia) that led to hospitalization for oxygen therapy, none required mechanical ventilation. One death was reported in an 83-year-old patient with non-corrected interventricular communication and compromised biventricular function. There was a significant association between the gravity of CHD and hospitalizations (p=0.02). Conclusion(s): Our pts had mainly mild to moderate symptoms and did not appear to have a disproportionately negative outcome;the need for hospitalization was more frequent in patients with higher CHD gravity. These findings are in line with the emerging data regarding COVID-19 in CHD P, and may be in part explained by the patient's young age and functional status.

Nutritional Experiences of Parents of Children Who Had Gastric Transposition Surgery.

This study aimed to understand the postoperative nutritional experiences of parents of children who had undergone gastric transposition surgery after corrosive esophageal injury. The study had a descriptive qualitative research design, and used a structured interview form as a result of the COVID-19 pandemic. The population of the study consisted of the parents of 12 children who had undergone gastric transposition surgery at the pediatric surgery clinic of a university hospital in an urban area in Turkey. Thematic analysis was conducted on the transcripts using the MAXQDA program. Four main themes emerged and five supporting sub-themes were identified. The main themes were what we experienced in the postoperative nutrition process, coping with how we live, what we want to know, and our recommendations to healthcare professionals. Family-centered care should be a main focus when caring children who have had gastric transposition surgery, and children and their parents should be supported by a multidisciplinary team.

Assessment in mathematics: a study on teachers' practices in times of pandemic.

Lockdowns imposed by many countries on their populations at the beginning of the COVID-19 crisis forced teachers to adapt quickly and without adequate preparation to distance teaching. In this paper, we focus on one of the most formidable challenges that teachers faced during the lockdowns and even in the post-lockdown emergency period, namely, developing assessment that maintains the pedagogical continuity that educational institutions typically require. Based on the results of a previous study, focused on the analysis of answers to an open-ended questionnaire administered to a population of 700 teachers from France, Germany, Israel and Italy, a semi-structured interview series was designed and implemented by the authors of this paper with a small group of teachers. The transcripts of these interviews were analysed according to the interpretative phenomenological analysis methodology, with the aim of investigating teachers' own perspectives on the following: (a) the difficulties with which they had to contend, with respect to the question of assessment; (b) the techniques adopted to deal with these difficulties; and (c) the ways in which the lockdown experience could affect the future evolution of teachers' assessment practices. This analysis supported us in formulating hypotheses concerning the possible long-term effects of lockdown on modes of assessment in mathematics.

Public perception of microorganisms and microbiology education: a need for enhancing society's microbiology literacy

Understanding the public perception of health risk and trust in information sources is a matter of great relevance, especially nowadays with conflicting messages from different agencies, media and social platforms causing unnecessary scares and creation of inappropriate risk perceptions by the public. The example of SARS-CoV-2 and COVID-19 pandemic social messages influencing public perception is used in this chapter to understand the notion of conceptions and social representations, and their implications in education, particularly in microbiology education. Didactic transposition applied to SARS-CoV-2 and COVID-19 pandemic is discussed based on the KVP model (Knowledge, Values and Practices), and common pupils' perception of microorganisms is described. Special attention is given to the need for reinforcing microbiology in national curricula and providing students' positive experiences in microbiology learning, including hands-on and experimental activities. Museums, scientific societies and scientific journals enthusiastic activities provide citizens' knowledge and awareness about microorganisms and contribute to enhancing society's microbiology literacy. © 2022 Elsevier Inc. All rights reserved.

"EU INVEST PROGRAM" - FINANCING UNION MECHANISM OF MEMBER STATES FOR POST-PANDEMIC ECONOMIC RECOVERY

This research material aims to approach from an analytical perspective the implications that the implementation of the InvestEU Program generates at the level ofthe European Union. The Union framework rule governing this program and its implications at Member State level is Regulation (EU) 2021/523 of the European Parliament and of the Council of 24 March 2021 establishing the "InvestEU Program" and amending Regulation (EU) 2015/1017. Specifically, the InvestEU Program contributes to the achievement of some of the objectives proposed by the Union coordinator in terms of energy effectiveness1, in the field of investments in the infrastructure of the European Union, especially in the creation of a unique transport space, in the field of sustainable infrastructure policy, regarding funding for innovation, research and digitization. All these goals are considered essential for achieving the Union's sustainable development goals committed by the European Commission under the leadership of President Ursula von der Leyer in the 2030 Agenda for Sustainable Development. The research methods used in the research are: a) the logical-concretized method by using the union framework norms as well as the internal transposition norms as a source of information and analysis;b) comparative method - in order to carry out a comparative analysis of the main financing mechanisms at Member State level.

Detrimental Intrauterine Stress Exposure and Post-natal Outcomes in Prenatally Diagnosed Congenital Heart Disease

Background: Prenatal diagnosis of congenital heart disease (CHD) is a stressful event that leads to anxiety, depression and traumatic stress in expectant parents. Cortisol is elevated in times of stress, and when present in mothers, crosses the placenta and leads to suppression of the fetus' own production of cortisol. When those neonates go on to require stressful procedures in the first months of life, some are unable to effectively mount a cortisol mediated stress response which can lead to poor outcomes and even death. We sought to investigate the relationship between maternal stress during pregnancy, and neonatal outcomes. Methods: We conducted a retrospective chart review of pregnancies complicated by a fetal diagnosis of critical CHD (including transposition of the great arteries, tetralogy of Fallot, total anomalous pulmonary venous return, and coarctation) who were born between 5/1/2019 and 5/1/2021. Maternal data included demographics and medical comorbidities. Composite maternal prenatal stress score (PSS) was calculated based upon 1) prenatal mental health diagnoses, 2) housing/food insecurity 3) income insecurity, 4) social support/child care, 5) legal involvement, 6) transportation issues and 7) other stressors. Categories ranged from 0 (no concerns) to 3 (significant concerns). Infant charts were reviewed for postnatal, and post-operative outcomes including infection, inotropic support, and exogenous steroid treatment. Results: 41 maternal-fetal dyads met inclusion criteria. Demographic and catheter based intervention at a median of 8 (2-54) days of life. 13 patients had single ventricle anatomy (8 initial surgical palliation, 5 catheterization). Mothers with higher composite PSS were more likely to have infants that required steroids after CHD surgery compared to mothers with lower scores (p=.01) (figure 1). Surgical patients needing bypass were more likely to require post-operative steroids than those not requiring bypass (18/22 vs 0/4, p<.005). None of the catheter-based interventions (including those with high risk single ventricle anatomy) required steroids (p <.0001). Maternal individual stress sub-categories, severity of prenatal CHD diagnosis, and counseling during the COVID-19 era did not correlate with steroid treatment. Finally, PSS did not correlate with individual outcomes such as birthweight, inotropic support, infection or hypoglycemia. Conclusion: Maternal prenatal stress is multifactorial and higher composite maternal prenatal stress scores are correlated with post-bypass steroid requirements, suggesting that a stressful intrauterine environment can be associated with worse postoperative outcomes for the neonate.

An Unexpected Occurrence of Malignancy in a Patient After a Fontan Operation.

An 18-year-old male with complex single ventricle physiology status post Fontan and Kawashima procedures who presented with progressive dyspnea was found to have severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), rhinovirus, and a new retroperitoneal mass. Biopsy of the retroperitoneal mass revealed a mixed germ cell tumor with areas consistent with choriocarcinoma. Imaging showed metastatic disease, including to the lungs which ultimately led to worsening respiratory failure that required intubation and ultimately, death.

Providing Online Learning Situations for In-Service Mathematics Teachers' External Transposition Knowledge During COVID-19 Pandemic: Case of Indonesia

Updating mastery of mathematics scholarly knowledge is vital for mathematics teachers' professional development in Indonesia. External transposition refers to the transposition of mathematics scholarly knowledge to the school curriculum. During the COVID-19 pandemic, online learning becomes the primary strategy for strengthening the external transposition knowledge of mathematics teachers in Indonesia. This study aims to describe the process of providing online learning situations in lifting the in-service mathematics teachers' external transposition knowledge during the COVID-19 pandemic. The online learning involved 57 in-service high school mathematics teachers in Indonesia as participants. The scholarly knowledge to be delivered was the visualization of matrix multiplication. This qualitative study is a didactical design research that includes a prospective learning situation analysis, a meta-technopedadidactic analysis, and a retrospective analysis. In the prospective learning situation, the solutions for re-situating face-to-face learning to online learning were disclosed. Moodle was used as the Learning Management System, and GeoGebra Classroom was used as the Task Response System. A meta-technopedadidactic is an educator's ability to comprehensively analyze pedagogic interaction, didactic interaction, and didactic pedagogy anticipation in using technology in a learning situation. The finding in the meta-technopedadidactic analysis showed the role of technology as a visualization tool in online learning, evidence of participants' external didactic transposition, constraints, and collaboration in learning. Finally, the retrospective analysis suggested some future improvements for better online learning situations. This study contributes to the comprehensive organization of e-learning courses in Indonesia for mathematics teachers' professional development based on pedagogic interaction, didactic interaction, and didactic pedagogy anticipation in the use of technology. Despite some of the study's limitations, the findings have the potential to be an advantage for the long-term sustainability of e-learning as a new norm for teachers' professional development programs, rather than just a foreshadowing of the pandemic.

THE COMPETENCES OF PUBLIC ENVIRONMENTAL PROTECTION AUTHORITIES IN CASE OF NATURAL DISASTERS

Statistics show that in the last 40 years alone, natural disasters across the EU have caused economic losses of more than EUR 511 billion (of which 71% were uninsured) and more than 91,000 victims.2 In the last century, Romania has faced 13 earthquakes that have resulted in 2,630 deaths and that affected more than 400,000 people, considering that the damages caused by the 1977 earthquake alone exceeded EUR 1.8 billion.3 The continuous threat caused by seismic risk, floods causing material damages and loss of life and the proliferation of seasonal vegetation wild fires amid the COVID-19 pandemic and an imminent economic crisis the early effects of which have already begun to occur, have made the effects of disasters a priority for the governments of the Member States of the European Union. In the matter of combating the effects of natural hazards, as a result of the transposition of international legislation but also of the elaboration of public policies and strategies by the competent authorities, at national level, a series of normative acts and strategic documents have been promulgated, of which the ones with the most great impact are: the National Climate Change Strategy11, the National Strategy for the Prevention of Emergency Situations12, the National Civil Protection Strategy13, the National Strategy for Combating the Effects of Drought14, the National flood risk management strategy15, the Flood Risk Management Plans16, the National Disaster Risk Management Plan17, the Law on Civil Protection18, the Emergency Ordinance on the National Emergency Management System19, the Government Decision on risk type management20 . 2. Romania is prone to a series of natural disasters, especially earthquakes, floods, droughts and extreme weather, but also to technological ones, such as chemical, nuclear or accidental pollution, which have had a significant physical, social and financial effect in recent decades.22 The following are considered to be disasters:23 destructive natural phenomena of geological or meteorological origin, or the illness of a large number of people or animals, occurring suddenly, as mass phenomena24, as well as events with particularly serious consequences for the environment, caused by accidents25 . The forms of manifestation depend on a series of factors (the presence of the irrigation system, etc.) at the origin of the phenomenon being the fluviometric deficit, the soil degradation, the increase of the ocean water temperature and the increase of the carbon dioxide concentration in the atmosphere.

From Other Journals: A Review of Recent Articles by Our Editorial Team.

In this review, we provide a brief description of recently published articles addressing topics relevant to pediatric cardiologists. Our hope is to provide a summary of the latest articles published recently in other journals in our field. The articles address the extracardiac anomalies in fetuses with congenital heart disease, post COVID-19 vaccination myocarditis, the use of cardiac magnetic resonance after the Fontan operation, congenitally corrected transposition in adults, robitically assisted congenital heart surgery and the increased risk of congenital heart surgery in patients receiving tracheal surgery during the same admission.

Impact of COVID-19 in adult patients with congenital heart disease

Background: COVID-19 is responsible for a worldwide pandemic, causing more than 13 000 deaths to date in Portugal. Data already exists regarding the increased risk of adverse events in patients with cardiovascular diseases, however the impact of SARS-CoV-2 infection in patients (P) with congenital heart disease (CHD) is still under investigation. Aims: To evaluate the impact of COVID-19 in adult patients with congenital heart disease in our tertiary centre Methods: Adult patients seen at the CHD outpatient's clinic at a tertiary centre, who became infected with SARS-CoV-2 infection up to February 2021 were included. Assessment of patients' symptoms, need for hospitalization and admission in an intensive care unit was assessed based on medical records. Results: We identified 36 patients (pts) with COVID-19 infection. Symptoms were present in 31 (86%). The median age was 39 (32-49) years, 58% were females. Seven P (19%) had complex cyanotic disease;three (8%) Tetralogy of Fallot;three (8%) transposition of great arteries (one after Senning procedure and 2 after arterial switch);six (14%) right ventricle obstacle;two (8%) atrioventricular canal defect;four (11%) atrial septal defect;five (14%) ventricular septal defect;five (14%) aortic coarctation;two aortopathies (one submitted do David procedure);one subaortic stenosis;two (6%) had Eisenmenger syndrome. The majority (61%) of P had previous surgery and 58% were at New York Heart Association class of I. Mild symptoms were reported by 24 P (67%). Seven adults experienced moderate symptoms (dyspnea and hypoxia) that led to hospitalization for oxygen therapy, although none required mechanical ventilation. One death was reported. There was a significant association between the gravity of CHD and hospitalizations (p=0.012). Conclusion: Our pts had mainly mild to moderate symptoms and did not appear to have a disproportionately negative outcome;the need for hospitalization was more frequent in patients with higher CHD gravity. These findings are in line with the emerging data regarding COVID-19 in CHD P, and may be in part explained by the patient's young age and functional status.

Severe COVID-19 acute respiratory distress syndrome in an adult with single-ventricle physiology: a case report.

BACKGROUND: COVID-19 can induce acute respiratory distress syndrome (ARDS). In patients with congenital heart disease, established treatment strategies are often limited due to their unique cardiovascular anatomy and passive pulmonary perfusion. CASE PRESENTATION: We report the first case of an adult with single-ventricle physiology and bidirectional cavopulmonary shunt who suffered from severe COVID-19 ARDS. Treatment strategies were successfully adopted, and pulmonary vascular resistance was reduced, both medically and through prone positioning, leading to a favorable outcome. CONCLUSION: ARDS treatment strategies including ventilatory settings, prone positioning therapy and cannulation techniques for extracorporeal oxygenation must be adopted carefully considering the passive venous return in patients with single-ventricle physiology.

Worse Hospital Outcomes for Children and Adults with COVID-19 and Congenital Heart Disease.

The aim of the current study is to investigate hospitalization outcomes of COVID-19 positive children and adults with moderate or severe congenital heart disease to children and adults without congenital heart disease. Retrospective review using the Vizient Clinical Data Base for admissions of patients with an ICD-10 code for COVID-19 from April 2020 to March 2021. Admissions with COVID-19 and with and without moderate or severe congenital heart disease (CHD) were stratified into pediatric (< 18 years) and adult (≥ 18 years) and hospital outcomes were compared. There were 9478 pediatric COVID-19 admissions, 160 (1.7%) with CHD, and 658,230 adult COVID-19 admissions, 389 (0.06%) with CHD. Pediatric admissions with COVID-19 and CHD were younger (1 vs 11 years), had longer length of stay (22 vs 6 days), higher complication rates (6.9 vs 1.1%), higher mortality rates (3.8, 0.8%), and higher costs ($54,619 vs 10,731; p < 0.001 for all). Adult admissions with COVID-19 and CHD were younger (53 vs 64 years, p < 0.001), had longer length of stay (12 vs 9 days, p < 0.001), higher complication rates (8 vs 4.8%, p = 0.003), and higher costs ($23,551 vs 13,311, p < 0.001). This appears to be the first study to report the increased hospital morbidities and costs for patients with CHD affected by COVID-19. Our hope is that these findings will help counsel patients moving forward during the pandemic.

Case report: double lung en bloc procurement from a donor after arterial switch operation.

The growing unmet demand for suitable organ donors increases each year. Despite relative contraindications for thoracic organ donation after previous cardiac surgery, experienced programmes and surgeons can successfully utilise the lungs from select donors who have undergone prior cardiac surgery. This is the first reported case of double lung en bloc procurement from a donor who had a previous arterial switch operation as an infant.

Coronary artery ectasia in a child after arterial switch operation for transposition of the great arteries and suspected multisystem inflammatory syndrome in children associated with COVID-19: a case report.

BACKGROUND: Multisystem inflammatory syndrome in children (MIS-C) with features resembling Kawasaki disease has been reported in association with coronavirus disease 2019 (COVID-19). CASE SUMMARY: We report the rare case of a 22 months old boy with a history of operated simple transposition of the great arteries (TGA), who developed features of MIS-C likely to be associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection and involving the coronary arteries. Cardiovascular magnetic resonance imaging and cardiac catheterization showed long-distance ectasia of both coronary arteries after their origins and an origin stenosis of the right coronary artery with a perfusion defect. The patient was treated with oral anticoagulation together with antiplatelet therapy and remains under careful monitoring. DISCUSSION: This rare case demonstrates that also patients with TGA after the arterial switch operation (ASO) can develop coronary artery dilatation in association with MIS-C. The most interesting finding in this patient was that the origins of the reimplanted coronary arteries were not dilated. We speculate that scar tissue formation in the area of coronary artery transfer after ASO has prevented proximal coronary artery dilation.

Tachyarrhythmia as a possible symptom of coronavirus in a neonate diagnosed with transposition of the great arteries.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic poses broad challenges to healthcare systems and providers. The manifestations of this disease are still being described in a variety of different contexts and patient populations. RESULTS: We report the case of a neonate who demonstrated COVID-19 after surgical correction of transposition of the great arteries. In addition, the patient demonstrated an evolving and persistent tachyarrhythmia consistent with neither the most likely postoperative complications nor typical COVID-19. DISCUSSION: The patient had negative preoperative testing for the virus and presented with profound oxygen desaturation and respiratory failure several days postoperatively. This raised concern for a complication of his arterial switch operation. It was found that one of the patient's caregivers was an asymptomatic carrier of COVID-19, and imaging ruled out intracardiac shunting. After initiating treatment for COVID-19, the patient's oxygen requirements and need for anti-arrhythmic agents improved. CONCLUSION: We propose that, despite negative preoperative testing, coronavirus infection may present as refractory tachyarrhythmia, and may be considered along with surgical complications as a cause for unexplained hypoxemia postoperatively.

Performing an urgent neonatal cardiac intervention safely during the COVID-19 pandemic.

The current pandemic has driven the medical community to adapt quickly to unprecedented challenges. Among these challenges is the need to minimize staff exposure to COVID-19 during neonatal cardiac procedures. In this report, we describe measures we have taken to protect health care workers while ensuring successful outcomes. These measures include wearing appropriate personal protective equipment, physical distancing, designating separate delivery and transport teams, and limiting the number of providers in direct contact with any patient who is infected or whose infection status is unknown. LEARNING OBJECTIVES: 1.To understand specific challenges caused by the COVID-19 pandemic for patients with congenital heart disease needing urgent neonatal intervention.2.To recognize measures that can be taken to minimize health care workers' exposures to the virus during high-risk neonatal cardiac procedures.3.To review the management of neonates with d-transposition of the great arteries and inadequate mixing.