The Use of the CardioCel 3D 60° Patch for Aortic Arch Reconstruction in Infancy - A Word of Caution.

BACKGROUND: There is limited data on outcomes following implantation of Cardiocel 3D 60° patch in great vessel repair. After anecdotally witnessing an increase in negative outcomes, we reviewed our experience using this patch in our neonate and infant patients undergoing aortic arch repair. METHODS: A total of 24 patients underwent aortic arch repair with implantation of CardioCel 3D 60° patch between July 2018 to July 2021. Dominant cardiac morphologies were Hypoplastic Left Heart Syndrome (66%), Atrioventricular Canal defects (13%) and Other (21%). Median age at implantation was 44 days (IQR 6-112). Recurrent obstruction was defined as need for reoperation or catheter intervention or recurrent peak pressure gradient of descending aorta ≥ 25 mm Hg on echocardiography. RESULTS: Five deaths occurred after median 217 days (IQR 69-239). Twelve patients (50%) had recurrent obstruction. Three patients (13%) required redo aortic arch operation after a median of 148 days (IQR 128-193), with extensive fibrous coating of the patch interior causing obstruction. Eleven patients (46%) required at least one balloon angioplasty on their aorta after a median of 102 days (IQR 83-130) following repair, and three needed more than one catheter intervention. The estimated probability of having recurrent obstruction at 6 months was 85% and at 1 year follow up was 71% (p=0.06). CONCLUSIONS: Recurrent aortic obstruction occurred in half of our patients shortly after repair. The use of the CardioCel 3D 60° patch for aortic arch reconstruction in neonates and infants should be re-evaluated.

Pediatric Tele-Critical Care: Initial Experience with a Continuous Surveillance Model Aiming to Prevent Cardiac Arrest in Children with Critical Heart Disease.

Introduction: Despite advances in treatment of children with critical heart disease, cardiac arrest (CA) remains a common occurrence. We provided virtual support to bedside teams (BTs) from a tele-critical care (TCC) unit in a pediatric cardiac intensive care unit (CICU) and focused on early detection of concerning trends (CT) and avoidance of CA. Virtual surveillance workflows included a review of remote monitoring, video feed from patient room cameras, medical records, and artificial intelligence tools. We present our initial experience with a focus on critical communications (CCs) to BTs. Methods: A retrospective, descriptive review of TCC activities was conducted from January 2019 to December 2022, involving electronic databases and electronic medical records of patients in the CICU, including related CCs to BTs, responses from BTs, and related CA. Results: We conducted 18,171 TCC activities, including 2,678 non-CCs and 248 CCs. Over time, there was a significant increase in the proportion of CCs related with CT (p = 0.002), respiratory concerns (<0.001), and abnormalities in cardiac rhythm (p = 0.04). Among a sample of 244 CCs, subsequent interventions by BTs resulted in adjustment of medical treatment (127), respiratory support (68), surgery or intervention (19), cardiac rhythm control (17), imaging study (14), early resuscitation (9), and others (10). Conclusions: CCs from a TCC unit in a pediatric CICU changed over time with an increased focus on CT and resulted in early interventions, potentially contributing to avoiding CA. This model of care in pediatric cardiac critical care has the potential to improve patient safety.

Reconstruction of Fibrous Skeleton of the Heart for Double-Valve Replacement in A Pediatric Patient - Modified Commando Procedure.

The so-called Commando procedure, initially described by David and colleagues, consists in the reconstruction of the mitro-aortic fibrous lamina by a patch that enlarges both annuli. Its use has been described to upsize the aortic and mitral annulus for double valve replacement in adolescents. We describe a modified technique of this reconstruction of the fibrous skeleton of the heart, combined with Konno procedure to further enlarge the aortic annulus. In modified Commando procedure, following the reconstruction of aortomitral continuity with a bovine pericardium CardioCel patch (Admedus Regen Pty Ltd, Perth, WA, Australia), an aortic valved conduit that was made on the bench in order to have bottom skirt that enabled the suturing of the composite conduit far inside the left ventricle outflow tract. Coronary buttons were implanted at the supra-commissural level. The advantages of this modified Commando procedure are (1) the creation of a new aortic annulus when the integrity of this annulus has been compromised, (2) the upsizing of both annuli to any possible size of aortic and mitral prostheses, and (3) the relief of any residual left ventricular outflow tract obstruction.

Hawaiian Philodoria (Lepidoptera, Gracillariidae, Ornixolinae) leaf mining moths on Myrsine (Primulaceae): two new species and biological data.

This paper provides new taxonomic and biological data on a complex of gracillariid moths in the endemic genus Philodoria Walsingham, 1907 that are associated with Myrsine (Primulaceae) in the Hawaiian Islands, United States. Two new species, Philodoria kauaulaensis Kobayashi, Johns & Kawahara, sp. n. (host: Myrsine lanaiensis, M. lessertiana, and M. sandwicensis) and P. kolea Kobayashi, Johns & Kawahara, sp. n. (host: M. lessertiana) are described. Biological data are provided for two previously described species that also feed on Myrsine: P. auromagnifica Walsingham, 1907 and P. succedanea Walsingham, 1907. For the first time we detail and illustrate genital structures, immature stages, biology, and host plants of P. auromagnifica and P. succedanea. Philodoria kolea, P. auromagnifica, and P. succedanea occur in sympatry on the island of Hawaii (Big Island), but each species differs in behavioral characters: P. kolea utilizes leaves of seedlings and forms a serpentine mine, whereas the latter two utilize leaves of larger plants, and form linear or serpentine to blotch mines. More broadly, leaf mine forms and diagnostic characteristics of the Myrsine-feeding species complex of Philodoria (as currently known) are reviewed and illustrated.