Beyond 30 Days: Analysis of Unplanned Readmissions During the First Year Following Congenital Heart Surgery.

OBJECTIVE: We investigated the incidence and etiologies for unplanned hospital readmissions during the first year following congenital heart surgery (CHS) at our institution and the potential association of readmissions with longer term survival. METHODS: We retrospectively reviewed 263 patients undergoing CHS at our institution from August 2011 to June 2015. Scheduled readmissions were excluded. RESULTS: Seventy patients accrued a total of 120 readmissions (1.7 readmission/patient) within one year after surgery. The first readmission for 57% of the patients was within 30 days postdischarge. Twenty-two patients were first readmitted between 31 and 90 days postdischarge. Eight patients were first readmitted between 90 days and 1 year postdischarge. Median time-to-first readmission was 21 days. Median hospital length of stay at readmission was two days. Causes of 30-day readmissions included viral illness (25%), wound infections (15%), and cardiac causes (15%). Readmissions between 30 and 90 days included viral illness (27%), gastrointestinal (27%), and cardiac causes (9%). Age, STAT category, length of surgery, intubation, intensive care unit, and hospital stay were risk factors associated with readmissions based on logistic regression. Distance to hospital had a significant effect on readmissions (P < .001). Patients with higher family income were less likely to be readmitted (P < .001). There was no difference in survival between readmitted and non-readmitted patients (P = .68). CONCLUSIONS: The first 90 days is a high-risk period for unplanned hospital readmissions after CHS. Complicated postoperative course, higher surgical complexity, and lower socioeconomic status are risk factors for unplanned readmissions the first 90 days after surgery. Efforts to improve the incidence or readmission after CHS should extend to the first 3 months after surgery and target these high-risk patient populations.

Pitfalls in diagnosis: suspected anomalous origin of the right coronary artery from the pulmonary artery.

Anomalous coronary arteries are rare in the general population. We report the case of a term neonate who underwent an echocardiogram to evaluate a possible patent ductus arteriosus. Unexpectedly, an apparent anomalous origin of the right coronary artery from the main pulmonary artery was detected by surface 2-dimensional transthoracic echocardiography and color-flow Doppler imaging. Because ventricular size and function were normal, the patient ultimately underwent cardiac catheterization to verify the anatomy before proposed surgery. Angiograms showed that the right coronary artery arose from the left anterolateral portion of the mid-ascending aorta. The patient did not require surgery. This case report illustrates pitfalls that can occur in the diagnosis of coronary artery anomalies.

Propranolol treatment of infantile hemangiomas: anticipatory guidance for parents and caretakers.

Infantile hemangiomas (IH) are benign tumors of endothelial-like cells. Occurring in 4.5% of children, they are the most common tumor of childhood. The great majority of patients with IH will not need treatment, but 10% require systemic treatment. Many treatments have been described for the treatment of IH, but the Food and Drug Administration has not approved any. Over the last decade, numerous reports of successful treatment of IH with propranolol have been published. Despite its widespread use, little is known regarding the proper dosing, safety monitoring, and during of treatment or long-term outcomes for propranolol treatment of IH. Given its potential side effects, detailed education regarding proper administration of the medication as well as warning signs to watch for is necessary for parents and caretakers. Herein, we provide a parental handout that practitioners can individually tailor for use in their clinics when educating parents and caretakers about the use of propranolol for IH. Updates will also need to be made as more is learned regarding the optimal dosing and safety monitoring when using propranolol for this indication.

Initiation and use of propranolol for infantile hemangioma: report of a consensus conference.

Infantile hemangiomas (IHs) are common neoplasms composed of proliferating endothelial-like cells. Despite the relative frequency of IH and the potential severity of complications, there are currently no uniform guidelines for treatment. Although propranolol has rapidly been adopted, there is significant uncertainty and divergence of opinion regarding safety monitoring, dose escalation, and its use in PHACE syndrome (PHACE = posterior fossa, hemangioma, arterial lesions, cardiac abnormalities, eye abnormalities; a cutaneous neurovascular syndrome characterized by large, segmental hemangiomas of the head and neck along with congenital anomalies of the brain, heart, eyes and/or chest wall). A consensus conference was held on December 9, 2011. The multidisciplinary team reviewed existing data on the pharmacologic properties of propranolol and all published reports pertaining to the use of propranolol in pediatric patients. Workgroups were assigned specific topics to propose protocols on the following subjects: contraindications, special populations, pretreatment evaluation, dose escalation, and monitoring. Consensus protocols were recorded during the meeting and refined after the meeting. When appropriate, protocol clarifications and revision were made and agreed upon by the group via teleconference. Because of the absence of high-quality clinical research data, evidence-based recommendations are not possible at present. However, the team agreed on a number of recommendations that arose from a review of existing evidence, including when to treat complicated IH; contraindications and pretreatment evaluation protocols; propranolol use in PHACE syndrome; formulation, target dose, and frequency of propranolol; initiation of propranolol in infants; cardiovascular monitoring; ongoing monitoring; and prevention of hypoglycemia. Where there was considerable controversy, the more conservative approach was selected. We acknowledge that the recommendations are conservative in nature and anticipate that they will be revised as more data are made available.

Fetal and neonatal presentation of noncompacted ventricular myocardium: expanding the clinical spectrum.

BACKGROUND: Noncompaction of the ventricular myocardium (NCVM) is a rare cardiomyopathy characterized by varying degrees of ventricular dysfunction and numerous, prominent trabeculations with deep intertrabecular recesses caused by arrest in myocardial embryogenesis. NCVM is rarely described in fetal and neonatal patients, and only isolated reports exist to date. METHODS: We conducted a review of clinical and echocardiographic data from 6 neonates found to have NCVM to elucidate aspects of prenatal manifestations, initial presentations, and clinical course/outcome. RESULTS: Six neonates met criteria for diagnosis of NCVM. Five were initially evaluated during fetal life, whereas one patient presented for initial cardiology examination as a neonate. Three of the 5 fetuses had NCVM recognized at the initial examination. Both unrecognized fetuses also had severe prenatal left ventricular dilation and dysfunction. Left ventricular enlargement or increased wall thickness with decreased ejection fraction was evident in all patients at presentation. Mean ejection fraction at presentation was 36% and improved to 57% during an average follow-up of 2 years. Associated congenital cardiac anomalies were noted in 3 patients. After initial improvement, two patients had transient, late decreases in ejection fraction, which improved with medication adjustment. There have been no deaths. CONCLUSION: Fetuses with enlarged and poorly functioning left ventricles should be evaluated for NCVM, which may not be easily recognized on initial fetal studies. Unlike previous reports of neonatal NCVM, all 6 neonates, including the 3 requiring inotropic support, showed significant early recovery of cardiac function with aggressive therapy.

Three-Dimensional Imaging Used for Virtual Dissection, Image Banking and Physical Replication of Anatomy and Physiology.

Historically, techniques of dissection have been used to aid in our understanding of human anatomy, physiology, and pathology. However, these techniques alter the structures and fine details being studied. New advances in computer technology, imaging equipment, data acquisition, processing, storage, and display now allow multidimensional imaging. Interactive computer programs can electronically display both static three-dimensional and higher-dimensional images that retain features such as motion, pressure, and temporal change. Multidimensional images can be reconstructed and manipulated using different holographic, stereolithographic, or interactive two-dimensional displays. We describe the unique potential of multidimensional reconstruction, virtual dissection, and replication of cardiovascular structures using ultrasound data. Ultrasound technology has the advantage of depicting both anatomy and physiology. The ability to perform virtual dissection and surgery in the living patient without disruption of anatomy or physiology provides the clinician with a powerful new tool for diagnosis, teaching, and therapeutics.