Understanding the Impact of Fluid Restriction on Growth Outcomes in Infants Following Cardiac Surgery.

OBJECTIVE: Fluid restriction is reported to be a barrier in providing adequate nutrition following cardiac surgery. The specific aim of this study was to evaluate the adequacy of nutritional intake during the postoperative period using anthropometrics by comparing preoperative weight status, as measured by weight-for-age z scores, to weight status at discharge home. DESIGN: Prospective cohort study. SETTING: Cardiac ICU at Miami Children's Hospital. PATIENTS: Infants from birth to 12 months old who were scheduled for cardiac surgery at Miami Children's Hospital between December 2013 and September 2014 were followed during the postoperative stay. INTERVENTIONS: Observational study. MEASUREMENTS AND MAIN RESULTS: Preoperative and discharge weight-for-age z scores were analyzed. The Risk Adjustment for Congenital Heart Surgery 1 categories were obtained to account for the individual complexity of each case. In patients who had preoperative and discharge weights available (n = 40), the mean preoperative weight-for-age z score was -1.3 ± 1.43 and the mean weight-for-age z score at hospital discharge was -1.89 ± 1.35 with a mean difference of 0.58 ± 0.5 (p < 0.001). A higher Risk Adjustment for Congenital Heart Surgery 1 category was correlated with a greater decrease in weight-for-age z scores (r = -0.597; p = 0.002). CONCLUSIONS: Nutritional status during the postoperative period was found inadequate through the use of objective anthropometric measures and by comparing them with normal growth curves. Increase in surgical risk categories predicted a greater decrease in weight-for-age z scores. The development of future protocols for nutritional intervention should consider surgical risk categories.

Utility of preoperative Holter monitoring in children undergoing extracardiac conduit Fontan operation.

BACKGROUND: In patients undergoing extracardiac conduit Fontan (ECF) who require postoperative pacing, epicardial leads are usually required because of anatomical constraints. If indicated, these could be conveniently placed at the time of ECF. We have routinely performed ambulatory 24-hour Holter monitoring before ECF to determine the presence or absence of preoperative sinus node dysfunction, in an attempt to avoid repeat sternotomy at a later time. METHODS: We performed a retrospective study of all patients undergoing ECF from January 2000 to December 2015. RESULTS: Two hundred sixteen patients met inclusion criteria. Patients were separated into two groups, those with preoperative Holter monitoring (PHM, n = 150) and those without (No-PHM, n = 66). Ten patients (4.6%) underwent permanent pacemaker implantation at the time of ECF (eight patients [5.3%] in PHM vs two patients [3.0%] in No-PHM, P = 0.46). There were seven (3.2%) patients who underwent pacemaker implantation after ECF requiring repeat sternotomy (four patients [2.7%] in PHM vs three patients [4.5%] in No-PHM, P = 0.47). Fourteen (6.5%) patients underwent permanent epicardial lead placement without a pulse generator at the time of ECF. None from this group underwent pacemaker implantation to date (median follow-up of 5.7 years). The overall incidence of pacemaker implantation was 9.3% (20 patients). CONCLUSIONS: In our series, arrhythmia disturbances requiring pacing after ECF occurred in just over 9% of patients. While PHM in those patients may help predict which patients might require postoperative pacing, this approach did not result in a significant decrease in those patients requiring repeat sternotomy for pacemaker implantation.

Screening the apparently healthy athlete for risk: a paradigm in transition.

It has largely been accepted that pre-participation screening for student athletes is necessary, but there is still no consensus on the most effective and efficient ways to accomplish this. Most clinical strategies are based on retrospective case series. By applying the European Society of Cardiology and Seattle criteria, electrocardiography appears to afford the lowest false-positive rate for identifying potentially dangerous cardiac abnormalities in athletes. Prospective, randomised trials may help determine the most effective primary prevention. Normative data for age, gender, and ethnicity for screening tools need to be formulated to further reduce false-positive results. Targeted advanced screening aimed at the highest risk groups may be the most beneficial and cost-effective application of primary prevention.

Risk Factors for Longer Hospital Stay Following the Fontan Operation.

OBJECTIVES: Children with functional single ventricle undergoing the Fontan operation consume considerable resources. The purpose of this study is to evaluate pre- and intraoperative risk factors for longer hospital stay and to describe the perioperative course at a single institution over a 15-year period. DESIGN: Retrospective cohort study. SETTING: A single pediatric cardiac ICU. PATIENTS: All consecutive patients undergoing a first-time Fontan operation from 2000 to 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Prolonged length of stay was defined as hospital stay greater than 75 percentile at our institution after surgery. Of 218 patients who met inclusion criteria, median length of stay was 10 days (interquartile range, 8-14 d); prolonged length of stay was defined greater than or equal to 15 days. Independent pre- and intraoperative risk factors for prolonged length of stay included higher hemoglobin (odds ratio, 1.29; p = 0.003), higher mean pulmonary artery pressure (odds ratio, 1.14; p = 0.037), and lower aortic saturation (odds ratio, 0.92; p = 0.008) in the entire group. When patients with hepatic vein inclusion (following previous Kawashima) were excluded, higher hemoglobin (odds ratio, 1.24; p = 0.027), lower aortic saturation (odds ratio, 0.92; p = 0.017), and placement of a fenestration (odds ratio, 2.438; p = 0.021) were associated with prolonged length of stay. Fifty-eight patients (26.6%) had major complications defined by Pediatric Cardiac Critical Care Consortium. Placement of a fenestration (odds ratio, 2.297; p = 0.014) and longer aortic cross-clamp time (odds ratio, 1.015; p = 0.003) were independently associated with Pediatric Cardiac Critical Care Consortium major complications. CONCLUSIONS: In this series, 75% of patients had a postoperative length of stay less than or equal to 2 weeks. Preoperative factors suggesting worse hypoxemia/decreased pulmonary blood flow (higher hemoglobin and lower oxygen saturation) and increased pulmonary artery pressure were associated with prolonged length of stay. These findings may help risk stratify this complex patient population, provide more accurate family counseling, and provide preliminary data for changes in preoperative timing of the Fontan and/or changes to postoperative management strategies for those at high risk for increased ICU morbidity.

Creation of partial fascicular block: an approach to ablation of idiopathic left ventricular tachycardia in the pediatric population.

BACKGROUND: Catheter ablation of idiopathic left ventricular tachycardia in the pediatric population remains challenging. A recent multicenter study reported limited success with 14% not undergoing ablation due to inability to induce ventricular tachycardia (VT) or blood pressure instability during tachycardia. Creating complete or partial fascicular block with radiofrequency catheter ablation is a technique that may eliminate VT. This approach is performed during sinus rhythm, enabling atrioventricular conduction monitoring and maintaining stable hemodynamics. Importantly, induction of VT is not necessary for mapping or assessing efficacy of the procedure. METHODS: A retrospective review of pediatric patients (3-17 years) with recurrent, documented idiopathic left ventricular tachycardia by electrocardiogram who received catheter ablation by creating fascicular block as a therapeutic endpoint was performed. All had ablation at the site of an identified Purkinje potential. RESULTS: There were six patients with idiopathic left ventricular tachycardia, five originating from the posterior fascicle and one from the anterior fascicle. VT was not induced or spontaneous in four patients using programmed stimulation and isoproterenol infusion. All patients had a QRS axis shift following ablation, though none met criteria for fascicular block. At follow up (7-49 months, mean 27 months), all patients had persistence of this shift. There were no recurrences of VT and none of the patients were taking antiarrhythmic medication. CONCLUSION: The technique of creating partial fascicular block appears to be a safe and effective approach to ablation of idiopathic left ventricular tachycardia in children.

Web-based survey of current trends in hemodynamic monitoring after congenital heart surgery.

Strategies for monitoring patients recovering after congenital heart surgery have evolved considerably as technology continues to progress. Monitoring techniques traditionally centered around the comprehensive physical examination have been replaced by a number of revolutionary technologies developed to objectively evaluate various components of the cardiovascular system. Despite scant evidence that these methodologies actually improve outcomes, some have been embraced by clinicians. We developed an Internet survey designed to describe current practices of clinicians who care for patients after congenital heart surgery. There were 162 respondents to our survey with the majority from the United States. The views of cardiologists, intensivists, those dual trained in both cardiology and critical care medicine, and surgeons are all robustly represented in the results. Serial lactate monitoring was the strategy that was utilized most often by respondents (94%), followed by multisite near-infrared spectrometry (NIRS, 67%). There were 78% who utilized the combination of serial lactate and NIRS monitoring. Serial lactate monitoring was the technique that was thought to best represent cardiovascular well-being after heart surgery (40%). The results of this survey suggest that despite the paucity of evidence that clinical outcomes of patients recovering after congenital heart surgery are improved by any of these monitoring techniques, there is almost universal acceptance to monitor patients with serial lactate monitoring, NIRS monitoring, or a combination of these techniques.

Care models and associated outcomes in congenital heart surgery.

OBJECTIVE: Recently, there has been a shift toward care of children undergoing heart surgery in dedicated pediatric cardiac intensive care units (CICU). The impact of this trend on patient outcomes is unclear. We evaluated postoperative outcomes associated with a CICU versus other ICU models. PATIENTS AND METHODS: Society of Thoracic Surgeons Congenital Heart Surgery Database participants (2007-2009) who completed an ICU survey were included. In multivariable analysis, we evaluated outcomes associated with a CICU versus other ICUs, adjusting for center volume, patient factors, and Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery surgical risk category. RESULTS: A total of 20 922 patients (47 centers; 25 with a CICU) were included. Overall unadjusted mortality was 3.8%, median length of stay was 6 days (interquartile range: 4-13), and 21% had 1 or more complications. In multivariable analysis, there was no difference in mortality comparing CICUs versus other ICUs (odds ratio: 0.88 [95% confidence interval: 0.65-1.19]). In stratified analysis, CICUs were associated with lower mortality only among those in Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery category 3 (odds ratio: 0.47 [95% confidence interval: 0.25-0.86]), primarily related to atrioventricular canal repair and arterial switch operation. There was no difference in length of stay or complications overall or in stratified analysis. CONCLUSIONS: We were not able to detect a difference in postoperative morbidity or mortality associated with the presence of a dedicated CICU for children undergoing heart surgery. There may be a survival benefit in certain subgroups .

The Fontan operation: the pursuit of associated lesions and cumulative trauma.

Our programmatic approach to the Fontan operation has evolved to include using an extracardiac conduit with aggressive presumptive treatment of associated lesions either in the catheterization laboratory or the operating room. Fenestration is used selectively based on hemodynamics, anatomy, and presence of associated lesions. We reviewed our experience to determine the effectiveness and outcome of this strategy and to assess the cumulative trauma to the patients. The records of 137 consecutive patients who underwent Fontan at Miami Children's Hospital from 1995 to 2008 were reviewed. At mean follow up of 5.76 years, freedom from death or transplantation is 94.2% (129/137). Median age at operation was 4.6 years. Longer length of stay correlated with older operative age (P = 0.0056). Pacemakers were implanted in 11.7% (16/137). Additional (not pre-Glenn or pre-Fontan) interventional catheterizations were performed in 51.8% (71/137). Additional operations were done in 10.2% (14/137). No patient has required replacement or revision of the extracardiac conduit. Our current approach to the Fontan operation provides acceptable midterm results. The pursuit of residual lesions results in a significant number of additional interventional catheterizations and operative procedures but might have an important influence on long-term survival after the Fontan procedure.

New approach to interstage care for palliated high-risk patients with congenital heart disease.

OBJECTIVE: Home surveillance monitoring might identify patients at risk for interstage death after stage 1 palliation for hypoplastic left heart syndrome. We sought to identify the effect that a high-risk program might have on interstage mortality and identification of residual/recurrent lesions after neonatal palliative operations. METHODS: Between January 2006 to January 2010, newborns after stage 1 palliation for hypoplastic left heart syndrome or shunt placement were invited to participate in our high-risk program. Patients enrolled in our high-risk program comprise the study group. Patients who had similar operations between January 2002 and December 2005 comprise the control group. Comparisons are made between the 2 groups with respect to interstage mortality and the frequency and timing of interstage admissions requiring medical, catheter, or surgical treatment. RESULTS: Seventy-two patients met the criteria for our high-risk program. Fifty-nine (82%) of 72 patients were enrolled. Among 19 patients with hypoplastic left heart syndrome in our high-risk program, outpatient interstage mortality was zero. Outpatient interstage mortality for the 36 control subjects with hypoplastic left heart syndrome was 6%. Among 40 patients with shunts in the study group, there was 1 outpatient interstage death compared with 4 (6%) deaths in 68 subjects in the control group. Significant residual/recurrent lesions were identified with similar frequency between the 2 groups. However, after shunt operations, these lesions were detected and treated at significantly younger mean ages for patients followed in the high-risk program (P < .005). CONCLUSIONS: Initiation of a high-risk program might decrease interstage mortality after high-risk neonatal palliative operations. Such an approach might contribute to earlier detection of significant residual/recurrent lesions amenable to therapy.

Urgent permanent pacemaker implantation in critically ill preterm infants.

The management of complete heart block in premature low birth-weight infants, particularly those with hydrops fetalis, is challenging. We report emergent implantation of permanent epicardial pacemakers in the first 48 hours of life in two premature infants (one with hydrops fetalis) with birth weights of 1,400 grams and 1,000 grams.

Transforming patient and family access to medical information: utilisation patterns of a patient-accessible electronic health record.

OBJECTIVE: The purpose of this study was to evaluate the utilisation of a web-based multimedia patient-accessible electronic health record, for patients with congenital cardiac disease. PATIENTS AND METHODS: This was a prospective analysis of patients undergoing congenital cardiac surgery at a single institution from 1 September, 2006 to 1 February, 2009. After meetings with hospital administration, physicians, nurses, and patients, we configured a subset of the cardiac program's web-based clinical electronic health record for patient and family access. The Electronic Health Record continuously measured frequency and time of logins, logins during and between hospitalisations, and page views by type (imaging versus textual data). RESULTS: Of the first 270 patients offered access to the system, 252 became users (93% adoption rate). System uptime was 99.9%, and no security breaches were reported. Users accessed the system more often while the patients were in hospital (67% of total logins) than after discharge (33% of total logins). The maximum number of logins by a family was 440, and the minimum was 1. The average number of logins per family was 25. Imaging data were viewed significantly more frequently than textual data (p 0.001). A total of 12 patients died during the study period and 11 members of their families continued to access their Electronic Health Records after the date of death. CONCLUSIONS: A web-based Patient Accessible Electronic Health Record was designed for patients with congenital cardiac disease. The adoption rate was high, and utilisation patterns suggest that the Electronic Health Record could become a useful tool for health information exchange.

Hyperlactatemia in neonates admitted to the cardiac intensive care unit with critical heart disease.

Neonates with critical heart disease are at risk of significant deficiencies in systemic oxygen delivery. The incidence and clinical pattern of hyperlactatemia in neonates presenting with critical heart disease has not been described. We reviewed the lactate pattern of neonates transferred to our cardiac intensive care unit for surgical management of their heart disease over a 1-year period. Stabilization of these neonates began in the referring institutions. From 8/4/03 to 8/4/04, 75 neonates with critical heart disease were transferred to our unit for stabilization and subsequent surgery. Blood lactate was measured on admission and subsequently in any patient thought to be at risk of low systemic oxygen delivery. Lactate was measured in 59 patients on admission and in 63 patients within the first 48 h of admission. Median age on admission was 1 day (range 0-13). Median age at surgery was 8 days (range 1-30). Median length of stay was 20 days. Peak lactate was noted on admission in 51 patients, and at 12-24 h in 8 patients. Mild hyperlactatemia (2.3-5 mmol/l) was present in 30 patients on admission and moderate-to-severe hyperlactatemia (>or=5 mmol/l) was present in 8 patients. Mean lactate level on admission was 3.1 +/- 0.6 mmol/l, and this did not return to normal (<2.3 mmol/l) until 36 h after admission. Severe hyperlactatemia patients also were noted to have normal lactate levels by 36 h. The presence of hyperlactatemia did not affect length of stay or mortality. There were no preoperative deaths and 4 postoperative deaths (1 death in 38 patients with mild or severe hyperlactatemia). Hyperlactatemia is frequently present in neonates admitted to a tertiary care center for management of congenital heart disease. Blood lactate levels normalize within 36 h. The presence of preoperative hyperlactatemia, even when moderate-to-severe, does not have significant adverse effect on postoperative mortality.

Variation in models of care delivery for children undergoing congenital heart surgery in the United States.

Limited data are available regarding contemporary models of care delivery for patients undergoing congenital heart surgery. The purpose of this survey was to evaluate current US practice patterns in this patient population. Cross-sectional evaluation of US centers caring for patients undergoing congenital heart surgery was performed using an Internet-based survey. Data regarding postoperative care were collected and described overall and were compared in centers with a pediatric intensive care unit (PICU) versus dedicated pediatric cardiac intensive care unit (CICU). A total of 94 (77%) of the estimated 122 US centers performing congenital heart surgery participated in the survey. The majority (79%) of centers were affiliated with a university. Approximately half were located in a free-standing children's hospital and half in a children's hospital in a hospital. Fifty-five percent provided care in a PICU versus a CICU. A combination of cardiologists and/or critical care physicians made up the largest proportion of physicians primarily responsible for postoperative care. Trainee involvement most often included critical care fellows (53%), pediatric residents (53%), and cardiology fellows (47%). Many centers (76%) also used physician extenders. In centers with a CICU, there was greater involvement of cardiologists and physicians with dual training (cardiology and critical care), fellows versus residents, and physician extenders. Results of this survey demonstrate variation in current models of care delivery used in patients undergoing congenital heart surgery in the United States. Further study is necessary to evaluate the implications of this variability on quality of care and patient outcomes.

Radiofrequency ablation of pediatric AV nodal reentrant tachycardia during the ice age: a single center experience in the cryoablation era.

BACKGROUND: Radiofrequency catheter ablation of atrioventricular nodal reentrant tachycardia (AVNRT) has proven to be an effective therapy in the pediatric population. However, concerns of inadvertent permanent AV nodal block have resulted in many pediatric programs adopting cryoablation as their primary ablation approach for AVNRT. METHODS: A retrospective analysis of the results of pediatric radiofrequency catheter ablation at a single institution over the most recent 5 years (January 2004 through December 2008) was performed. Acute, intermediate, and long-term success, along with the incidence of AV block, were determined. RESULTS: There were 65 patients with a mean age of 12.1 + or - 5.2 years and weight of 46.5 + or - 17.3 kg who underwent radiofrequency catheter ablation for AVNRT. There was 100% acute success with no recurrences at a mean follow up of 32.5 months. Although two patients had a brief second-degree AV block, there was no permanent AV block of any degree. CONCLUSIONS: The safety and efficacy of radiofrequency catheter ablation for pediatric AVNRT demonstrated in this study support its continued application and should not be abandoned as a method of treatment.

Amiodarone for pediatric resuscitation: a word of caution.

Intravenous administration of amiodarone has recently been recommended for use during pediatric resuscitation of pediatric patients with ventricular fibrillation or pulseless ventricular tachycardia. We present two pediatric patients who received amiodarone for polymorphic ventricular tachycardia, although they were ultimately determined to have congenital long QT syndrome. Amiodarone is contraindicated in this setting and may have exacerbated the ventricular arrhythmia.

Midterm results for collaborative treatment of pulmonary atresia with intact ventricular septum.

BACKGROUND: We report a single-institution experience using a collaborative surgical and catheter-based approach to the initial treatment of pulmonary atresia with intact ventricular septum. METHODS: A retrospective review was conducted of all neonates admitted with pulmonary atresia with intact ventricular septum from 1996 to March 2007. RESULTS: We identified 24 patients with a mean age at first intervention of 4.5 days with mean follow-up of 6.05 years (range, 1.9 to 12.7 years). Initial palliation was determined by right ventricular size, morphology, and presence or absence of right ventricular-dependent coronary circulation. Initial catheter-based pulmonary valve perforation and valvuloplasty was performed in 41.7% (10 of 24 patients; group A), and 58.3% (14 of 24 patients) had an initial systemic-to-pulmonary artery shunt (group B). Tricuspid valve size was significantly smaller in group B (median z-score, -0.52 group A versus -2.40 group B; p < 0.001). Placement of a shunt after valvuloplasty in group A was required in 70.0% (7 of 10 patients). There was no mortality in group A, and 70.0% (7 of 10 patients) are in a two-ventricle pathway and 30.0% (3 of 10 patients) are in a 1.5-ventricle pathway. Group B had mortality of 14.3% (2 of 14 patients), both within 5 days of surgery. All group B patients remain in a single-ventricle pathway. Overall survival is 91.7% (22 of 24 patients). CONCLUSIONS: An individualized approach to this complex lesion has good results. If the right ventricle can be safely decompressed and appears usable, the need for a shunt after valvuloplasty does not preclude two-ventricle (or 1.5-ventricle) repair. Anatomy mandating a shunt as initial palliation has substantial early mortality.

Frequency and indications for tracheostomy and gastrostomy after congenital heart surgery.

Patients undergoing congenital heart surgery may occasionally require additional surgical procedures in the form of tracheostomy and gastrostomy. These procedures are often performed in an attempt to diminish hospital morbidity and length of stay. We reviewed the Web-based medical records of all patients undergoing congenital heart surgery at Miami Children's Hospital from February 2002 through August 2007. Patients who were deemed preterm and had undergone closure of a patent ductus arteriosis were eliminated. The records of all other patients were queried for the terms gastrostomy, g-tube, Nissan, fundal plication, tracheostomy, or tracheotomy. Patients' medical records in which these terms appeared in any portion were completely reviewed. There were 1660 congenital heart operations performed in the study period. There were 592 operations performed on patients whose age ranged from 1 month to 1 year and 441 neonatal operations. Mortality was 2%. Median postoperative stay was 8 days (range, 1-191 days), 12 days for neonates (range, 3-142 days), and 19 days for neonates undergoing RACHS-1 category 6 operations (range, 4-142 days). Tracheostomies were performed in four patients (0.2%). Gastrostomies were performed on eight patients (0.4%), representing 0.8% of patients <1 year of age, 1.4% of neonates, and 2.4% of patients undergoing RACHS-1 category 6 operations. The rate of patients undergoing either tracheostomy or gastrostomy after congenital heart surgery at our institution was quite low. Avoidance of either of these two procedures was achieved without increased morbidity or length of stay. The rate at which these procedures need to be performed may reflect the magnitude of the patients' lifetime trauma related to their underlying condition and acute and total surgical experiences.

Congenital cardiac surgery without routine placement of wires for temporary pacing.

OBJECTIVE: Temporary pacing wires have been associated with serious postoperative complications. Recommendations for their routine use after open heart surgery are decades old, and may not reflect current surgical techniques and outcomes. METHODS: The electronic web-enabled medical records of all patients undergoing congenital cardiac surgery from February, 2002, through December, 2005, were reviewed, excluding patients undergoing implantation of pacemakers as a primary procedure, or those undergoing ligation of a patent arterial duct. RESULTS: There were 1193 surgical procedures performed, 1041 with cardiopulmonary bypass. Median age of the patients was 5.8 months, with a range from 0 days to 54 years, weighing 6.2 kilograms, with a range from 1 to 114 kilograms. Mortality prior to discharge was 2.5%, and median postoperative stay was 6 days. No deaths were attributed to arrhythmias. Temporary pacing wires were placed 14 times (1.2%). Indications for placement included sinus nodal dysfunction in 8 patients, preoperative in 4 and intraoperative in 4, high degree atrioventricular block in 4 patients, and intraoperative atrial flutter in 2 patients. Of these patients, 4 (0.3%) eventually underwent permanent implantation of a pacemaker, 2 for persistent sinus nodal dysfunction, and 2 for persistent atrioventricular block. Postoperative junctional ectopic tachycardia requiring antiarrhythmic therapy occurred in 9 patients (0.8%). All recovered without incident, and none were treated with temporary pacing. CONCLUSIONS: The diminished risk of unexpected postoperative arrhythmias in the current era alleviates the necessity for routine placement of temporary pacing wires. Those institutions with experienced surgical and cardiac critical care teams may be able to predict the need for temporary pacing wires preoperatively or intraoperatively.

Rapid cardiopulmonary support in children with heart disease: a nine-year experience.

BACKGROUND: We developed a novel mechanical rapid cardiopulmonary support system (CPS) in 1996 to eliminate what we believed were shortcomings of conventional extracorporeal membrane oxygenation (ECMO) circuits when used in patients with congenital heart disease. We reviewed the use of this system over a nine year period to determine if we had been successful in improving results compared with ECMO and if outcomes have changed over this time. METHODS: All children supported with CPS (110 procedures) were reviewed. Noncardiac CPS cases (7) were excluded. The study population was divided into two time periods (1995 to 2000 and 2001 to 2004), which correlate with significant differences in intraoperative, postoperative, and CPS management. Patients were further analyzed by age (< or = 30 days or > 30 days), repair complexity (risk adjusted classification for congenital heart surgery [RACHS]-1 category 6 or categories 1 to 5), and length of support. RESULTS: Overall thirty day survival of cardiac CPS patients was 55% (57 of 103). Overall survival increased from 45% (23 of 51) during the first period to 65% (34 of 52) during the second period [p < or = 0.005]. Survival rates in neonates improved from 41% (11 of 27) to 56% (15 of 27) and RACHS-1 category 6 survival improved from 38% (5 of 13) to 69% (9 of 13), but neither change reached statistical significance. Intracranial hemorrhage occurred in 6.4% of all CPS patients. CONCLUSIONS: Cardiopulmonary support is an effective alternative to ECMO for pediatric cardiac support. Further, our experience suggests that patient survival may be improved by CPS compared with reported results for ECMO in cardiac patients.