Examining racial and socioeconomic disparity in the pediatric heart transplant evaluation.

Racial disparities have been reported among pediatric patients waitlisted for and undergoing heart transplantation but have not been studied further upstream in the transplant candidate evaluation process. We retrospectively studied our single-center experience in order to investigate any potential biases in the evaluation process. Results of the heart transplant evaluation in children ≤18 years old at our institution were analyzed. Primary outcome was final disposition to waitlist or not. Race was defined by family self-identification. Descriptive and comparative statistical analyses were performed. From 2013 to 2019, 133 unique patients were referred for listing consideration. While Black patients comprised 44% of the referral population and had more markers of socioeconomic disadvantage, they comprised 43% of the patients who were listed for transplantation with no significant difference between these proportions (p = .96). Black and White patients made up a similar proportion of patients deemed too well or too ill for listing. Black patients had lower annual household income estimates and rates of household marriage. Despite identifying significant social challenges in 27 patients (18 of them Black), only five patients (3 Black and 2 White) were turned down for listing due to social barriers. While limited by the small number of patients turned down for social barriers, our transplant evaluation process does not appear to result in racial disparities in access to listing. Further studies are needed using national cohorts to explore possible racial disparities upstream from waitlisting and transplantation, such as during the referral and evaluation.

Circumferential Aortic Endarterectomy Followed with Immediate Infrarenal Clamping Obviates Suprarenal Clamping for Juxtarenal Aortoiliac Occlusion.

BACKGROUND: Traditional open surgery for juxtarenal aortoiliac occlusive disease (AIOD) requires suprarenal aortic cross-clamping (SRCC), which is associated with high incidence of acute kidney injury (AKI). This study was to compare the outcomes of circumferential aortic endarterectomy followed by immediate infrarenal cross-clamping (IRCC) with the traditional approach of SRCC during surgery for juxtarenal AIOD. METHODS: A 10-year retrospective review of 87 patients who underwent open surgery for AIOD at our University Medical Center was performed. There were 52 males and 35 females (mean age of 52 years). Multivariate analysis was performed to assess operative time, blood loss, incidence of AKI, 30-day mortality, and recurrent aneurysm/pseudoaneurysm. RESULTS: Thirty-seven patients were found to have juxtarenal AIOD, which were divided into SRCC (n = 25) and IRCC (n = 12). Ten patients from the SRCC developed AKI versus 1 from the IRCC (30% vs. 8.3%, P = 0.04). SRCC demonstrated increased blood loss (1,681 vs. 591 mL, P = 0.004). Mean operative time was less in the IRCC group (5 vs. 7 hr, P = 0.0001). Thirty-day mortality in the SRCC group was 1 and 0 in the IRCC group, respectively. Recurrent aneurysm or pseudoaneurysm was not identified in endarterectomized aorta up to 4-year follow-up. CONCLUSIONS: Circumferential aortic endarterectomy followed with immediate IRCC is a feasible, safe, and effective approach for juxtarenal AIOD in properly selected patients. It may be associated with lower rates of AKI, intraoperative bleeding, operating room time, and length of hospital stay, when compared with the traditional SRCC.

Successful treatment of malar dermal melasma with a fractional ablative CO2 laser in a patient with type V skin.

BACKGROUND/OBJECTIVE: Melasma is a common disorder of hypermelanosis, and although numerous treatment modalities have been employed, many cases are refractory to treatment or the improvement after therapy is temporary. METHODS: The clinical files, treatment parameters, and photographs of a 59-year-old female with black skin with refractory malar dermal melasma treated using a fractionally ablative CO2 laser (Affirm 10,600 nm) for seven sessions were carefully reviewed. RESULTS: After treatment, clinical improvement was achieved. CONCLUSION: The fractional ablative CO2 laser is a potentially safe and effective modality for the treatment of dermal melasma in Fitzpatrick type V skin.

Surfactant treatment for congenital heart disease patients with acute respiratory distress syndrome.

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) can be a significant source of morbidity for pediatric cardiac patients in the intensive care unit. Children with unrepaired or palliated congenital heart disease are at increased risk for lower respiratory tract infections, while postoperatively they are at risk for ALI/ARDS precipitated by cardiopulmonary bypass. Surfactant dysfunction and inactivation are key contributors to the pathophysiology of ALI/ARDS, and there is growing evidence that exogenous intratracheal surfactant administration in noncardiac patients may ameliorate the lung injury seen in children with ALI/ARDS, leading to improved outcomes and survival. Evidence for a beneficial effect of exogenous surfactant treatment in congenital heart disease patients with ALI/ARDS is lacking. We present three consecutive children with congenital heart disease and ARDS who had significant and sustained improvement in lung function and oxygenation after treatment with exogenous surfactant, hastening their recovery from life-threatening hypoxemia.