Health Systems Strengthening to Tackle the Global Burden of Pediatric and Congenital Heart Disease: A Diagonal Approach

1 Background Congenital heart disease(CHD)is the most common major congenital anomaly,affecting approximately one in every 100 live births[1].Among congenital anomalies,66%of preventable deaths are due to CHD,and 58%of the avertable morbidity and mortality due to congenital anomalies would result from scaling congenital heart surgery services[2].Every year,nearly 300,000 children and adults die from CHD,the majority of whom live in low-and middle-income countries(LMICs)[3].Approximately 49%of all individuals with CHD will require surgical or interventional care at some point in their lifetime[4];as a result of advances in access to and the delivery of such services,over 95%of children born with CHD in high-income countries now live into adulthood[3].Here,adults have surpassed children in the number of CHD cases at a ratio of 2:1[5].

Congenital Heart Disease Referred for Surgery: Analysis and Epidemiological Description in the Cardiology Department of CHU Ignace Deen

Introduction: Congenital heart disease includes all cardiac and vascular malformations. It accounts for approximately one third of all congenital malformations and is a public health problem, particularly in developing countries. The aim of this study was to analyze the epidemiological, clinical and paraclinical aspects of congenital heart disease. Methods: This was a retrospective descriptive and analytical study based on the records of 135 patients referred for surgery and followed up in the cardiology department of the Ignace Deen University Hospital, collected in November 2022. Results: Hospital prevalence was 5%. The mean age was 71 months, ranging from 1 month to 19 years. The age group over 24 months was the most represented (62%). The M/F sex ratio was 1.36. Urban origin was predominant (58%). The rate of children not attending school or dropping out was high (16%). Siblings with fewer than 4 children were the most common (88%). A heart murmur was the most frequent sign (78%), followed by cyanosis (36%) and heart failure (29%). The association between heart murmurs and CHD was proven with a p-value Conclusion: CHDs represent the main indication for paediatric cardiac surgery and follow-up (95%). We stress the importance of implementing a screening and management strategy for congenital heart disease.

Psychological needs of parents of children with complicated congenital heart disease after admitting to pediatric intensive care unit: A questionnaire study

BACKGROUND Parents of children with complicated congenital heart disease(CHD)have different needs after surgery.Little literature reports the impact factors for psychological needs of parents of children with complicated CHD.AIM To investigate the status quo of the needs of parents of children after surgery for complex CHD,and analyze the influencing factors,in order to provide a theoretical basis for formulating corresponding nursing countermeasures.METHODS A modified Chinese version of the Critical Care Family Needs Inventory(MCCFNI)was used to select 200 parents of children with complex CHD after surgery within 72 h after admission to the intensive care unit in our hospital to conduct an online questionnaire survey.The aim was to understand the needs of parents in relation to the following five aspects:The support from medical staff,comfort of the parents themselves,the acquisition of information,their closeness to the children,and assurance of the child’s condition.RESULTS Parents of children with complex CHD had a higher degree of demand,especially in terms of condition assurance,acquisition of information,and closeness to the children.The age,education level,and residence of the parents were related to the five dimensions of the needs of parents of children with complex CHD who had undergone surgery.CONCLUSION In practice,nurses should formulate corresponding nursing strategies based on the different cultural and social backgrounds of parents of children after complex CHD surgery to meet their different needs,and improve satisfaction.These findings provide a theoretical basis for constructing a family participatory nursing model for children in the intensive care unit in the future.

A New Three-Dimensional(3D)Printing Prepress Algorithm for Simulation of Planned Surgery for Congenital Heart Disease

Background:Three-dimensional printing technology may become a key factor in transforming clinical practice and in significant improvement of treatment outcomes.The introduction of this technique into pediatric cardiac surgery will allow us to study features of the anatomy and spatial relations of a defect and to simulate the optimal surgical repair on a printed model in every individual case.Methods:We performed the prospective cohort study which included 29 children with congenital heart defects.The hearts and the great vessels were modeled and printed out.Measurements of the same cardiac areas were taken in the same planes and points at multislice computed tomography images(group 1)and on printed 3D models of the hearts(group 2).Pre-printing treatment of the multislice computed tomography data and 3D model preparation were performed according to a newly developed algorithm.Results:The measurements taken on the 3D-printed cardiac models and the tomographic images did not differ significantly,which allowed us to conclude that the models were highly accurate and informative.The new algorithm greatly simplifies and speeds up the preparation of a 3D model for printing,while maintaining high accuracy and level of detail.Conclusions:The 3D-printed models provide an accurate preoperative assessment of the anatomy of a defect in each case.The new algorithm has several important advantages over other available programs.They enable the development of customized preliminary plans for surgical repair of each specific complex congenital heart disease,predict possible issues,determine the optimal surgical tactics,and significantly improve surgical outcomes.

Cardiac biomarkers in pediatric heart disease:A state of art review

Every year there are more than 11000 hospitalizations related to heart failure in children resulting in significant morbidity and mortality.Over the last two decades,our understanding,diagnosis and management of pediatric heart failure is evolving but our ability to prognosticate outcomes in pediatric heart acute heart failure is extremely limited due to lack of data.In adult heart failure patients,the role of cardiac biomarkers has exponentially increased over the last two decades.Current guidelines for management of heart failure emphasize the role of cardiac biomarkers in diagnosis,management and prognostication of heart failure.It is also noteworthy that these biomarkers reflect important biological processes that also open up the possibility of therapeutic targets.There is however,a significant gap present in the pediatric population with regards to biomarkers in pediatric heart failure.Here,we seek to review available data regarding cardiac biomarkers in the pediatric population and also explore some of the emerging biomarkers from adult literature that may be pertinent to pediatric heart failure.

Effects of Palivizumab Guideline Changes on RSV Admissions in Patients with Congenital Heart Disease and Prematurity

Background: Respiratory syncytial virus (RSV) causes significant morbidity and mortality in patients with a history of prematurity and congenital heart disease (CHD). In 2014, the guidelines for Palivizumab became more restrictive for this population. We hypothesized the percentage of RSV+ admissions would increase overall and in this target group (TG) specifically. Methods: We conducted a retrospective review of patients under age 2 years admitted with bronchiolitis two seasons prior to the change (Pre) and two seasons after (Post). Our TG included patients who were eligible prior to the 2014 changes but currently no longer eligible. We used chi-square analysis to answer the two main hypotheses: 1) Percent RSV+/total bronchiolitis Pre vs Post and 2) Percent of TG/RSV+ Pre vs Post. Results: 1283 patients (546 pre, 737 post) were admitted with the diagnosis of RSV between 2012-2016, 866 actually tested positive for RSV (367 Pre, 499 Post). There was no significant difference in the number of total patients admitted with RSV (Pre = 67.2%, Post = 67.7%) or in our TG (Pre 7.1% vs Post 8.2%). TG overall had a more complicated course: longer length of stay, median 5 days, IQR 2 - 12 vs 3 days, IQR 1 - 5, (p < 0.001), intensive care unit admissions (36% vs 22.8%, p = 0.02), positive pressure ventilation (25.4% vs 15.4%, p = 0.03) and intubation (16.4% vs 6.8%, p = 0.004), but there was no difference Pre vs Post. Conclusion: The TG had an overall higher acuity, but there was no increase in the number of patients hospitalized with RSV or severity as a result of the Palivizumab guideline changes.

Management of Specific Complications after Congenital Heart Surgery(I)

In addition to the general consequences of surgery and cardiopulmonary by-pass, lesion-specific complications can occur after surgery for congenital heart disease. It is important for the pediatric intensive care specialist to fully understand the preoperative anatomy and the intraoperative details of these patients. This allows a timely and appropriate treatment of general and lesion-specific complications. In this article we provide a list of commonly-performed surgical procedures and possible associated problems to be anticipated in the early postoperative period. Then it follows a discussion about the diagnosis and management of these complications, based on their pathophysiological features.

Kabuki-Syndrome and Congenital Heart Disease-A Twenty-Year Institutional Experience

Background:Patients with genetic syndromes who undergo surgery to correct congenital heart defects can be at risk for increased morbidity or mortality.Surgical outcomes and postoperative courses following congenital heart surgery in patients with Kabuki-Syndrome(KS)have not been well studied.Objectives:The purpose of this study was to describe the postoperative courses and associated outcomes in the largest set of KS patients undergoing congenital heart surgery to date.Methods:Patients with a confirmed molecular diagnosis of KS and a diagnosis of a CHD admitted to Texas Children’s Hospital between January 1,2000 and January 1,2020 were included(n=20).Demographics and medical histories were collected from the hospitals’electronic health records.Results:Of 20 patients identified with KS and a CHD,15 required surgical correction of their congenital cardiac malformation.Median age and weight at the time of surgery was 2 months and 4.1 kg,respectively.Median duration of hospital stay was 49 days for all surgeries and 151 days for the Norwood procedure.Postoperative infections and pleural effusions were detected and treated in 45.8%and 50%of patients,respectively.There was no in-hospital mortality for any surgery.Median follow up time was 5.6 years;survival at 6 years was 94%.Conclusions:Although KS patients seem to be at increased risk for a more complicated,prolonged postoperative course than that of patients without a genetic syndrome,patients with a diagnosis of a CHD and KS do not appear to be at increased risk of mortality following congenital heart surgery.

Pterygium Popliteal Syndrome Concerning a Case in the Pediatric Surgery Department of the Donka National Hospital (Conakry CHU)

Introduction: Popliteal pterygium syndrome is a rare birth defect, combining craniofacial, genitourinary and musculoskeletal abnormalities. It is an autosomal dominant disease caused by a mutation in the IRF6 gene. We report in this observation the 1st Guinean case corrected by the surgical method as well as a review of the literature for a diagnostic and therapeutic approach. Patient and observation: We present the case of a 7-day old male newborn weighing 2700 g who was received for bilateral cleft lip and palate, lower lip fossa or sinuses, bilateral popliteal pterygium, and triangular skin fold above the hallux. The patient underwent several surgical procedures aimed at correcting these abnormalities. The correction of the pterygium of the lower limbs was ensured by excision of the fibrous band, the tenoplasty in z of the calcaneal tendon on the right side and the skin plasty in z in series then immobilized by plaster splints. The immediate postoperative follow-up was straightforward. Conclusion: Popliteal pterygium syndrome is a rare congenital malformation, the diagnosis is primarily clinical. Early soft tissue lengthening surgery and serial z-skin plasty provide better correction of the knee pterygium. Correct correction of facial abnormalities gives the child a better appearance. The management of this syndrome is multidisciplinary.

Comparison of clinical outcomes and postoperative recovery between two open heart surgeries:minimally invasive right subaxillary vertical thoracomy and traditional median sternotomy

Objective: To compare the clinical outcomes of minimally invasive right subaxillary vertical thoracotomy and traditional median stemotomy through right atrium in treatment of common congenital heart diseases. Methods: Clinical data of 59 cases of common congenital heart diseases treated with minimally invasive right axillary vertical thoracotomy from May, 2011 to February, 2013 and 77 cases of same diseases with traditional median stemotomy in the past three years were retrospectively analyzed, including atrial septal defect, membranous ventricular septal defect and partial endocardial cushion defect. The results were compared from the two groups, including the time for operation and cardiopulmonary bypass, amount of blood transfusion, postoperative drainage, ventilation time, hospital stay, and prognosis. Results: No severe complications happened in both groups, like deaths or secondary surgery caused by bleeding. No significant differences were in CPB time and postoperative ventilator time between groups (P>0.05), while for all of the operative time, the length of incision, postoperative drainage and hospital stay, minimally invasive right axillary vertical thoracotomy was superior to median stemotomy, with statistically significant differences (P<0.05). In six month followup after operation, no complications of residual deformity and pericardial effusion were found in both groups by doing echocardiography, but mild pectus carinatum was found in 8 patients in the traditional median sternotomy group (traditional group), whereas patients in another group were well recovered. Conclusions: Minimally invasive right subaxillary vertical thoracotomy for common congenital heart diseases is as safe as traditional median stemotomy, without the increasing incidence of postoperative complications. Additionally, compared with traditional median stemotomy, minimally - invasive right subaxillary vertical thoracotomy is better in the aspects of hidden incision, appearance, and postoperative recovery.

Prediction of Pulmonary Arterial Pressure Level after Repair of Congenital Cardiac Communications and Discharge from the Hospital: Role of Down Syndrome and Early Postoperative Hemodynamics

Background:Postoperative pulmonary hypertension limits the success of surgical treatment in some patients with unrestrictive congenital cardiac communications.Identifying patients at risk of developing postoperative pulmonary hypertension is important to individualize follow-up strategies.Methods:We analyzed a prospective cohort of 52 pediatric patients(age 3 to 35 months)looking for perioperative predictors of mildly elevated pulmonary arterial pressure 6 months after surgery,defined as a systolic pressure greater than 30 mmHg by transthoracic echocardiography.This corresponds to a mean pulmonary arterial pressure of>20 mmHg.Clinical,echocardiographic and hemodynamic parameters were investigated.Perioperative hemodynamics was assessed by directly measuring pulmonary and systemic arterial pressures using indwelling catheters.Early postoperative pulmonary hemodynamics was defined as the mean pulmonary/systemic mean arterial pressure ratio(PAP/SAP)obtained per patient during the first 6 h of postoperative care.Results:Among the factors that were investigated as possible predictors,perioperative hemodynamics and the presence of Down syndrome were initially selected using univariate analysis(p<0.030).Early postoperative PAP/SAP was correlated with PAP/SAP obtained in the operating room just after cardiopulmonary bypass(r=0.70,p<0.001),and it was higher in subjects with Down syndrome than in nonsyndromic individuals(p=0.003).Early postoperative PAP/SAP was the only predictor selected using multivariate analysis.It was characterized as an independent predictor after adjustments for possible confounders.An early postoperative PAP/SAP of>0.35 was 76%sensitive and 74%specific at predicting a systolic pulmonary arterial pressure of>30 mmHg 6 months after surgery(hazard ratio with 95%CI 8.972[2.428–33.158],p=0.002).Conclusion:The hypertensive early postoperative behavior of the pulmonary circulation was strongly but not exclusively associated with Down syndrome,and it was characterized as an independent predictor of altered pulmonary arterial pressure after discharge from the hospital.

SURGICAL EXPERIENCE OF COMPLEX CONGENITAIL HEART DEFECTS IN CHILDREN AND INFANTS

From January 1982 to June 1990, 2730 patients with congenital heart defects (CHDS) were treated at Xinhua Hospital there were 537 cases of complex lesions. Fifty of 537 patients died, the hospital mortality rate was 9.31%. On the basis of our clinical experience, it is important that the accurate diagnosis was made promptly in neonate with complex CHDs. The surgical results can be improved by the use of PGEI and balloon atrial septostomy in the cyanotic neonate. For the congestive CHDs, the operation must be per formed in the early life to prevent pulmonary hypertension. Improved methods of preoperative and postoperative care have contributed to these results.

Blood conservation pediatric cardiac surgery in all ages and complexity levels

AIM To demonstrate the feasibility of blood conservation methods and practice across all ages and risk categories in congenital cardiac surgery.METHODS We retrospectively analyzed a collected database of 356 patients who underwent cardiac surgery using cardiopulmonary bypass(CPB) from 2010-2015. The patients were grouped into blood conservation(n = 138) and nonconservation(n = 218) groups and sub-grouped based on their ages and procedural complexity scores. RESULTS There were no statistical differences in gender,weight,pre-operative and pre-CPB hematocrit levels in both groups. Despite equivalent hematocrit levels during and after CPB for both groups,there was significantly less operative homologous blood utilized in blood conservation group across all ages and complexity levels. CONCLUSION Blood conservation surgery can be performed in con-genital patients needing cardiac surgery in all age groups and complexity categories. The above findings in addition to attendant risks and side effects of blood transfusion and the rising cost of safer blood products justify blood conservation in congenital cardiac surgery.

CLINICAL OUTCOMES OF 22 PEDIATRIC PATIENTS WITH CONGENITAL HEART DISEASE MANAGED WITH MECHANICAL CIRCULATORY SUPPORT AFTER CARDIAC SURGERY

Objective To investigate the clinical outcomes of children with congenital heart disease （CHD） requiring extracorporeal membrane oxygenation （ECMO） and left ventricular assist device （LVAD） support after cardiac surgery. Methods A total of 22 patients with CHD who required postcardiotomy mechanical circulatory support between March 2004 and March 2011 （85 months ） were analyzed retrospectively. Median age of the patients was 420 d （ 15 d - 4 years） and median weight was 3.4 kg （ 2 - 14. 5 kg ）. Eight patients were put on ECMO, while 14 patients were placed on LVAD. Results Thirteen （59%） patients died and 9 （41% ） survived to discharge. In survivals, the duration of LVAD and the duration of ECMO were both shorter than those of nonsurvivals （P 〈 O. 05）. The main complication was bleeding. Conclusion The earlier treatment and application of more advanced cardiac support devices for CHD patients are key factors for reducing complications.

Predictive value of C-reactive protein and the Pediatric Risk of Mortality Ⅲ Score for occurrence of postoperative ventilator-associated pneumonia in pediatric patients with congenital heart disease

Importance:Ventilator-associated pneumonia (VAP) is one of the most common complications after cardiac surgery in children with congenital heart disease (CHD).Early prediction of the incidence of VAP is important for clinical prevention and treatment.Objective:To determine the value of serum C-reactive protein (CRP) levels and the Pediatric Risk of Mortality Ⅲ (PRISM Ⅲ) score in predicting the risk of postoperative VAP in pediatric patients with CHD.Methods:We performed a retrospective review of clinical data of 481 pediatric patients with CHD who were admitted to our pediatric intensive care unit.These patients received mechanical ventilation for 48 hours or longer after corrective Surgery.On the basis of their clinical manifestations and laboratory results,patients were separated into two groups of those with VAP and those without VAP.CRP levels were measured and PRISM Ⅲ scores were collected within 12 hours of admission to the pediatric intensive care unit.The Pearson correlation coefficient was used to evaluate the association of CRP levels and the PRISM score with the occurrence of postoperative VAP.A linear regression model was constructed to obtain a joint function and receiver operating curves were used to assess the predictive value.Results:CRP levels and the PRISM Ⅲ score in the VAP group were significantly higher than those in the non-VAP group (P < 0.05).Receiver operating curves suggested that using CRP + the PRISM Ⅲ score to predict the incidence of VAP after congenial heart surgery was more accurate than using either of them alone (CRP + the PRISM Ⅲ score:sensitivity:53.2%,specificity:85.7%).When CRP + the PRISM Ⅲ score was greater than 45.460,patients were more likely to have VAP.Interpretation:Although using CRP levels plus the PRISM Ⅲ score to predict the incidence of VAP after congenial heart surgery is more accurate than using either of them alone,its predictive value is still limited.

Cardiovascular impact of COVID-19 with a focus on children: A systematic review

BACKGROUND Since the beginning of the pandemic,coronavirus disease-2019(COVID-19)in children has shown milder cases and a better prognosis than adults.Although the respiratory tract is the primary target for severe acute respiratory syndrome coronavirus 2(SARS-CoV-2),cardiovascular involvement is emerging as one of the most significant and life-threatening complications of SARS-CoV-2 infection in adults.AIM To summarize the current knowledge about the potential cardiovascular involvement in pediatric COVID-19 in order to give a perspective on how to take care of them during the current pandemic emergency.METHODS Multiple searches in MEDLINE,PubMed were performed using the search terms“COVID-19”or“SARS-CoV-2"were used in combination with“myocardial injury”or"arrhythmia"or“cardiovascular involvement”or"heart disease"or"congenital heart disease"or“pulmonary hypertension”or"long QT"or“cardiomyopathies”or“channelopathies”or"Multisystem inflammatory system"or"PMIS"or“MIS-C”or”Pediatric multisystem inflammatory syndrome"or"myocarditis"or"thromboembolism to identify articles published in English language from January 1st,2020 until July 31st,2020.The websites of World Health Organization,Centers for Disease control and Prevention,and the Johns Hopkins Coronavirus Resource Center were reviewed to provide up to date numbers and infection control recommendations.Reference lists from the articles were reviewed to identify additional pertinent articles.Retrieved manuscripts concerning the subject were reviewed by the authors,and the data were extracted using a standardized collection tool.Data were subsequently analyzed with descriptive statistics.For Pediatric multisystemic inflammatory syndrome temporally associated with COVID-19(PMIS),multiple meta-analyses were conducted to summarize the pooled mean proportion of different cardiovascular variables in this population in pseudo-cohorts of observed patients.RESULTS A total of 193 articles were included.Most publications used in this review were single case reports,small case series,and observational small-sized studies or literature reviews.The meta-analysis of 16 studies with size>10 patients and with complete data about cardiovascular involvement in children with PMIS showed that PMIS affects mostly previously healthy school-aged children and adolescents presenting with Kawasaki disease-like features and multiple organ failure with a focus on the heart,accounting for most cases of pediatric COVID-19 mortality.They frequently presented cardiogenic shock(53%),ECG alterations(27%),myocardial dysfunction(52%),and coronary artery dilation(15%).Most cases required PICU admission(75%)and inotropic support(57%),with the rare need for extracorporeal membrane oxygenation(4%).Almost all of these children wholly recovered in a few days,although rare deaths have been reported(2%).Out of PMIS cases we identified 10 articles reporting sporadic cases of myocarditis,pulmonary hypertension and cardiac arrythmias in previously healthy children.We also found another 10 studies reporting patients with preexisting heart diseases.Most cases consisted in children with severe COVID-19 infection with full recovery after intensive care support,but cases of death were also identified.The management of different cardiac conditions are provided based on current guidelines and expert panel recommendations.CONCLUSION There is still scarce data about the role of cardiovascular involvement in COVID-19 in children.Based on our review,children(previously healthy or with preexisting heart disease)with acute COVID-19 requiring hospital admission should undergo a cardiac workup and close cardiovascular monitoring to identify and treat timely life-threatening cardiac complications.

Perioperative extracorporeal membrane oxygenation in pediatric congenital heart disease:Chinese expert consensus

Background Congenital heart disease(CHD)is one of the main supportive diseases of extracorporeal membrane oxygena-tion in children.The management of extracorporeal membrane oxygenation(ECMO)for pediatric CHD faces more severe challenges due to the complex anatomical structure of the heart,special pathophysiology,perioperative complications and various concomitant malformations.The survival rate of ECMO for CHD was significantly lower than other classifica-tions of diseases according to the Extracorporeal Life Support Organization database.This expert consensus aims to improve the survival rate and reduce the morbidity of this patient population by standardizing the clinical strategy.Methods The editing group of this consensus gathered 11 well-known experts in pediatric cardiac surgery and ECMO field in China to develop clinical recommendations formulated on the basis of existing evidences and expert opinions.Results The primary concern of ECMO management in the perioperative period of CHD are patient selection,cannulation strategy,pump flow/ventilator parameters/vasoactive drug dosage setting,anticoagulation management,residual lesion screening,fluid and wound management and weaning or transition strategy.Prevention and treatment of complications of bleeding,thromboembolism and brain injury are emphatically discussed here.Special conditions of ECMO management related to the cardiovascular anatomy,haemodynamics and the surgical procedures of common complex CHD should be considered.Conclusions The consensus could provide a reference for patient selection,management and risk identification of periop-erative ECMO in children with CHD.

COVID-19 and congenital heart disease:a case series of nine children

Background Coronavirus disease 2019(COVID-19)is the current pandemic disease without any vaccine or efficient treat-ment to rescue the patients.Underlying diseases predispose the patients to a more severe disease and to a higher mortality rate.However,little evidence exists about COVID-19 outcomes in the pediatric population with congenital heart disease(CHD).Here,we report nine children with COVID-19 and concomitant CHD.Methods Our study included nine children with COVID-19 and concomitant CHD who were admitted to Children Medical Center Hospital during March and April 2020.The patients were classified based on the final outcome(death),and their clinical sign and symptoms,type of CHD,and drugs administered were compared.Results Among the nine patients,two died and we compared different characteristics,laboratory results and clinical findings of these cases based on the mortality.The deceased patients had severe types of CHD,worse arterial blood gases,severe clinical symptoms,higher mean level of partial thromboplastin time and C-reactive protein,and required more medications.Conclusions The present study showed that the general consideration of mild COVID-19 in children does not include patients with CHD and that it is necessary to pay greater attention to children with CHD to determine guidelines for treatment of COVID-19 in these children.Owing to the scarcity of CHD and COVID-19,we reported only nine cases.However,further studies are highly required in this regard.

Late intervention in an asymptomatic pediatric patient with anomalous left coronary artery

Anomalous left coronary artery from the pulmonary artery(ALCAPA) is most commonly diagnosed within the first year of life with congestive heart failure symptomatology reflecting left ventricle(LV) dysfunction. The late diagnosis of ALCAPA is presented in a 5-yearold without significant LV dysfunction, mild LV dilatation and only mild mitral regurgitation that did not change significantly after surgery. The timing of surgical intervention in the late diagnosis of ALCAPA remains unclear despite risks of significant ongoing myocardial injury secondary to coronary artery hypoperfusion and progressive mitral valve dysfunction. Intervention in this case allows for revascularization which may reverse ventricular and valvular dysfunction.

A Rare Case of Infective Mediastinitis after Melody Valve Implantation

Pulmonary valve implant is frequently necessary in children and adults with congenital heart disease.Infective endocarditis represents a rare but life-threatening complication after transcatheter pulmonary valve implantation.There are various treatments for native or prosthetic valve endocarditis.Surgical intervention,combined with intravenous antibiotic treatment,is of paramount importance,in case of concomitant mediastinal infection,in order to ensure the radical debridement of all infected tissue,avoiding any recurrent endocarditis.In this report,we describe a rare case of mediastinitis,associated with an infected endocarditis,occurring 8 months after Melody(Medtronic
,Minneapolis,USA)valve implant,successfully treated with the implantation of a homograft to reconstruct the right ventricular outflow tract.