Risk Factors for Abuse in Children with Congenital Heart Disease Presenting at a Pediatric Tertiary Care Hospital

Background:Congenital heart disease(CHD)is a chronic medical condition often diagnosed at birth and requires surgical intervention,multiple hospitalizations,and lifelong care.This can put significant stress on the family,leading to altered maternal mental health,bonding and attachment issues,and the potential for child abuse.The purpose of this study is to explore the characteristics of a sample of young children with CHD who experienced hospitalization with concurrent concern for child abuse in a free-standing pediatric tertiary care hos-pital.Methods:Electronic medical records were reviewed for children aged 0–5 years old who were hospitalized with concern for child abuse between 2016 and 2020.Variables were extracted related to the history of presenta-tion,and sociodemographics including SDOH,admission,and discharge condition/follow-up.Descriptive statis-tics were used to characterize the sample and correlations to identify an association with abuse type.Results:Out of 251 hospitalizations involving concern for child abuse,49(19.5%)had a diagnosis of CHD.The majority of cases were neglect(51%),<1 year of age(80%),male(57%),Hispanic ethnicity(45%),and publicly insured(90%).CHD severity was moderate to severe(71%)with multiple co-occurring medical conditions(genetic syn-drome,failure to thrive(FTT),prematurity,history of a feeding tube,developmental delay,and intrauterine drug exposure).Correlations associated with physical abuse were age,maternal mental health,head injury,and history of Child Protective Services(CPS)involvement.Neglect correlated with age,FTT,head injury,history of a feeding tube,previous CPS involvement,and substance use.Correlates specifically related to prenatal substance use included age,maternal mental health status,history of domestic violence,CPS involvement,feeding tube,FTT,lack of housing,employment status,and public insurance.Conclusions:Our study highlights the risk for abuse in children with CHD,regardless of defect severity.The most common abuse type was neglect(mostly prenatal substance use)which was associated with few child characteristics,but many parent/caregiver and neighborhood factors.This underscores the need for individual and/or family-based screening and approaches to provide psy-chological support and needed resources to assist parents of children with CHD to prevent abuse.Interventions should focus on families of low socioeconomic status with limited support and/or resources.

Hypoxic hepatitis in children after cardiac surgery

To the Editor: Hypoxic hepatitis(HH), also known as ischemic hepatitis or shock liver, is a liver injury characterized by necrosis of centrilobular hepatocytes with a rapid increase in serum aminotransferase levels. The incidence rate of HH among patients in the intensive care unit(ICU) was found to be 0.9%-11.9% [1]. Occurrence of HH appears to have a significant impact on the clinical outcome.

A Systematic Approach to Pulmonary Valve Replacement in the Current Era

Background:Pulmonary valve replacement(PVR)can be accomplished via surgical,transcatheter,or hybrid approaches.There are inherent advantages to transcatheter PVR and hybrid PVR without cardiopulmonary bypass.We review the methods and results of a standardized institutional approach to PVR.Methods:Retrospective review of all PVR cases between February 2017 and February 2020.Hybrid PVR entailed off-pump RVOT plication with percutaneous transcatheter PVR.Results:Primary transcatheter PVR was attempted in 37,hybrid PVR was performed in 11,and on-pump surgical PVR was performed in 9.Median age at PVR was 27 years(6–65).Primary transcatheter PVR was successful in 35/37(2 converted to surgical).Standard surgical PVR was utilized for positive coronary compression testing(n=4),stent/valve system migration(n=2),or patient preference(n=3).In the hybrid group mean RVOT diameter was 34 mm(32–38).Median length of stay was 1 day for transcatheter PVR,5 for surgical,and 3 for hybrid(p=0.02).Median follow-up was 1.5 years.Re-interventions were one balloon valve dilation in a transcatheter PVR,and one valve dilation with subsequent transcatheter valve-in-valve PVR in the surgical cohort.One hybrid patient expired 11 months post procedure.Conclusions:A systematic approach to PVR utilizing all approaches in pre-defined order of preference leads to consistent outcomes in a wide variety of anatomic configurations.Transcatheter PVR may be accomplished in the majority of patients.When necessary,hybrid off-pump RVOT plication with transcatheter PVR avoids the need for cardiopulmonary bypass.

Significant exercise limitations after recovery from MIS-C related myocarditis

Background Myocarditis is one of the presentations of multisystemic infammatory syndrome in children(MIS-C)following coronavirus disease 2019(COVID-19).Although the reported short-term prognosis is good,data regarding medium-term functional capacity and limitations are scarce.This study aimed to evaluate exercise capacity as well as possible cardiac and respiratory limitations in children recovered from MIS-C related myocarditis.Methods Fourteen patients who recovered from MIS-C related myocarditis underwent spirometry and cardiopulmonary exercise testing(CPET),and their results were compared with an age-,sex-,weight-and activity level-matched healthy control group(n=14).Results All participants completed the CPET with peak oxygen uptake(peak.V O2),and the results were within the normal range(MIS-C 89.3%±8.9%and Control 87.9%±13.7%predicted.V O2).Five post-MIS-C patients(35%)had exerciserelated cardio-respiratory abnormalities,including oxygen desaturation and oxygen-pulse fattening,compared to none in the control group.The MIS-C group also had lower peak exercise saturation(95.6±3.5 vs.97.6±1.1)and lower breathing reserve(17.4%±7.5%vs.27.4%±14.0%of MVV).Conclusions Patients who recovered from MIS-C related myocarditis may present exercise limitations.Functional assessment(e.g.,CPET)should be included in routine examinations before allowing a return to physical activity in post-MIS-C myocarditis.Larger,longer term studies assessing functional capacity and focusing on physiological mechanisms are needed.