Alaina K. Kipps

Background: Pseudoaneurysms of the left ventricular outflow tract (LVOT) are a life‐threatening entity, typically developing as a complication of infective endocarditis or prior cardiac surgery. They should be repaired to reduce the risk of systemic embolization and the catastrophic risks of rupture. Surgical resection has been the gold standard; however, percutaneous transcatheter closure has emerged as an alternative for patients deemed to be at prohibitive surgical risk. The procedural access routes and technical methods for closure remain variable and patient specific. Aims: This study aims to describe unique cases of percutaneous LVOT pseudoaneurysm closure in patients with mechanical valves. Methods: From 2023 to 2026, 4 patients underwent percutaneous transcatheter closure of LVOT pseudoaneurysms at our center after prior mechanical aortic valve or root replacement (AVR). Results: Case 1 highlights an antegrade transseptal approach to pack a wide‐necked post‐endocarditis pseudoaneurysm with coils. Case 2 demonstrates the ability of a microcatheter to engage a slit‐like orifice and utilization of coil embolization without device closure of the orifice due to proximity to the aortic valve ring. Case 3 illustrates a combined approach using devices to close 2 separate orifices and coils to pack a large aneurysm sac. Case 4 represents the first reported case of an excluded LVOT pseudoaneurysm accessed via a percutaneous, transthoracic puncture of the RV free wall and subsequent traversal of the interventricular septum. Conclusions: In our experience, percutaneous transcatheter closure is a feasible option in most cases and should be considered prior to operative revision unless there is an unstable valve, active endocarditis, or other complicating circumstance that mandate prosthetic valve removal or a surgical approach for other reasons.

Background: Pediatric acute care cardiology is a distinct subspecialty field within paediatric cardiology that has grown rapidly in recognition, with previously documented heterogeneity in its practice across 31 centres surveyed in 2017. Unit composition and care delivery across centres participating in the Paediatric Acute Care Cardiology Collaborative (PAC ³ ) have not been formally reassessed and shared, despite significant growth in the field. Methods: A 214-stem question Hospital Survey was created with 454 total response fields across eight domains important to paediatric acute care cardiology such a demographics, staffing, resources and therapies, and standard practices. PAC ³ centres were surveyed in September 2023 via REDCap. Descriptive statistics were performed. Results: Surveys were completed by 100% (47/47) of PAC ³ centers. Diverse unit composition exists with 37% of centres utilising a single, dedicated acute care cardiology unit, 28% using mixed-specialty acute care units, and 19% using acuity adaptable units, housing critical and acute care patients in one physical space. Since 2017, acute care cardiology-dedicated multidisciplinary staff has increased (physical therapy (PT): 0 to 4; occupational therapy (OT): 1 to 5; speech-language pathology (SLP): 0 to 4; PharmD: 7 to 26). There is heterogeneity in utilisation of many of the resources and therapies used in acute care cardiology, and use of ventricular assist devices on the acute care cardiology unit has increased. Conclusion: Significant variability exists in unit structure and care delivery models across a diverse group of centres providing acute care cardiology services. The Hospital Survey may assist in identifying best practices for similar centres across PAC ³ .

Background: Infective endocarditis is a leading cause of morbidity and mortality in children and adolescents with underlying CHD. Appropriate diagnostic workup and management in the inpatient setting can be challenging in this patient population due to the spectrum of disease complexity and the dynamic nature of the field. Therefore, the Paediatric Acute Care Cardiology Collaborative has undertaken the creation of this clinical practice guideline. Methods: A panel of paediatric cardiologists, infectious disease specialists, intensivists, advanced practice practitioners, pharmacists, cardiothoracic surgeons, and a dentist was convened. The literature was systematically reviewed for relevant articles on the management of infective endocarditis in patients with CHD. Using the modified Delphi technique, recommendations were generated and put through iterative Delphi rounds to achieve consensus for inclusion. Results: Based on 127 articles that met the inclusion criteria, 82 recommendations were generated, 50 of which achieved consensus for inclusion and are included in this guideline. They address risk factors specific to CHD lesion type and prior interventions including implanted material, diagnostic considerations, management strategies, and recommendations on counselling other healthcare providers, patients, and families. Of the 50 consensus recommendations, 36 are strong recommendations, though 20 have low or very low quality of evidence. Conclusions: A central theme in this guideline is that an individual’s specific CHD lesion and prior interventions must be carefully considered for risk stratification, diagnostic approach, and management. While most are strong recommendations, many are supported by low quality of evidence, emphasising the need for further research in this subject.

Objective: The Pediatric Acute Care Cardiology Collaborative (PAC ³ ) previously showed decreased postoperative chest tube duration and length of stay in children undergoing 9 Society of Thoracic Surgeons benchmark operations. Here we report how these gains were sustained over time and spread to 8 additional centers within the PAC ³ network. Methods: Patient data were prospectively collected across baseline and intervention phases at the original 9 centres (Pioneer) and 8 new centres (Spread). The Pioneer baseline phase was 6/2017–6/2018 and Spread was 5/2019–9/2019. The Pioneer intervention phase was 7/2018–7/2021 and Spread 10/2019–7/2021. The primary outcome measure was postoperative chest tube duration in hours, with the aim of 20% overall reduction. Balancing measures included chest tube reinsertion and readmission for pleural effusion. Statistical process control methods and traditional statistics were used to analyse outcomes over time. Results: Among 5,042 patients at 17 centres, demographics were comparable. The Pioneer cohort ( n = 3,383) sustained a 22.6% reduction in mean chest tube duration (from 91.9 hours to 70.5 hours), while the Spread cohort ( n = 1,659) showed a 9.7% reduction (from 73.1 hours to 66.0 hours) in the first 13 months following intervention. Across both cohorts, rates of reinsertion (2.0% versus 2.1%, p = 0.869) and readmission for effusion did not change (0.3% versus 0.5%, p = 0.285). Conclusions: This multicenter prospective quality improvement study demonstrated sustained reduction in chest tube duration at 9 centres while successfully spreading improvement to 8 additional centres. This project serves as a model for post-operative multicentre quality improvement across a large cohort of congenital cardiac surgery patients.

Background: Specialised training opportunities in paediatric cardiology are rare for advanced practice providers, creating an educational gap for novice practitioners. Standardised curricula have been cited as a beneficial intervention to optimally prepare these providers for highly specialised fields. We sought to understand the current onboarding practices of advanced practice providers in paediatric acute care cardiology to identify opportunities for curricular improvement. Materials and methods: A survey developed by a task force by the Pediatric Acute Care Cardiology Collaborative (PAC ³ ) was distributed across PAC ³ programmes in May 2023 to evaluate the onboarding practices of advanced practice providers at paediatric heart centres nationwide. Results: Survey responses reflected orienting practices at 19 paediatric heart centres representing varying programme and team sizes. Of the respondents, 32% felt their current model does not meet all the needs of the new team member. Key successful onboarding elements included a structured curriculum with goals and objectives, dedicated education time and materials, standardised assessments, and individualised learning in the presence of a supportive team. All respondents agreed that an online curriculum would be beneficial. Conclusions: There is no national standardised educational pathway for advanced practice providers entering paediatric acute care cardiology practice. There are opportunities to develop a formalised curriculum with structured learner assessment at a national level, which could be modified at the institution or learner level to enhance current onboarding practices.