Joyce T. Johnson

Management of infants with hypoplastic left heart syndrome is resource-intensive. Trends in initial Stage 1 palliation choice and associated hospital cost and outcomes over time are unclear. Using a retrospective cohort of infants n = 5194) underwent a Norwood with modified Blalock-Taussig shunt, (NmBT) 22.06% ( n = 1699) underwent a Norwood with right ventricle to pulmonary artery conduit (NRVPA), and 10.49% ( n = 808) underwent a hybrid procedure. The annual prevalence of NRVPA surpassed that of NBT in 2017. In the pooled analysis, infants undergoing NRV-PA had the lowest in-hospital mortality (11.2%, P < 0.0001) and lowest cost at $335,406 (IQR: $208,624 to $583,322 ( P = 0.001). A trend for increased median estimated hospitalisation cost was observed across time for all procedure choices ( P for trend <0.0001 for all). These data suggest that the NRV-PA is the preferred palliation choice, has the lowest in-hospital mortality, and is the most cost-effective option. Our findings suggest that all Stage 1 palliation options have become more expensive with no observed change in mortality.

Objectives: We leveraged decomposition analysis, commonly used in labor economics, to understand determinants of cost differences related to location of admission in children undergoing neonatal congenital heart surgery. Design: A retrospective cohort study. Setting: Pediatric Health Information Systems database. Patients: Neonates (p < 0.001) versus cardiac ICU/PICU admission. Characteristic effects accounted for higher costs in the neonatal ICU ($28,958 ± $2,044; p < 0.001). Differing levels of prematurity, genetic syndromes, hospital volume, age at admission, and infection contributed to higher neonatal ICU costs, with infection rate providing the most significant contribution ($13,581; p < 0.001). Aggregate structural effects were not associated with cost differences for those admitted to the neonatal ICU versus cardiac ICU/PICU (p = 0.1). Individually, prematurity and age at admission were associated with higher costs due to structural effects for infants admitted to the neonatal ICU versus cardiac ICU/PICU. Conclusions: The difference in cost between neonatal ICU and cardiac ICU/PICU admissions is largely driven by differing prevalence of risk factors between these units. Infection rate was a modifiable factor that accounted for the largest difference in costs between admitting units.

A comprehensive cardiac magnetic resonance (cardiac MR) study including both late gadolinium enhancement (LGE) and MR angiography may be indicated for patients with a history of acquired or congenital heart disease. To study the novel use of an extracellular agent for assessment of LGE combined with a blood pool contrast agent for detailed MR angiography evaluation to yield a comprehensive cardiac MR study in these patients. We reviewed clinical cardiac MR studies utilizing extracellular and blood pool contrast agents and noted demographics, clinical data and adverse events. We rated LGE image quality and MR angiography image quality for each vascular segment and calculated inter-rater variability. We also quantified contrast-to-noise ratio (CNR). Thirty-three patients (mean age 13.9 ± 3 years) received an extracellular contrast agent (10 gadobenate dimeglumine, 23 gadopentetate dimeglumine) and blood pool contrast agent (33 gadofosveset trisodium). No adverse events were reported. MRI indications included Kawasaki disease (8), cardiomyopathy and coronary anatomy (15), repaired congenital heart disease (8), and other (2). Mean LGE quality was 2.6 ± 0.6 with 97% diagnostic imaging. LGE quality did not vary by type of contrast agent given (P = 0.07). Mean MR angiography quality score was 4.7 ± 0.6, with high inter-rater agreement (k = 0.6–0.8, P < 0.002). MR angiography quality did not vary by type of contrast agent used (P = 0.6). Cardiac MR studies utilizing both extracellular and blood pool contrast agents are feasible and safe and provide excellent-quality LGE and MR angiography images. The use of two contrast agents allows for a comprehensive assessment of both myocardial viability and vascular anatomy during the same exam.