Nigel E. Drury

Introduction: del Nido cardioplegia had not been commercially available in the United Kingdom prior to the DESTINY trial, a multi-centre individually randomised controlled trial to evaluate whether del Nido or St Thomas’ blood cardioplegia provides better myocardial protection in children of all ages. In this sub-study, we explored the experiences of surgeons and perfusionists using del Nido in the trial, to support implementation of del Nido in the United Kingdom and identify any practical or safety concerns. Methods: We conducted qualitative, semi-structured interviews with surgeons and perfusionists who had completed at least three cases with del Nido cardioplegia in the trial. Interviews were conducted face-to-face or via Zoom, digitally audio-recorded, transcribed, and analysed using a hybrid thematic approach, according to the Consolidated Framework for Implementation Research domains. Trial registration: ISRCTN13638147, registered July 2021. Results: Twelve participants were interviewed, six surgeons and six perfusionists from all four paediatric cardiac surgical centres participating in the trial. Four key themes emerged: (1) attitudes towards the use of del Nido cardioplegia; (2) practical aspects of delivering del Nido cardioplegia; (3) blood conservation techniques; and (4) adopting del Nido cardioplegia into routine clinical use beyond the trial. Conclusions: Surgeons and perfusionists reported that they found del Nido cardioplegia to have practical benefits over St Thomas’ blood cardioplegia but felt that further research on the optimal cooling temperature, blood conservation, and dosing for paediatric use are required to support the development of a best practice guideline and guide national implementation beyond the trial.

Objectives To understand healthcare professionals’ views on current physiotherapy service provision in children with congenital heart disease (CHD), how physiotherapy could be better used post-cardiac surgery and perceived barriers to service expansion. Design Cross-sectional survey using a one-off self-completed online questionnaire, with open and closed questions, in June–August 2024. Setting Each of the 12 level 1 paediatric cardiac surgical centres in the UK National Health Service and Children’s Health Ireland. Participants Healthcare professionals providing clinical care to children undergoing cardiac surgery. Results 80 responses were obtained, with at least one response from each centre. Healthcare professionals conduct motor, developmental and functional evaluations across all age groups, with referrals to physiotherapy primarily based on physical examination (39, 87%). They expressed dissatisfaction with community physiotherapy services (64, 81%) compared with inpatient services (29, 36%), although they indicated that expanding services would positively impact patients and families. There is a lack of consensus regarding intervention frequency, duration and which patient groups should be prioritised. Respondents identified a lack of funding as the primary barrier to service expansion (76, 95%). Reported barriers for families included volume of medical appointments (69, 86%), transportation (66, 83%) and finances (62, 78%). Conclusions Healthcare professionals appreciate the positive impact physiotherapy can have on post-surgical management of children with CHD. The importance of expanding services was emphasised. However, to effectively support clinical practice, it is crucial to understand which patient groups should be prioritised and at what stage, as well as determining the optimal amount of physiotherapy that positively impacts patient outcomes.

Background: Children with congenital heart disease demonstrate developmental and functional impairment throughout their life. Published literature is limited but suggests postsurgical physiotherapy positively impacts developmental and functional outcomes in these children. We aimed to understand parental opinions of their child’s development or function, their experiences of physiotherapy services, how they feel physiotherapy could be used to support their child and what impacted access to services. Methods: A qualitative study using semistructured online interviews was conducted among parents of children with a diagnosis of congenital heart disease under the age of 16 years, who had undergone cardiac surgery in the UK. Data were collected between July and December 2024. The data were explored using reflexive thematic analysis and the study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research checklist. Results: 12 semistructured interviews were completed involving 12 mothers and 1 father. Themes identified were parental priorities; understanding and experience of physiotherapy; access to physiotherapy and ideal physiotherapy service. Parental expectations of their child’s development were influenced by antenatal care and postnatal experiences. Parents continually evaluate the need for their child to access developmental and functional support. Engagement with physiotherapy is influenced by parental understanding, quality of service provision, impact of interventions on their child and the practical and emotional consequences to their family. Parents want physiotherapy services to deliver parental education and individualised support throughout their child’s life, particularly around key life events. Conclusions: Parental engagement with physiotherapy services is influenced by parental expectations of their child’s development and function, and their understanding of the potential benefits of physiotherapy. Physiotherapists should prioritise promoting and increasing awareness of physiotherapists’ role in children with congenital heart disease, alongside parental education and individualised care, to facilitate engagement.

Introduction: Neonatal aortic arch surgery is associated with neurological morbidity of varying severity which is detected and potentially limited through neuroprotective strategies. We conducted a survey of healthcare professionals at all neonatal cardiac surgery centres in the United Kingdom and Ireland to determine current intraoperative neuromonitoring and neuroprotection practice. Methods: An online cross-sectional survey was sent to congenital cardiac surgeons, cardiac anaesthetists, clinical perfusion scientists, and clinical neurophysiology professionals in all 12 level 1 paediatric cardiac surgical centres. Information was sought on their current clinical practice in neonates undergoing aortic arch surgery, including pharmacological management, cardiopulmonary bypass, acid-base and blood pressure management, neuromonitoring, and hypothermic circulatory arrest, and the feasibility and willingness to participate in a future clinical trial of neuroprotective strategies in these patients. Results: We received 55 (34%) responses, including representatives of all four clinical disciplines in 9 (75%) centres. Cooling to a nasopharyngeal temperature of 18°C before hypothermic circulatory arrest, selective antegrade cerebral perfusion, and near-infrared spectroscopy (NIRS) monitoring are common practice, whereas pharmacology, acid-base management, blood pressure and flow parameters, and NIRS-based interventions vary. In 7 (58%) centres, respondents from all four disciplines were willing to consider participation in a future clinical trial on neuroprotection. Conclusions: Aspects of intraoperative neuroprotection and neuromonitoring are common across centres, although key areas of practice differ between practitioners and institutions. Most respondents were willing to participate in a future multi-centre clinical trial, which suggests clinical equipoise in the optimal strategy to protect the neonatal brain during aortic arch surgery.

Objectives: Many models of bioprosthesis are available for pulmonary valve replacement in adults with congenital heart disease, but there is a lack of randomized evidence to guide practice. We surveyed congenital cardiac surgeons to establish current practice and willingness to change within a clinical trial. Methods: An online survey was sent to all consultant congenital cardiac surgeons in adult congenital centres in the United Kingdom and Ireland. Information was sought on preferred prostheses, factors influencing decision-making, implant technique, postoperative anticoagulation, practice variations in adolescents, and willingness to randomize patients to different prostheses within a trial. Results: Responses were obtained from 27 (69%) surgeons. A total of 19 (70%) preferred an Edwards bovine pericardial valve, most commonly the Inspiris Resilia (7, 26%). Only 2 (7%) favoured the Hancock II valve; the remaining 6 (22%) preferred pulmonary homografts. Data regarding long-term freedom from reintervention (23, 85%) was the most important factor influencing prosthesis choice. A total of 22 (81%) surgeons were willing to randomize adult patients to either a bovine pericardial valve or a porcine xenograft in a clinical trial, with Perimount Magna Ease and Hancock II being the most acceptable, respectively. Willingness to randomize dropped to 11 (41%) surgeons for adolescent patients. Conclusions: This survey demonstrates heterogeneity in the choice of pulmonary valve prosthesis. Combined with a lack of evidence from clinical trials, our findings support the presence of clinical equipoise. Most surgeons are willing to change practice, suggesting that a pragmatic, multicentre, randomized controlled trial comparing bovine pericardial versus porcine xenograft for pulmonary valve replacement in adults is feasible.

Introduction While survival rates following neonatal surgery for congenital heart disease (CHD) have improved over the years, neurodevelopmental delays are still highly prevalent in these patients. After correcting for the CHD subtype, the severity of developmental impairment is dependent on multiple factors, including intraoperative brain injury, which is more frequent and more severe in those undergoing aortic arch repair with deep hypothermic circulatory arrest (DHCA). It is proposed that brain injury may be reduced if cooling is stopped at the point of electrocerebral inactivity (ECI) on electroencephalogram (EEG), but there is limited evidence to support this as few centres perform perioperative EEG routinely. This study aims to assess the feasibility of EEG monitoring during neonatal aortic arch repair and investigate the relationship between temperature and EEG to inform the design of a future clinical trial. Methods and analysis Single-centre prospective observational cohort study in a UK specialist children’s hospital, aiming to recruit 74 neonates (≤4 weeks corrected age) undergoing aortic arch repair with DHCA. EEG will be acquired at least 1–3 hours before surgery, and brain activity will be monitored continuously until 24 hours following admission to intensive care. Demographic, clinical, surgical and outcome variables will be collected. Feasibility will be measured by the number of patients recruited, data collection procedures, technically successful EEG recordings and adverse events. The main outcomes are the temperature at which ECI is achieved and its duration, EEG patterns at key perioperative steps and neurodevelopmental outcomes at 24 months postsurgery. Ethics and dissemination The study was approved by the Yorkshire and The Humber Sheffield National Health Service Research Ethics Committee (20/YH/0192) on 18 June 2020. Written informed consent will be obtained from the participant’s parent/guardian prior to surgery. Findings will be disseminated to the academic community through peer-reviewed publications and presentations at conferences. Parents/guardians will be informed of the results through a newsletter in conjunction with local charities.

Introduction Myocardial protection against ischaemia–reperfusion injury is a key determinant of heart function and outcome following cardiac surgery in children. However, myocardial injury still occurs routinely following aortic cross-clamping, as demonstrated by the ubiquitous rise in circulating troponin. del Nido cardioplegia was designed to protect the immature myocardium and is widely used in the USA but has not previously been available in the UK, where St. Thomas’ blood cardioplegia is most common. The del Nido versus St. Thomas’ blood cardioplegia in the young (DESTINY) trial will evaluate whether one solution is better than the other at improving myocardial protection by reducing myocardial injury, shortening ischaemic time and improving clinical outcomes. Methods and analysis The DESTINY trial is a multicentre, patient-blinded and assessor-blinded, parallel-group, individually randomised controlled trial recruiting up to 220 children undergoing surgery for congenital heart disease. Participants will be randomised in a 1:1 ratio to either del Nido cardioplegia or St. Thomas’ blood cardioplegia, with follow-up until 30 days following surgery. The primary outcome is area under the time–concentration curve for plasma high-sensitivity troponin I in the first 24 hours after aortic cross-clamp release. Secondary outcome measures include the incidence of low cardiac output syndrome and Vasoactive-Inotropic Score in the first 48 hours, total aortic cross-clamp time, duration of mechanical ventilation and lengths of stay in the paediatric intensive care unit and the hospital. Ethics and dissemination The trial was approved by the West Midlands—Coventry and Warwickshire National Health Service Research Ethics Committee (21/WM/0149) on 30 June 2021. Findings will be disseminated to the academic community through peer-reviewed publications and presentation at national and international meetings. Parents will be informed of the results through a newsletter in conjunction with a national charity. Trial registration number ISRCTN13638147; Pre-results.

The James Lind Alliance (JLA) is a National Institute for Health and Care Research (NIHR)-funded initiative to identify and prioritise unanswered questions for research through priority setting partnerships (PSP).1 2 These comprise a three-stage consultation process: an initial survey to gather uncertainties; an interim prioritisation survey and a final priority setting workshop. PSPs are considered the gold standard, providing an equitable mechanism for agreeing which future research matters most to patients, their families and clinicians, through shared decision-making. Accordingly, the NIHR has a rolling funding call across four of their research programmes for studies which address JLA PSP research priorities.3 Of the 180 PSPs completed to date, several have generated Top 10 lists of priorities related to cardiovascular disease in the UK, including heart surgery,4 advanced heart failure5 and cardiomyopathy.6 In 2021–22, we developed, conducted and reported the congenital heart disease (CHD) PSP, bringing together patients with lived experience, parents, national charities and healthcare professionals from across the UK to determine national priorities for research in children and adults with CHD.7 8 In this article, we reflect on our experiences, what went well, what we could have done better and what we learnt from the process, to benefit others embarking on a similar priority-setting journey.

Background: Reinterventions may influence the outcomes of children with functionally single‐ventricle (f‐SV) congenital heart disease. Methods and Results: We undertook a retrospective cohort study of children starting treatment for f‐SV between 2000 and 2018 in England, using the national procedure registry. Patients were categorized based on whether they survived free of transplant beyond 1 year of age. Among patients who had transplant‐free survival beyond 1 year of age, we explored the relationship between reinterventions in infancy and the outcomes of survival and Fontan completion, adjusting for complexity. Of 3307 patients with f‐SV, 909 (27.5%), had no follow‐up beyond 1 year of age, among whom 323 (35.3%) had ≥1 reinterventions in infancy. A total of 2398 (72.5%) patients with f‐SV had transplant‐free survival beyond 1 year of age, among whom 756 (31.5%) had ≥1 reinterventions in infancy. The 5‐year transplant‐free survival and cumulative incidence of Fontan, among those who survived infancy, were 93.4% (95% CI, 92.4%–94.4%) and 79.3% (95% CI, 77.4%–81.2%), respectively. Both survival and Fontan completion were similar for those with a single reintervention and those who had no reinterventions. Patients who had >1 additional surgery (adjusted hazard ratio, 3.93 [95% CI, 1.87–8.27] P 1 additional interventional catheter (adjusted subdistribution hazard ratio, 0.71 [95% CI, 0.52–0.96] P =0.03) had a lower likelihood of achieving Fontan. Conclusions: Among children with f‐SV, the occurrence of >1 reintervention in the first year of life, especially surgical reinterventions, was associated with poorer prognosis later in childhood.

Introduction Intermittent cardiac output (CO) studies using thermodilution are considered the gold standard. We have developed a stroke volume (SV) calculator from pulmonary pulse pressure (PP) to allow continuous monitoring of SV and CO from PP. Methods Hemodynamic data on 169 patients following orthotopic heart transplantation were used to compare our calculator-derived SV (and SV index, or SVi) against thermodilution-derived SV on admission into intensive care unit immediately following heart transplantation (T0) and 6 h after admission (T6). Results The calculated SV correlated with thermodilution-derived SV T0 (r = 0.920, p < 0.001, coefficient of 0.539 and the constant of 2.06). The median calculator SV, adjusted for coefficient and constant, was 48.4 ml (37.7, 60.7), comparable to the median thermodilution-derived SV 47.9 ml (37.5, 61.0), p = 0.737 with acceptable agreement on Bland–Altman plots. The thermodilution-derived SVi was 28.1 ml (19.7, 38.7) and adjusted calculator-derived SVi 28.9 ml (19.7, 39.9), p = 0.781. At T6, median thermodilution-derived SVi was 27.7 ml (19.5, 35.9) compared to the calculator-derived SVi median of 26.1 ml (17.7, 37.7), p = 0.203. Conclusions Changes in PP can be used to track changes in SV using this calculator. Changes in PP may be used to assess response to treatment in the early post-operative period.