Emily M. Bucholz

Background: Access to quality health care is a key social determinant of health. We determined whether geographic access to pediatric cardiac services differed by neighborhood‐level opportunity, racial and ethnic population composition, and urbanicity. Methods: Geospatial analysis delineated geographic access to hospitals with pediatric cardiac and cardiac‐surgical services. Geographic access was defined in 4 drive‐time catchments (0–30, 31–60, 61–120, and 121–240‐minutes) and dichotomizing direct (≤60‐minute) versus limited (>60‐minute) access. Mean predicted Child Opportunity Index (COI), percentage of racial and ethnic populations considered medically underserved and rural–urban residence were compared by geographic access. Prevalence ratios compared the prevalence of limited geographic access for low COI and percentage of populations medically underserved catchments compared with high, and rural versus urban areas. Additional analyses controlled for hospital characteristics. Results: Limited access to pediatric cardiac and surgical care was more prevalent in very low quintile COI catchments versus very high (prevalence ratio, 3.64 [95% CI, 2.61–5.07] and 2.98 [95% CI, 2.04–4.35], respectively). Catchments with >60‐minute drive time to cardiac care had on average>6 point lower COI. Catchments closer to cardiac services were more urban and with a higher percentage of populations medically underserved. Prevalence of limited geographic access to pediatric cardiac care was higher in rural versus urban catchments (prevalence ratio, 3.48 [3.02, 4.00]). Incorporating hospital characteristics increased COI differences and attenuated the higher percentage of populations medically underserved with direct cardiac‐surgical access. Conclusions: On average, areas with fewer neighborhood‐level resources promoting healthy child development are associated with greater distance to pediatric cardiac services. Geospatial analyses identify specific areas with limited access to cardiac care to focus future resource allocation.

Background: Stroke is a recognized complication following transcatheter aortic valve replacement (TAVR). Although women have historically had a higher rate of bleeding and vascular complications after TAVR, contemporary data on sex differences in post‐TAVR stroke and stroke severity are lacking. Disabling strokes significantly affect quality of life and outcomes, underscoring the need to explore sex‐specific variations in post‐TAVR stroke risk. Methods: In this retrospective cohort study, we included all patients who underwent TAVR in the National Inpatient Sample from 2016 to 2021. Stroke and stroke severity were ascertained using validated claims‐based algorithms. Disabling strokes were defined as those resulting in death or discharge to a nonhome location. We used multivariable logistic regression to evaluate the association between sex and stroke while adjusting for covariates, including cerebral embolic protection use, and accounting for survey weights. Results: Among our weighted sample of 379 410 patients (43.9% female), women demonstrated higher overall in‐hospital stroke incidence compared with men (2.31% versus 1.69%; adjusted odds ratio [aOR], 1.208 [95% CI, 1.082–1.350]). This difference was driven primarily by disabling strokes, which were more common in women (1.61% versus 1.01%; aOR, 1.327 [95% CI, 1.158–1.520]). Conversely, the incidence of nondisabling stroke was not statistically different between sexes (0.70% versus 0.67%;( aOR, 1.013 [95% CI, 0.844–1.215]). Conclusions: Among patients undergoing TAVR in contemporary practice, women had a higher rate of any stroke and disabling strokes compared with men. These findings emphasize the need for tailored strategies to mitigate stroke risk and improve outcomes for female TAVR patients.

Background: Neurodevelopmental impairments are common in children with congenital heart disease. The Cardiac Neurodevelopmental Outcome Collaborative and Pediatric Cardiac Critical Care Consortium registry linkage allows for the analysis of associations between neurodevelopmental, medical, and sociodemographic variables in a large contemporary cohort. Methods: Children with congenital heart disease who required surgery with cardiopulmonary bypass at 1 standard deviation lower on all Bayley indices than those without ( P P <0.001) in both Cognitive and Motor indices; participants with transposition of the great arteries exhibited the highest scores compared with other cardiac diagnoses. Lower birth weight, male sex, older age at initial surgery, longer hospital length of stay, more cardiac catheterizations, and lower primary caregiver education were independently associated with worse performance in all indices. Conclusions: Findings from this multicenter cohort demonstrate variation in neurodevelopmental outcomes according to cardiac diagnosis. Regardless of cardiac diagnosis, the presence of a genetic diagnosis is associated with lower neurodevelopmental scores. Heterogeneous outcomes reinforce the importance of surveillance for all infants undergoing heart surgery in the first year of life. Clinical Perspective: What is new?: While genetic diagnoses confer the highest risk of developmental delays and disorders in patients with CHD, cardiac diagnosis also impacts early neurodevelopmental outcomes in non-syndromic patients. In non-syndromic patients, those with transposition of the great arteries exhibit higher scores on early ND testing than other common CHD subtypes, while those with single ventricle physiology and atrioventricular septal defects exhibit lower scores. Older age at surgery and greater number of interventional cardiac catheterizations may represent newly identified risk factors for adverse early ND outcomes in infants with CHD. What are the clinical implications?: Data from the CNOC registry emphasizes the importance of ND follow-up for all infants undergoing cardiac surgery, including those with simpler CHD subtypes. The improved outcomes we observed in patients with transposition of the great arteries suggest advances in routine clinical management, including early surgery, may have had a neuroprotective influence.

Right ventricular outflow dysfunction, manifesting as stenosis, regurgitation, or both, is nearly universal in patients with repaired tetralogy of Fallot, precipitating a complex pathophysiological cascade that leads to increasing rates of morbidity and mortality with advancing age. As the number of adolescent and adult patients with repaired tetralogy of Fallot continues to grow as a result of excellent survival during infancy, the need to improve late outcomes has become an urgent priority. This American Heart Association scientific statement provides an update on the current state of knowledge of the pathophysiology, methods of surveillance, risk stratification, and latest available therapies, including transcatheter and surgical pulmonary valve replacement strategies, as well as management of life-threatening arrhythmias. It reviews emerging evidence on the roles of comorbidities and patient-reported outcomes and their impact on quality of life. In addition, this scientific statement explores contemporary evidence for clinical choices such as transcatheter or surgical pulmonary valve replacement, discusses criteria and options for intervention for failing implanted bioprosthetic pulmonary valves, and considers a new approach to determining optimal timing and indications for pulmonary valve replacement.

BACKGROUND: Congenital heart defects (CHD) are the most common birth defects and previous estimates report the disease affects 1% of births annually in the United States. To date, CHD prevalence estimates are inconsistent due to varied definitions, data reliant on birth registries, and are geographically limited. These data sources may not be representative of the total prevalence of the CHD population. It is therefore important to derive high-quality, population-based estimates of the prevalence of CHD to help care for this vulnerable population. METHODS: We performed a descriptive, retrospective 8-year analysis using all-payer claims data from Colorado from 2012 to 2019. Children with CHD were identified by applying International Classification of Diseases-Ninth Revision (ICD-9 ) and International Classification of Diseases-Tenth Revision ( ICD-10 ) diagnosis codes from the American Heart Association–American College of Cardiology harmonized cardiac codes. We included children with CHD 2 test. We used direct standardization to calculate adjusted prevalence rates, controlling for age, sex, primary insurance provider, and urban-rural residence. RESULTS: We identified 1 566 328 children receiving care in Colorado from 2012 to 2019. Of those, 30 512 children had at least 1 CHD diagnosis, comprising 1.95% (95% CI, 1.93–1.97) of the pediatric population. Over half of the children with CHD also had at least 1 complex chronic condition. After direct standardization, the adjusted prevalence rates show a small increase in simple severity diagnoses across the study period (adjusted rate of 11.5 [2012]–14.4 [2019]; P <0.001). CONCLUSIONS: The current study is the first population-level analysis of pediatric CHD in the United States. Using administrative claims data, our study found a higher CHD prevalence and comorbidity burden compared with previous estimates.

BACKGROUND: The interstage period after discharge from stage 1 palliation carries high morbidity and mortality. The impact of social determinants of health on interstage outcomes is not well characterized. We assessed the relationship between childhood opportunity and acute interstage outcomes. METHODS: Infants discharged home after stage 1 palliation in the National Pediatric Quality Improvement Collaborative Phase II registry (2016–2022) were retrospectively reviewed. Zip code–level Childhood Opportunity Index (COI), a composite metric of 29 indicators across education, health and environment, and socioeconomic domains, was used to classify patients into 5 COI levels. Acute interstage outcomes included death or transplant listing, unplanned readmission, intensive care unit admission, unplanned catheterization, and reoperation. The association between COI level and acute interstage outcomes was assessed using logistic regression with sequential adjustment for potential confounders. RESULTS: The analysis cohort included 1837 patients from 69 centers. Birth weight ( P P =0.02) increased with COI level. Stage 1 length of stay decreased ( P =0.001), and exclusive oral feeding rate at discharge increased ( P <0.001), with higher COI level. More than 98% of patients in all COI levels were enrolled in home monitoring. Death or transplant listing occurred in 101 (5%) patients with unplanned readmission in 987 (53%), intensive care unit admission in 448 (24%), catheterization in 345 (19%), and reoperation in 83 (5%). There was no difference in the incidence or time to occurrence of any acute interstage outcome among COI levels in unadjusted or adjusted analysis. There was no interaction between race and ethnicity and childhood opportunity in acute interstage outcomes. CONCLUSIONS: Zip code COI level is associated with differences in preoperative risk factors and stage 1 palliation hospitalization characteristics. Acute interstage outcomes, although common across the spectrum of childhood opportunity, are not associated with COI level in an era of highly prevalent home monitoring programs. The role of home monitoring in mitigating disparities during the interstage period merits further investigation.

Congenital heart disease (CHD) is increasingly diagnosed prenatally and the ability to screen and diagnose the genetic factors involved in CHD have greatly improved. The presence of a genetic abnormality in the setting of prenatally diagnosed CHD impacts prenatal counseling and ensures that families and providers have as much information as possible surrounding perinatal management and what to expect in the future. This review will discuss the genetic evaluation that can occur prior to birth, what different genetic testing methods are available, and what to think about in the setting of various CHD diagnoses.

Background: Gaps in care (GIC) are common for patients with congenital heart disease (CHD) and can lead to worsening clinical status, unplanned hospitalization, and mortality. Understanding of how social determinants of health (SDOH) contribute to GIC in CHD is incomplete. We hypothesize that SDOH, including Child Opportunity Index (COI), are associated with GIC in patients with significant CHD. Methods and Results: A total of 8554 patients followed at a regional specialty pediatric hospital with moderate to severe CHD seen in cardiology clinic between January 2013 and December 2015 were retrospectively reviewed. SDOH factors including race, ethnicity, language, and COI calculated based on home address and zip code were analyzed. GIC of >3.25 years were identified in 32% (2709) of patients. GIC were associated with ages 14 to 29 years ( P P P =0.017), public health insurance ( P P P 3.25 years). Several SDOH, including a low COI, were associated with GIC. Hospitals should adopt formal GIC improvement programs focusing on SDOH to improve continuity of care and ultimately overall outcomes for patients with CHD.