Corno AF

Crossland DS

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EDITORIALpublished: 28 July 2020doi: 10.3389/fped.2020.00424Frontiers in Pediatrics | www.frontiersin.org 1 July 2020 | Volume 8 | Article 424Edited and reviewed by:Ruth Heying,University Hospital Leuven, Belgium*Correspondence:Antonio F. Cornotonycorno2@gmail.comSpecialty section:This article was submitted toPediatric Cardiology,a section of the journalFrontiers in PediatricsReceived: 13 May 2020Accepted: 19 June 2020Published: 28 July 2020Citation:Corno AF and Crossland DS (2020)Editorial: Controversies in PediatricCardiology. Front. Pediatr. 8:424.doi: 10.3389/fped.2020.00424Editorial: Controversies in PediatricCardiologyAntonio F. Corno 1* and David S. Crossland 2,31McGovern Medical School, Houston Children’s Heart Institute, Children’s Memorial Hermann Hospital, University TexasHealth, Houston, TX, United States, 2 Adult Congenital and Pediatric Heart Unit, Freeman Hospital, Newcastle upon Tyne,United Kingdom, 3Cardiovascular Research Centre, Institute of Genetic Medicine, Newcastle University,Newcastle upon Tyne, United KingdomKeywords: cardiology, pediatric cardiology, cardiology controversies, editorial, pediatricEditorial on the Research TopicControversies in Pediatric CardiologyThere remain many controversies across the spectrum of congenital cardiology which are notlimited to rare diagnoses and uncommonly preformed procedures. Factors contributing to thisinclude a paucity of randomized trials, the heterogeneous nature of congenital cardiac disease (evenwithin each headline diagnosis), differences health care systems offering care and an enthusiasmto carry out new procedures, often related to morbidity and mortality associated with currentstrategies. A natural and useful way of addressing and discussing these controversies is as partof debate sessions at speciality meetings. Although these are often delivered by experts withinthat area the total audience is often limited to those attending the meeting. The purpose of thisResearch Topic was to extend this debate to print allowing review of more detailed argument anddata presented by the experts to a wider audience.The three topics considered in this Research Topic are the pulmonary valve replacement forpulmonary valve regurgitation, the current role of echocardiography in the diagnosis of congenitalheart defects, and the best modality of cardiopulmonary bypass for pediatric heart surgery.In developed health care systems pulmonary valve replacement is the third most commonprocedure in congenital cardiology after atrial septal defect closure and patent ductus arteriosusclosure. Between 2014 and 2017 1,039 such procedures were carried out in the UK (260 in childrenand 779 in adults) of which 803 were surgical and 260 transluminal with a reported 30 daymortalityfor either procedure of <1%1. Given that this is a high frequency low mortality procedure debateas to the most appropriate option must also explore morbidity and long term outcomes fromthe procedure. In this edition Morgan and Corno present the controversy surrounding whetherpulmonary valve regurgitation should be addressed surgically or interventionally from the point ofview of the interventional cardiologist and the cardiac surgeon.Morgan explores the rapid developments in both the technique and technology in the fieldof percutaneous pulmonary valve implantation. Previous perceived limitations of the procedureand how these are being addressed are explored. In particular techniques used in the presenceof small right ventricular outflow tracts, including hybrid techniques, and large outflow tracts,including stents to build landing zones for valve implantation, developments of valve technologyto fill the redundant space, and use of a branch pulmonary artery to secure the some types ofvalve. The latest available models of percutaneously implantable valves are described in detail, withpotential advantages and disadvantages to orient the readers in the choice (Morgan). Finally in thediscussion the potential drawbacks and complications are thoroughly analyzed. Specific proceduralcomplications are discussed including the possibility of conduit rupture, valve embolization,1https://nicor4.nicor.org.uk/CHD/an_paeds.nsf/vwContent/home (accessed April 28, 2020).Corno and Crossland Controversies in Pediatric Cardiologytricuspid valve damage, and coronary compression as well as howthese can be avoided to give a very low procedural mortalityand morbidity. One of the main concerns about percutaneousvalves, namely the incidence of endocarditis is discussed, withthe suggestion that much of this may be related to the (oftennecessary) use of bovine jugular grafts, however these are placed,and that this will remain a hot topic going forward. The paucity ofhigh quality long-term data that can be used to directly comparepercutaneously and surgically implanted valves is highlighted asa major limitation to comparing the two options, in particularthe using “freedom from death or re-intervention” as a themain comparator.Corno explores all the currently available options to implant apulmonary valve either with direct surgical technique as well ashybrid approach combining surgical exposure and percutaneoustype of valve implantation, with pros and cons of both typesof choice. The interventionalists might argue that this middleground approach demonstrates increasing surgical acceptanceof the percutaneous option! He considers in the decision-making process the following elements: (a) morphology andsize of the right ventricular outflow tract, in particular in thepresence of a previously implanted trans-annular patch; (b)morphology and size of the pulmonary arteries in the case arequired enlargement or reconstruction; (c) presence of residualintra-cardiac defects; (d) presence of extremely dilated anddysfunctional right ventricle. Clearly the definitive choice willdepend upon the match of the characteristics of the individualpatient with the experience and outcomes of the operators.Each caregiver has to keep in mind that this type of problem,pulmonary valve regurgitation, exposes each patient to repeatedprocedures during the rest of his/her life, and therefore the choicehas to take in account the options left available for the futureneeds (Corno).With regard to the topic “is echocardiography enoughor cath-angio/CT scan/MRI are still needed?,” the group ofMárquez-González et al. reported a very large study of patientsin Mexico with right ventricular outflow tract obstruction. Theycompared the non-invasive approach using the echocardiogramderived Tei index (defined as the ratio of isovolumetriccontraction time to ejection time) with an invasive cardiaccatheterization definition of right ventricular dysfunction. Theauthors provide interesting data that the Tei index in thisgroup of patients can accurately predict catheterization-baseddiagnosis of right ventricular dysfunction (Márquez-Gonzálezet al.). Although the limitations of a lack of comparison withMRI and that catherization-based right ventricular dysfunctionis not synonymous with the need for intervention, the inferencesof this study may be important for low and middle-incomeenvironments where resources are not always available toperform other imaging modalities.Finally Corno et al. reported a clinical study with comparisonbetween two groups of patients homogeneous for age and weight,with the same STAT risk stratification, operated on for congenitalheart defects, one with normothermic and the other with mildhypothermic cardiopulmonary bypass. The data collected inthe operating room and during the first 24 post-operativehours shows that the normothermic group have a favorabledifference in biomarkers (arterial PH, lactate), lower vasoactiveinotropic score, reduced chest drain losses, reduced transfusionrequirement, shorter duration of mechanical ventilation andshorter stay in Pediatric Intensive Care Unit (PICU). In additionto the improved immediate clinical outcomes, the normothermicgroup had lower average cost per patient day of stay inPICU (Corno et al.). The authors conclude that wider useof normothermic cardiopulmonary bypass should be takeninto consideration for pediatric cardiac surgery and suggestprospective multi-center randomized controlled trials in a riskadjusted population of patients with complex congenital heartdefects to support their results.AUTHOR CONTRIBUTIONSAC drafted the manuscript. All authors revised and approved thefinal version.Conflict of Interest: The authors declare that the research was conducted in theabsence of any commercial or financial relationships that could be construed as apotential conflict of interest.Copyright © 2020 Corno and Crossland. This is an open-access article distributedunder the terms of the Creative Commons Attribution License (CC BY). The use,distribution or reproduction in other forums is permitted, provided the originalauthor(s) and the copyright owner(s) are credited and that the original publicationin this journal is cited, in accordance with accepted academic practice. No use,distribution or reproduction is permitted which does not comply with these terms.Frontiers in Pediatrics | www.frontiersin.org 2 July 2020 | Volume 8 | Article 424

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Editorial: Controversies in Pediatric Cardiology

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Editorial: Controversies in Pediatric Cardiology

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