Introduction: Transposition of the great arteries (TGA) is one of the most common cyanotic congenital heart diseases in the neonatal period, and arterial switch operation (ASO) is the standard surgical treatment. Postoperative low cardiac output syndrome remains an important cause of morbidity. This study evaluated the association between serial vasoactive–inotropic score (VIS) measurements and postoperative intensive care unit (ICU) length of stay in neonates with TGA undergoing ASO. Methods: This retrospective study included neonates with TGA who underwent ASO and were followed in a tertiary Pediatric Cardiac Intensive Care Unit between 1 August 2020, and 1 August 2022. ICU length of stay was analyzed as a continuous primary outcome. Prolonged ICU stay, defined as the upper quartile of ICU length of stay in the study cohort (≥9 days), was evaluated as a secondary exploratory outcome. VIS values were recorded at ICU admission and at 24, 48, and 72 h after surgery. Associations between VIS parameters and continuous ICU length of stay were assessed using Spearman’s rank correlation. ROC analysis and logistic regression were performed for prolonged ICU stay. Results: A total of 60 neonates were included, and 15 patients (25%) had a prolonged ICU stay. Admission VIS values were similar between groups. However, VIS values at 24 and 48 h were significantly higher in the prolonged ICU stay group (p = 0.005 and p = 0.001, respectively), whereas no significant difference was observed at 72 h. VIS at 48 h showed the strongest correlation with ICU length of stay (Spearman’s r = 0.52, p < 0.001), followed by ΔVIS48 (r = 0.48, p = 0.001) and VIS at 24 h (r = 0.44, p = 0.002). In secondary exploratory analyses, VIS at 48 h demonstrated a numerically higher AUC than VIS at 24 h (0.82 vs. 0.74). ΔVIS48 was associated with prolonged ICU stay in multivariable logistic regression (OR, 1.18 per unit increase; 95% CI, 1.05–1.33; p = 0.006). Firth’s penalized logistic regression yielded a similar estimate (OR, 1.15; 95% CI, 1.03–1.30; p = 0.012). Conclusions: In neonates with TGA undergoing ASO, higher VIS during the first 24–48 postoperative hours, particularly an increase from admission to 48 h, was associated with longer ICU stay. These findings support serial VIS assessment as a marker of early postoperative clinical trajectory. Cohort-derived VIS thresholds should be considered exploratory and require external multicenter validation before clinical application.

Background: In congenital heart disease patients with single-ventricle physiology, accurate anatomical and hemodynamic evaluation prior to the Fontan completion procedure is critical for surgical planning and long-term outcomes. Although conventional catheter angiography (CCA) remains the reference standard for hemodynamic evaluation, cardiac computed tomography angiography (CTA) has emerged as an increasingly valuable tool for anatomical assessment in the preoperative evaluation of Fontan candidates. Objective: To compare the anatomical and hemodynamic information provided by CTA and CCA before Fontan completion and to evaluate their complementary roles in the preoperative assessment of pediatric patients with single-ventricle physiology. Methods: This single-center, retrospective study included 32 patients with single-ventricular physiology who underwent staged palliation and Fontan completion. All patients underwent TTE and CCA. Twenty-three patients also underwent cardiac CTA with three-dimensional reconstruction. Anatomical and hemodynamic findings obtained from CTA and CCA were compared, with particular focus on extracardiac anatomy, collateral vessels, and findings relevant to surgical planning. Results: Cardiac CTA showed concordant detection of clinically significant anatomical findings identified by CCA, while providing a more comprehensive assessment of extracardiac anatomy. While CCA remained superior for hemodynamic assessment, CTA provided more comprehensive evaluation of extracardiac anatomy. In this cohort, catheterization findings did not alter the planned surgical strategy (0%, 95% CI 0–10.9%). Conclusions: CTA may provide valuable anatomical information for preoperative assessment and surgical planning; however, larger prospective multicenter studies are required before less invasive pre-Fontan evaluation strategies can be considered.

Background: Necrotizing enterocolitis (NEC) is a severe gastrointestinal complication that may develop in term neonates with critical congenital heart disease (CHD), despite the absence of prematurity. We aimed to evaluate the incidence of NEC and identify clinical factors associated with NEC development in term neonates with critical CHD. Methods: This retrospective cohort study included term neonates (≥37 weeks’ gestation) with critical CHD admitted to a tertiary pediatric cardiac intensive care unit between 1 January 2022, and 1 January 2026. NEC was defined as stage IIA or higher according to modified Bell’s criteria. Demographic, clinical, perioperative, and nutritional variables were analyzed. Multivariable logistic regression analysis was performed to identify factors independently associated with NEC development. Results: A total of 780 term neonates with critical CHD were included. NEC developed in 18 infants (2.3%). The median age at NEC diagnosis was 7 days (IQR 5–10), and four patients (22%) required surgical intervention. Seven NEC cases occurred preoperatively, whereas 11 developed after cardiac surgery; among postoperative cases, 64% occurred within the first 72 h after surgery. Birth weight < 2.5 kg (aOR 4.1, 95% CI 1.2–13.4; p = 0.021), gestational age < 38 weeks (aOR 3.9, 95% CI 1.3–12.0; p = 0.018), functional single-ventricle physiology (aOR 5.8, 95% CI 1.6–20.7; p = 0.007), and mechanical ventilation dependency (aOR 5.1, 95% CI 1.7–15.2; p = 0.004) were independently associated with NEC development. Mortality was significantly higher among infants with NEC compared with those without NEC (50% vs. 7.7%, p < 0.001). Conclusions: NEC remains an important complication associated with substantial mortality in term neonates with critical CHD, despite its relatively low incidence. Early-term birth, low birth weight, functional single-ventricle physiology, and dependence on mechanical ventilation were independently associated with increased NEC risk in this vulnerable population.

Background: Extracorporeal membrane oxygenation (ECMO) is lifesaving in pediatric patients with respiratory and/or cardiovascular failure. Cardiac catheterization is an important diagnostic and therapeutic tool in patients with congenital heart disease supported by ECMO, allowing the assessment of residual lesions, hemodynamically significant anatomical abnormalities, and unexplained indications for ongoing ECMO support. The timing and clinical contribution of cardiac catheterization in these patients are still debated. Objective: This study aimed to evaluate the indications, safety, and impact of cardiac catheterization on clinical management in pediatric patients receiving postoperative ECMO support. Methods: This single-center, retrospective study examined 39 pediatric patients under the age of 18 who underwent postoperative cardiac catheterization with ECMO support between January 2022 and December 2025. Demographic data, procedure characteristics, and clinical outcomes were analyzed. Results: Of the 190 patients under postoperative ECMO support, 39 underwent catheterization. The median age of the patients was 2.5 months (range, 6 days–180 months) and median weight was 4.2 kg (range, 2.8–57 kg). The most frequent diagnoses were ventricular septal defect-pulmonary atresia (VSD-PA) in 20.5% (n = 8) and transposition of the great arteries (TGA) in 15.3% (n = 6). The indication for catheterization was to investigate the reason for ECMO placement in 26 patients (66.6%). Most patients underwent catheterization within the first 24 h after ECMO initiation. Patients who underwent catheterization represented a higher-risk subgroup, with a greater proportion of STAT 4-5 procedures (59% vs. 40%) compared with the overall ECMO cohort. Cardiac catheterization resulted in a change in clinical management in 25.6% of patients through catheter-based intervention or surgical revision. Survival in the catheterized subgroup was 12.8%, reflecting the high-risk nature of this population. Conclusions: Cardiac catheterization in pediatric patients on postoperative ECMO support can be performed with a low complication rate and can significantly alter clinical management. Cardiac catheterization should be considered an important diagnostic and therapeutic modality, particularly in the presence of suspected residual lesions or unexplained hemodynamic instability. Additionally, we recommend that cardiac catheterization be performed promptly within the first 24–48 h in this patient group on ECMO support.

Introduction We read with great interest the study by Talay et al. (1) entitled “Factors affecting mortality in patients during postoperative follow-up after cardiac surgery in a pediatric intensive care unit.” The authors should be congratulated for addressing an important and clinically relevant issue in pediatric cardiac intensive care. Their retrospective cohort of 124 children provides valuable real-world information regarding postoperative complications and mortality following congenital cardiac surgery. Overall mortality was 8.8% (11/124), and preoperative pulmonary hypertension, lower postoperative albumin levels, higher C-reactive protein (CRP)/albumin ratios, nitric oxide administration, infection, and cardiopulmonary bypass (CPB) use were reported to be associated with mortality. We would nevertheless like to highlight several points that may further strengthen the interpretation of these findings. First, the study population represents a considerably heterogeneous spectrum of congenital heart disease and surgical procedures, ranging from ventricular septal defect closure to bidirectional cavopulmonary anastomosis and complex neonatal procedures. The authors appropriately attempted to account for surgical complexity using the Risk Adjustment for Congenital Heart Surgery (RACHS-1) classification. However, RACHS-1 was dichotomized into low-risk (categories 1–2) and high-risk (≥3) groups. Although high-risk surgery was associated with approximately threefold higher odds of mortality, this did not reach statistical significance (OR 3.07, 95% CI 0.85–11.13; p=0.087), and the reported AUC of 0.626 indicated limited discrimination. In this context, procedure-specific analyses or complementary risk adjustment may provide additional information, particularly because the prognostic significance of postoperative variables may differ substantially between biventricular repair, staged single-ventricle palliation, and neonatal surgery. Our previous pediatric cardiac intensive care cohort, for example, used both RACHS-1 and Aristotle-based complexity classifications to characterize the postoperative surgical population (4). Second, the relatively small number of mortality events (n=11) appropriately limited the possibility of multivariable modeling, as acknowledged by the authors. This limitation warrants caution when interpreting associations between individual perioperative variables and mortality. Interventions such as inhaled nitric oxide and advanced extracorporeal support are generally initiated in response to clinical deterioration and may therefore represent markers of disease severity rather than independent determinants of outcome. Indeed, the authors appropriately acknowledge this possibility in their discussion. A conceptual framework integrating preoperative condition, surgical complexity, and the postoperative hemodynamic trajectory may therefore be more informative than interpreting individual postoperative interventions in isolation. Several numerical inconsistencies may also merit clarification. The Results state that 29 patients (23.4%) developed postoperative complications, whereas Table IV reports complications in 35 survivors and six non-survivors, implying a total of 41 affected patients. Similarly, Table IV reports CPB use in 39/113 (34.5%) survivors and 3/11 (27.3%) non-survivors, despite the Results and Discussion describing CPB use as being associated with mortality and more frequently observed among non-survivors. In addition, the maximum vasoactive-inotropic score (VIS) within the first 24 hours among non-survivors is reported as 22 in the Results, whereas Table IV reports a median value of 19.5; both sections report a value of 12 among survivors and p=0.076. Clarification of these discrepancies would improve the interpretability and reproducibility of the findings. The findings regarding vasoactive-inotropic support are also noteworthy. Although the maximum VIS within the first 24 hours was higher among non-survivors, the difference did not reach statistical significance (p=0.076). Previous studies have demonstrated associations between VIS and clinically important outcomes after pediatric cardiac surgery, including prospective validation in neonates and infants (2,3). Importantly, postoperative hemodynamic instability is dynamic, and its prognostic significance may not be fully captured by a single maximum value. Serial measurements or assessment of VIS trajectory at predefined postoperative intervals could potentially distinguish transient early vasoactive requirements from persistent circulatory instability. The discussion of extracorporeal support also warrants clarification. The authors cite our previously published pediatric cardiac intensive care experience as reporting ECMO use in 26 patients (2.9%) with transposition of the great arteries as the primary diagnosis and state that ECMO was initiated mainly for hypoxemia secondary to PARDS. However, in the original cohort of 895 patients, ECMO was used in 26 patients (2.9%) for failure to separate from cardiopulmonary bypass (n=11), low cardiac output syndrome (n=8), E-CPR (n=5), and hypoxemia (n=2); only five of the ECMO-supported patients had transposition of the great arteries (4). Nineteen patients (73%) were successfully weaned from ECMO and 12 (46%) survived to discharge. Therefore, correction of this citation would more accurately reflect the original data and further emphasizes that ECMO after congenital cardiac surgery represents a heterogeneous intervention whose prognostic implications depend strongly on the underlying indication and physiology. In conclusion, Talay et al. (1) provide valuable real-world data regarding postoperative outcomes following pediatric cardiac surgery. Their findings also underscore the challenges of interpreting individual postoperative variables in a heterogeneous congenital heart disease population with a limited number of mortality...

Background: Pulmonary hypertension (PHT) is a rare but serious condition in children, requiring early diagnosis to prevent right ventricular failure. Non-invasive imaging modalities such as computed tomography angiography (CTA) have gained importance in assessing vascular changes, including main pulmonary artery (MPA) dilatation, increased vessel stiffness, and elevated pulmonary vascular resistance, which are characteristic of pulmonary hypertension (PHT). Objective: This study aimed to evaluate the diagnostic value of the main pulmonary artery-to-ascending aorta (MPA/AA) and main pulmonary artery-to-descending aorta (MPA/DA) ratios on CTA in pediatric patients with confirmed PHT. Methods: In this retrospective cohort study, 76 pediatric patients who underwent both cardiac catheterization and thoracic CTA were included. Patients were divided into PHT (mean pulmonary artery pressure ≥ 25 mmHg) and non-PHT groups. Vascular measurements were obtained from CTA, and MPA/AA and MPA/DA ratios were calculated. Statistical analyses included Mann–Whitney U tests and ROC curve analysis. Results: The MPA diameter and MPA/AA and MPA/DA ratios were significantly higher in the PHT group compared to controls (p < 0.05). ROC analysis showed strong diagnostic performance for both ratios. The MPA/DA ratio had an AUC of 0.927 with 78.5% sensitivity and 94% specificity at a cut-off value of 1.85. The MPA/AA ratio had an AUC of 0.896 with 76.5% sensitivity and 95% specificity at a cut-off value of 1.25. Conclusions: Both MPA/AA and MPA/DA ratios are reliable non-invasive indicators of pediatric PHT, with the MPA/DA ratio demonstrating slightly higher diagnostic accuracy. These findings support the use of CTA-derived vascular ratios, especially MPA/DA, as effective screening tools in clinical practice.