Background-Percutaneous pulmonary valve implantation using a stent-based bioprosthetic valve provides an alternative to surgery in select patients. Systemic infections in Melody valve-implanted patients with and without identified valve involvement have been reported, yet the incidence is unknown, and risk factors remain unidentified. Methods and Results-Between 2007 and 2012, a total of 147 consecutive patients with congenital heart disease underwent Melody percutaneous pulmonary valve implantation at our institution. Demographic and clinical variables were collected at baseline and at follow-up and analyzed as predictors. The occurrence of bloodstream infection (BSI), defined as a bacterial infection treated with ≥4 weeks of antibiotics, served as our primary outcome. The mean age at implantation for the study population was 21.5±11 years, and tetralogy of Fallot was the cardiac condition in 59%. During a median followup of 19 months, 14 patients experienced BSI (9.5%; 95% confidence interval, 5.3%-15%). Of these, 4 (2.7%) patients had Melody valve endocarditis. Two patients died during the event, neither of whom had known valve involvement. The median procedure to infection time was 15 months (range, 1-56). In univariate analysis, male sex, previous endocarditis, in situ stents in the right ventricular outflow tract, and presence of outflow tract irregularities at the implant site were associated with BSI occurrence. Conclusions-In this cohort, 9.5% of patients who underwent Melody percutaneous pulmonary valve implantation experienced subsequent BSI, occurring 1 to 56 months after implant, and 2.7% of patients had prosthetic endocarditis. Our findings suggest that patient and nonvalve anatomic factors may be associated with BSI after percutaneous pulmonary valve implantation. (Circ Cardiovasc Interv. 2013;6:301-310.)

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Objective: Acute kidney injury (AKI) is a predictor of outcomes in heterogeneous populations of children undergoing cardiac surgery. We investigated its causes and consequences in a cohort undergoing Fontan completion, hypothesizing that central venous pressure is independently associated with development of AKI.Methods: In this retrospective cohort study of patients undergoing Fontan (n ¼ 211), univariable and multivariable analyses identified factors associated with AKI within 3 days of surgery. Secondary analyses identified factors associated with hospital length of stay, and examined effects of perioperative kidney injury on follow-up renal function.Results: Acute kidney injury occurred in 42% of cases (n ¼ 89), with the following independent risk factors: mean renal perfusion (mean arterial minus central venous) pressure on postoperative day zero (per mm Hg; adjusted odds ratio [AOR] 0.83; P < .001); preoperative atrioventricular valve regurgitation > mild (AOR 6.78; P ¼ .02); bypass time (per 10 minutes, AOR 1.08; P ¼ .04); peak inotrope score on postoperative day zero (per point, AOR 1.17; P < .001); and preoperative pulmonary vascular resistance (per Wood unit, AOR 1.69; P ¼ .04). Central venous pressure was not independently associated with AKI. Moderate and severe (but not mild) AKI were independently associated with prolonged hospital length of stay (adjusted hazard ratios, 0.56; P ¼ .004, and .41; P ¼ .006, respectively). Perioperative injury was not associated with longer-term renal dysfunction.Conclusions: Acute kidney injury is common after Fontan completion and has several potentially modifiable risk factors. Moderate-to-severe injury is associated with longer hospital length of stay but not with renal dysfunction at follow-up. (J Thorac Cardiovasc Surg 2015;150:190-7) Effect of acute kidney injury on length of stay after Fontan completion. Central MessageAcute kidney injury is common after Fontan completion, and moderate-to-severe AKI predicts longer hospital length of stay. Injury seems to be mediated more by systemic hypotension than by central venous hypertension. Maintaining postoperative renal perfusion pressure while moderating inotrope use might reduce risk of injury and thus length of stay. PerspectiveAcute kidney injury in adults undergoing cardiac surgery is strongly associated with adverse outcomes. The importance of cardiac surgery-associated AKI in children is less clear. Patients undergoing Fontan completion face an acute rise in renal venous pressure and thus comprise an appealing model population. Acute kidney injury is common after the Fontan procedure, and moderate-to-severe AKI predicts longer hospital length of stay. Lower renal perfusion pressure and higher peak inotrope score are independent risk factors for AKI, whereas higher central venous pressure is not. This study provides important insight on the pathophysiology of AKI, and suggests strategies to mitigate AKI in this population.