Early plication should be considered for patients with diaphragm paresis requiring prolonged respiratory support after cardiac bypass surgery. Longer follow-up evaluation is required to better define the long-term implications of plication.

Centralisation of services such as cardiology, cardiac surgery, and intensive care in many parts of the world has resulted in the need to safely transport children with critical cardiac disease from local hospitals to specialist centres for diagnostic, surgical, and/or critical care intervention. The transport of this cohort of children, whether locally or internationally, can present specific clinical and logistical challenges. An international group of clinicians with expertise in cardiac care and critical care transport worked together to summarise current clinical practice relating to key areas of transport. This expert review covers the transport of the child with critical cardiac disease in terms of referral triage and advice, enabling optimal management of locally available resources, clinical stabilisation before transport, international air transport, transport considerations in low-and middleincome countries, and the transport of children with specific cardiac conditions. As specialist services are centralised to fewer large centres, the need for safe and timely inter-hospital transport of children with critical cardiac disease is only expected to rise in the future. The key principles outlined in this review will be helpful for practitioners in global settings who are, or might be, involved in transporting children between hospitals.

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Introduction: Diaphragm paresis can occur as a complication of pediatric cardiac surgery that can prolong ventilation and length of ICU stay. Diaphragm plication (DP) may be necessary to improve respiratory mechanics and decrease duration of ventilation support. Early identification of patients who are likely to benefit from DP has not been studied. Methods: Patients at our institution diagnosed with diaphragm paresis between 2002 - 2012 were identified. Mode of diagnosis, demographics, operative procedures during index admission, and intervals of care were evaluated. Associations between predictors and DP were assessed by univariable and multivariable logistic regressions. Results: Diaphragm paresis was diagnosed in 161 patients following 6448 index surgeries, of whom 31 (19%) underwent DP (DP+). Paresis was diagnosed by ultrasound in 160 (99%) subjects at a median (IQR) time from surgery of 7 (3, 11) days in DP+ vs 10 (6, 19) days in DP- (p=0.02). DP was completed after a median (IQR) of 4 (1, 17) days after diagnosis. DP+ were younger in age [median (IQR) days DP+ 42 (14, 84) vs DP- 168 (28, 784); p<0.001], underwent surgery of higher RACHS-1 score [DP+ 3 (3, 4) vs DP- 3 (2, 4); p=0.02], and had a higher rate of hypothermic circulatory arrest [DP+ 14 (45%) vs DP- 23 (18%); p=0.001]. DP+ subjects had a rate of single ventricle physiology (32%), median sternotomy (94%), and bypass (87%) similar to DP- subjects. Only younger age (OR 1.003 per day, p=0.02) and use of hypothermic circulatory arrest (OR 3.06, p=0.01) remained significant on multivariable modeling. DP+ subjects had longer duration of ventilator support [DP+ 15 (9, 30) vs DP- 6.5 (3, 12.5) days; p<0.001] and ICU admission [DP+ 23 (18, 42) vs DP- 8 (5, 17) days; p<0.001]. However, ventilation was discontinued after a median of 1 (1,2) day after plication. The time interval from index surgery to diagnosis (EST 0.91, p<0.0001) and interval from diagnosis to DP (EST 0.94, p<0.0001; r2=0.91) were associated with a longer ICU stay even after adjusting for age and bypass time. Conclusion: Diaphragm paresis is common after congenital heart surgery. Earlier diagnosis and plication may shorten length of ventilation support and ICU stay, particularly in younger patients. Long-term outcome studies following DP are required.