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identified, plication of the diaphragm is generally sufficient to wean the patient from mechanical ventilation.181–185 Attempts should also be made to wean him or her from sedative agents and steroids Primary pulmonary, neurogenic, and infectious etiologies must also be considered The decision to commit a neonate to a tracheostomy, with or without chronic mechanical ventilation, is difficult; however, once undertaken, a postoperative tracheostomy typically expedites weaning from sedatives, advancing nutritional status, and improving neurologic development.171,186,187 Acute kidney injury may significantly delay postoperative recovery In neonates, the net effect of acute kidney injury is more typically impaired filtration rather than solute clearance An inability to mobilize fluid will rapidly lead to poor cardiac and lung compliance Filtration disorders in the neonate may be addressed with peritoneal dialysis The need for dialysis in the early postoperative period following neonatal palliation for univentricular heart disease is associated with a significantly increased mortality risk.188–191 Nutritional deficiencies may also delay progress; most studies report the use of supplemental tube feeding of 40% or more following neonatal palliation for fUVH.192–194 The clinician should ensure that the appropriate nutritional goals are being met via enteral or parenteral means If the patient is tolerating enteral feeds, a careful assessment of the vocal cords, swallowing, and reflux risk should be made prior to the initiation of oral feeds Once the patient has achieved a stable physiologic profile, consideration of a surgically placed gastric tube will be possible.187,195,196 Family Support and Discharge Planning Comprehensive discharge planning following surgical interventions in all neonates is critical and perhaps most important in this fragile patient population As with all neonates requiring interventions after birth, the baby has never been home, family support structures have not yet been established, and a formal visit with the primary care provider has not taken place For the neonate with a multidistribution circulation, these risks are compounded by a tenuous physiology, complex hospital course, and a high frequency of additional medical concerns As part of the comprehensive risk-reduction strategy discussed in Chapter 72, establishment of a medical home is critical This requires proactive multidisciplinary coordination starting well before patients are medically ready for discharge Parents must be well educated and as emotionally prepared as possible for the realities of caring for a neonate with a tenuous circulation Interstage monitoring programs provide elevated monitoring of infant wellness as well as parental coping Parents should be encouraged to perform all infant care, medication measurement, and delivery prior to discharge and may benefit from the opportunity to “room in” for 24 to 48 hours prior to discharge Discharge is overwhelming and fear-inducing for many families, so education should be ongoing throughout admission rather than clustered toward the end of the hospitalization Ideally, over the course of admission the parent will become as comfortable with the needs of the infant as the bedside staff and medical team have become.56,197–200 Second-Stage Palliation: The Superior Cavopulmonary Connection Staged surgical palliation for patients with a fUVH typically includes an intermediate or second-stage procedure, the superior cavopulmonary anastomosis, which eliminates volume load on the ventricle This reduces both wall stress and (potentially) AV valve insufficiency as well as increasing effective pulmonary blood flow and achieving a more efficient in-series circulation In patients with a prior systemic-to-pulmonary artery shunt, this also includes increased diastolic pressure with improved coronary artery perfusion see Box 71.5.201–204 Box 71.5 Goals of Superior Cavopulmonary Connection ■ Surgical connection of the superior vena cava(e) to the ipsilateral pulmonary artery ■ Reduce volume load ■ Performance of additional procedures (e.g., pulmonary artery plasty, septectomy, valvuloplasty) Preoperative Evaluation Preoperative evaluation of the infant with a fUVH prior to the SCPC requires a number of components to assess risk and guide surgical planning (Table 71.8) Traditionally cardiac catheterization, along with echocardiography, has been used for the complete evaluation, although there is considerable variability in practice as well as specificity and sensitivity in the various modes of investigation.3,205–210 Studies comparing echocardiography with angiography have demonstrated suboptimal performance of echocardiography in adequately evaluating the relevant vascular anatomy A single-center prospective randomized trial comparing cardiac magnetic resonance (CMR) with cardiac