Consensus-based method for risk adjustment for surgery for congenital heart disease

Urine NGAL predicts severity of acute kidney injury after cardiac surgery: a prospective study

BACKGROUND AND OBJECTIVES

The authors have previously shown that urine neutrophil gelatinase-associated lipocalin (NGAL), measured by a research ELISA, is an early predictive biomarker of acute kidney injury (AKI) after cardiopulmonary bypass (CPB). In this study, whether an NGAL immunoassay developed for a standardized clinical platform (ARCHITECT analyzer, Abbott Diagnostics Division, Abbott Laboratories, Abbott Park, IL) can predict AKI after CPB was tested.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In a pilot study with 136 urine samples (NGAL range, 0.3 to 815 ng/ml) and 6 calibration standards (NGAL range, 0 to 1000 ng/ml), NGAL measurements by research ELISA and by the ARCHITECT assay were highly correlated (r = 0.99). In a subsequent study, 196 children undergoing CPB were prospectively enrolled and serial urine NGAL measurements obtained by ARCHITECT assay. The primary outcome was AKI, defined as a > or = 50% increase in serum creatinine.

RESULTS

AKI developed in 99 patients (51%), but the diagnosis using serum creatinine was delayed by 2 to 3 d after CPB. In contrast, mean urine NGAL levels increased 15-fold within 2 h and by 25-fold at 4 and 6 h after CPB. For the 2-h urine NGAL measurement, the area under the curve was 0.95, sensitivity was 0.82, and the specificity was 0.90 for prediction of AKI using a cutoff value of 100 ng/ml. The 2-h urine NGAL levels correlated with severity and duration of AKI, length of stay, dialysis requirement, and death.

CONCLUSIONS

Accurate measurements of urine NGAL are obtained using the ARCHITECT platform. Urine NGAL is an early predictive biomarker of AKI severity after CPB.

Surgery-related posttraumatic stress disorder in parents of children undergoing cardiopulmonary bypass surgery: a prospective cohort study

OBJECTIVE

We aimed at evaluating surgery-related posttraumatic stress disorder (PTSD) in parents of children undergoing cardiopulmonary bypass surgery. Risk factors for parental PTSD symptoms were explored.

DESIGN

A prospective cohort study was performed assessing PTSD symptoms immediately after discharge and 6 months after cardiopulmonary bypass surgery.

SETTING

Recruitment took place at a tertiary pediatric medical center in Switzerland.

SUBJECTS

German-speaking parents of children with congenital heart defects aged between 0 and 16 yrs undergoing cardiopulmonary bypass surgery were eligible (n = 228). After child discharge, 135 mothers and 98 fathers of 139 children (response rate 61.0%) participated. Six months after surgery, 121 mothers and 92 fathers of 128 children (response rate, 56.1%) took part in the study.

INTERVENTIONS

Assessment via a screening instrument and self-rating scale, and extraction of data from charts.

MEASUREMENTS AND MAIN RESULTS

The Posttraumatic Diagnostic Scale was applied to estimate self-reported symptoms of PTSD. Following discharge, 16.4% of mothers and 13.3% of fathers met diagnostic criteria for acute PTSD. Another 15.7% of mothers and 13.3% of fathers experienced significant symptoms of posttraumatic stress. Six months after surgery, PTSD rates were 14.9% and 9.5%, respectively. Mothers experienced more severe symptoms of PTSD, but gender differences were not detected with regard to the frequency of PTSD at either time. After controlling for socioeconomic status and child preoperative morbidity, PTSD symptom severity after discharge remained the only significant predictor of PTSD severity at 6 months. Pre-, peri-, and postoperative factors did not predict parental PTSD.

CONCLUSIONS

Parents of children undergoing cardiopulmonary bypass surgery are at increased risk for intermediate and long-term psychological malfunctioning. Acute symptoms of PTSD in parents shortly after discharge of their child are a major risk factor for the development of chronic PTSD. Clinicians need to identify parents at risk at an early stage to provide them with systematic support.

Application of a complication screening method to congenital heart surgery admissions: a preliminary report

There have been comprehensive screening methods developed to identify unwanted inpatient events. A comprehensive assessment of complication diagnoses during congenital heart surgery admissions has not been performed. We examined the frequency of complications identified by a complication screening method and their relationship to patient characteristics among congenital heart surgery admissions. Data were obtained from the Healthcare Cost and Utilization Project Kids' Inpatient Database 2000. Among congenital heart surgery admissions, age < or =20 years, we identified International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) codes indicating complication. Complication diagnoses were categorized as related to drug/biologic, procedures, devices, implants and grafts, and radiation. We used the Risk Adjustment for Congenital Heart Surgery risk categories (1-6) to examine the association between case complexity and complications. Multivariate analyses estimated the odds for a complication diagnosis by patient characteristics, including age, prematurity, chromosomal anomalies, noncardiac structural anomalies, and surgical risk category. Among 12,717 cases, 4014 (32%) had at least 1 complication diagnosis code. Procedure-related complication diagnoses represented 75% of complication diagnoses; device, implant, or graft represented 21%; drug/biologic represented 4% and radiation represented 0%. Multivariate analyses demonstrated that higher surgical case complexity and older age had a greater risk for a complication diagnosis: Risk Category 2, odds ratio (OR) 1.8; 3 OR 2.9; 4 OR 2.9; 5 OR 5.0; 6 OR 4.1, relative to category 1, all p < 0.01; age > or =12 years, OR 1.3, p < 0.001; <1 year OR 1.1, p = 0.31. Premature cases had decreased odds OR 0.4, p < 0.001. This complication screening method indicates that unwanted patient events occur frequently during congenital heart surgery admissions. Children undergoing complex congenital heart surgery are at greatest risk for these unwanted events. Further study of these events is needed to determine their preventability and severity.

Risk factors for acute renal failure requiring dialysis after surgery for congenital heart disease in children

BACKGROUND

Limited data exist on the risk factors for acute renal failure (ARF) following cardiac surgery in children with congenital heart disease. This cohort study was conducted to examine this subject, as well as changes in the incidence of ARF from 1993 to 2002, the in-hospital mortality and the time spent in the intensive care unit (ICU).

METHODS

One thousand, one hundred and twenty-eight children, operated on for congenital heart disease between 1993 and 2002, were identified from our prospectively collected ICU database to obtain data on potential risk factors.

RESULTS

A total of 130 children (11.5%) developed ARF after surgery. A young age [> or =1.0 vs. <0.1 year; odds ratio (OR), 0.23; 95% confidence interval (CI), 0.12-0.46], high Risk Adjusted Classification of Congenital Heart Surgery (RACHS-1) score (OR, 2.72; 95% CI, 1.66-4.45) and cardiopulmonary bypass (CPB) (<90 min vs. none; OR, 2.68; 95% CI, 1.03-6.96; > or =90 min vs. none; OR, 12.94; 95% CI, 5.46-30.67) were independent risk factors for ARF. The risk of ARF decreased during the study period. Children with ARF spent a significantly longer time in the ICU (2-7 days vs. <2 days, P = 0.002; > or =7 days vs. <2 days, P < 0.001) compared with non-ARF patients, and showed increased in-hospital mortality (20% vs. 5%, P < 0.001).

CONCLUSION

A young age, high RACHS-1 score and CPB were independent risk factors for ARF after surgical procedures for congenital heart disease in children. The risk of ARF decreased during the study period. Children with severe ARF spent a longer time in the ICU, and the mortality in ARF patients was higher than that in non-ARF patients.

Extubation after cardiothoracic surgery in neonates, children, and young adults: One year of institutional experience

OBJECTIVE:: Describe risk factors associated with successful and early extubation in the pediatric cardiac intensive care unit. DESIGN:: Retrospective chart review. SETTING:: University hospital, cardiac intensive care unit. MEASUREMENTS AND MAIN RESULTS:: Review of 212 consecutive surgical admissions from January 2003 to January 2004, excluding deaths. Preoperative, intraoperative, and postoperative variables were studied. Successful extubation was defined as no reintubation at any time during the cardiac intensive care unit course and early extubation was defined as mechanical ventilation </=24 hrs. Median subject age was 8 months (range, 1 day-25 yrs), with 57% <1 yr of age and 22% neonates. Fifty-eight (27%) were extubated in the operating room and 122 (58%) were extubated at <24 hrs (mean, 6.1 +/- 7.7 hrs). Only seven patients failed extubation: three in the operating room because of upper airway obstruction and four in the cardiac intensive care unit for acute respiratory failure associated with atelectasis (n = 2), ventricular dysfunction (n = 1), and arrhythmia (n = 1). There were no extubation failures in patients extubated >24 hrs after surgery. A history of prematurity (odds ratio [OR], 5.84, 2.29-14.9; p < .001), base excess (OR, 1.47, 1.27-1.70; p < .001), cardiopulmonary bypass time (OR, 1.01, 1.01 to -1.2; p < .05), and the need for surgical reintervention (OR, 18.29, 2.78 to -120.07; p < .05) were associated with intubation for >24 hrs. CONCLUSION:: Extubation without the need for reintubation can be achieved in nearly all children following cardiothoracic surgery. The majority of successful extubations can be achieved within 24 hrs of surgery.

B-type natriuretic peptide levels predict outcome after neonatal cardiac surgery

OBJECTIVES

Neonates undergoing cardiac surgery are at high risk for adverse outcomes. B-type natriuretic peptide is used as a biomarker in patients with cardiac disease, but the predictive value of B-type natriuretic peptide after cardiac surgery in neonates has not been evaluated. Therefore, the objective of this study was to determine the predictive value of perioperative B-type natriuretic peptide levels for postoperative outcomes in neonates undergoing cardiac surgery.

METHODS

Plasma B-type natriuretic peptide determinations were made before and 2, 12, and 24 hours after surgery in 36 consecutive neonates. B-type natriuretic peptide levels and changes in perioperative B-type natriuretic peptide were evaluated as predictors of postoperative outcome.

RESULTS

B-type natriuretic peptide levels at 24 hours were lower than preoperative levels (24-h/pre B-type natriuretic peptide ratio < 1) in 29 patients (81%) and higher (24-h/pre B-type natriuretic peptide ratio > or = 1) in 7 patients (19%). A 24-hour/pre B-type natriuretic peptide level of 1 or greater was associated with an increased incidence of low cardiac output syndrome (100% vs 34%, P = .002) and fewer ventilator-free days (17 +/- 13 days vs 26 +/- 3 days, P = .002), and predicted the 6-month composite end point of death, an unplanned cardiac operation, or cardiac transplant (57% vs 3%, P = .003). A 24-hour/pre B-type natriuretic peptide level of 1 or greater had a sensitivity of 80% and a specificity of 90% for predicting a poor postoperative outcome (P = .003).

CONCLUSION

In neonates undergoing cardiac surgery, an increase in B-type natriuretic peptide 24 hours after surgery predicts poor postoperative outcome.

Analysis of outcomes for congenital cardiac disease: can we do better?

This review discusses the historical aspects, current state of the art, and potential future advances in the areas of nomenclature and databases for the analysis of outcomes of treatments for patients with congenitally malformed hearts. We will consider the current state of analysis of outcomes, lay out some principles which might make it possible to achieve life-long monitoring and follow-up using our databases, and describe the next steps those involved in the care of these patients need to take in order to achieve these objectives. In order to perform meaningful multi-institutional analyses, we suggest that any database must incorporate the following six essential elements: use of a common language and nomenclature, use of an established uniform core dataset for collection of information, incorporation of a mechanism of evaluating case complexity, availability of a mechanism to assure and verify the completeness and accuracy of the data collected, collaboration between medical and surgical subspecialties, and standardised protocols for life-long follow-up. During the 1990s, both The European Association for Cardio-Thoracic Surgery and The Society of Thoracic Surgeons created databases to assess the outcomes of congenital cardiac surgery. Beginning in 1998, these two organizations collaborated to create the International Congenital Heart Surgery Nomenclature and Database Project. By 2000, a common nomenclature, along with a common core minimal dataset, were adopted by The European Association for Cardio-Thoracic Surgery and The Society of Thoracic Surgeons, and published in the Annals of Thoracic Surgery. In 2000, The International Nomenclature Committee for Pediatric and Congenital Heart Disease was established. This committee eventually evolved into the International Society for Nomenclature of Paediatric and Congenital Heart Disease. The working component of this international nomenclature society has been The International Working Group for Mapping and Coding of Nomenclatures for Paediatric and Congenital Heart Disease, also known as the Nomenclature Working Group. By 2005, the Nomenclature Working Group crossmapped the nomenclature of the International Congenital Heart Surgery Nomenclature and Database Project of The European Association for Cardio-Thoracic Surgery and The Society of Thoracic Surgeons with the European Paediatric Cardiac Code of the Association for European Paediatric Cardiology, and therefore created the International Paediatric and Congenital Cardiac Code, which is available for free download from the internet at [http://www.IPCCC.NET]. This common nomenclature, the International Paediatric and Congenital Cardiac Code, and the common minimum database data set created by the International Congenital Heart Surgery Nomenclature and Database Project, are now utilized by both The European Association for Cardio-Thoracic Surgery and The Society of Thoracic Surgeons. Between 1998 and 2007 inclusive, this nomenclature and database was used by both these two organizations to analyze outcomes of over 100,000 patients undergoing surgical treatment for congenital cardiac disease. Two major multi-institutional efforts that have attempted to measure the complexity of congenital heart surgery are the Risk Adjustment in Congenital Heart Surgery-1 system, and the Aristotle Complexity Score. Current efforts to unify the Risk Adjustment in Congenital Heart Surgery-1 system and the Aristotle Complexity Score are in their early stages, but encouraging. Collaborative efforts involving The European Association for Cardio-Thoracic Surgery and The Society of Thoracic Surgeons are under way to develop mechanisms to verify the completeness and accuracy of the data in the databases. Under the leadership of The MultiSocietal Database Committee for Pediatric and Congenital Heart Disease, further collaborative efforts are ongoing between paediatric and congenital cardiac surgeons and other subspecialties, including paediatric cardiac anaesthesiologists, via The Congenital Cardiac Anesthesia Society, paediatric cardiac intensivists, via The Pediatric Cardiac Intensive Care Society, and paediatric cardiologists, via the Joint Council on Congenital Heart Disease and The Association for European Paediatric Cardiology. In finalising our review, we emphasise that analysis of outcomes must move beyond mortality, and encompass longer term follow-up, including cardiac and non cardiac morbidities, and importantly, those morbidities impacting health related quality of life. Methodologies must be implemented in these databases to allow uniform, protocol driven, and meaningful, long term follow-up.

Effect of inhaled corticosteroid on pulmonary injury and inflammatory mediator production after cardiopulmonary bypass in children

OBJECTIVE

To determine whether inhaled steroid administration after cardiopulmonary bypass will attenuate pulmonary inflammation and improve lung compliance and oxygenation.

DESIGN

Randomized, prospective, double-blind, placebo-controlled clinical trial.

SETTING

Children's Hospital of Michigan, intensive care unit.

PATIENTS

Thirty-two children <2 yrs of age with congenital heart disease requiring cardiopulmonary bypass.

INTERVENTIONS

Participants were randomly assigned to one of two groups. Group 1 (n = 16) received an inhaled steroid, Budesonide (0.25 mg/2 mL), and group 2 (n = 16) received an inhaled placebo (2 mL of inhaled 0.9% saline). The nebulizations were given at the end of cardiopulmonary bypass, 6 hrs after cardiopulmonary bypass, and 12 hrs after cardiopulmonary bypass. Two hours after each nebulization, bronchoalveolar lavage for interleukin-6 and interleukin-8 was collected.

MEASUREMENTS AND MAIN RESULTS

The concentrations of interleukin-6 and interleukin-8 in the bronchoalveolar lavage increased in both groups after cardiopulmonary bypass. Interleukin-6 peaked 2 hrs after cardiopulmonary bypass and was decreasing by 14 hrs after cardiopulmonary bypass. However, administration of corticosteroid did not affect the production of interleukin-6 when compared with the placebo group (378 +/- 728 vs. 287 +/- 583 pg/mL pre-cardiopulmonary bypass, 1662 +/- 1410 vs. 1584 +/- 1645 pg/mL at the end of cardiopulmonary bypass, 2601 +/- 3132 vs. 3677 +/- 4935 pg/mL 2 hrs after cardiopulmonary bypass, and 1792 +/- 3100 vs. 1283 +/- 1344 pg/mL 14 hrs after cardiopulmonary bypass; p > .05). Likewise, interleukin-8 in the lavage fluid was similar in both the placebo and steroid groups at all time points (570 +/- 764 vs. 990 +/- 1147 pg/mL pre-cardiopulmonary bypass, 1647 +/- 1232 vs. 1394 +/- 1079 pg/mL at the end of cardiopulmonary bypass, 1581 +/- 802 vs. 1523 +/- 852 pg/mL 2 hrs after cardiopulmonary bypass, and 1652 +/- 1069 pg/mL vs. 1808 +/- 281 pg/mL 14 hrs after cardiopulmonary bypass; p > .05). Lung compliance and oxygenation were similar in both groups.

CONCLUSIONS

Cardiopulmonary bypass is associated with a pulmonary inflammatory response. Inhaled corticosteroid did not affect the pulmonary inflammatory response as measured by interleukin-6 and interleukin-8 concentrations in the lung lavage after cardiopulmonary bypass. Pulmonary mechanics and oxygenation were not improved by the use of inhaled corticosteroid.

Improving patient safety by identifying latent failures in successful operations

BACKGROUND

The risk of technical failure during operations is recognized, but there is evidence that further improvements in safety depend on systems factors, in particular, effective team skills. The hypotheses that small problems can escalate to more serious situations and that effective teamwork can prevent the development of serious situations, were examined to develop a method to assess these skills and to provide evidence for improvements in training and systems.

METHOD(S)

Observations were made during 24 pediatric cardiac and 18 orthopedic operations. Operations were classified by accepted indicators of risk and the observations used to generate indicators of performance. Negative events were recorded and organized into 3 levels of clinical importance (minor problems, those negative events that were seemingly innocuous; intraoperative performance, the proportion of key operating tasks that were disrupted; and major problems, events that compromised directly the safety of the patient or the quality of the treatment). The ability of the team to work together safely was classified using a validated scale adapted from research in aviation. Operative duration was also recorded.

RESULT(S)

Both escalation and teamwork hypotheses were supported. Multiple linear regression suggests that for every 3 minor problems above the 9.9 expected per operation (P <.001), intraoperative performance reduces by 1% (P = .005), and operative duration increases by 10 minutes (P = .032). Effective teams have fewer minor problems per operation (P = .035) and consequently higher intraoperative performance and shorter operating times. Operative risk affected intraoperative performance (P = .004) and duration (P <.001), with the type of operation affecting only duration (P <.001). Eight major problems were observed; these showed a strong association with risk, intraoperative performance, teamwork, and the number of minor problems.

CONCLUSION(S)

Structured observation of effective teamwork in the operating room can identify substantive deficiencies in the system, even in otherwise successful operations. Decreasing the number of minor problems can lead to a smoother, safer, and shorter operation. Effective teamwork can help decrease the number of small problems and prevent them from escalating to more serious situations. The most effective and sustainable route to improved safety is in capturing these minor problems and identifying related system improvements, combined with training in safe team working. This method is a validated and practical way to improve performance during otherwise successful operations.

Pediatric cardiac surgery without homologous blood transfusion, using a miniaturized bypass system in infants with lower body weight

OBJECTIVE

We have established a low-priming volume cardiopulmonary bypass system for pediatric heart surgery to avoid homologous blood transfusion. The priming volume of our system is down to 140 mL for patients weighing less than 7 kg. We can prime the bypass circuits without blood products for patients weighing more than 4 kg.

METHODS

Seventy consecutive patients weighing 4 to 7 kg underwent heart surgery with a bloodless prime from October 2003 to September 2006. The type of procedures (Risk Adjustment in Congenital Heart Surgery category) included the following: category 1: atrial septal defect (n = 3); category 2: ventricular septal defect, tetralogy of Fallot, bidirectional Glenn shunt, and others (n = 55); category 3: atrioventricular septal defect, double-outlet right ventricle, and others (n = 8); category 4: Rastelli procedure for transposition of the great arteries (n = 3); and category 6, Damus-Kaye-Stansel procedure (n = 1). Transfusion criteria were hematocrit less than 20%, mixed venous oxygen saturation less than 70%, regional cerebral oxygenation less than 50%, and plasma lactate level greater than 4.0 mmol/L during bypass.

RESULTS

The mean age and body weight were 7.3 +/- 5.4 months and 5.4 +/- 0.8 kg, respectively. Forty-five patients (64%) underwent transfusion-free procedures. Preoperative hematocrit, age, body weight, complexity of procedure and cardiopulmonary bypass time were compared between patients with and without transfusion. Bypass time and Risk Adjustment in Congenital Heart Surgery risk category in patients with transfusion were significantly greater than those in patients without (P < .0001, and P < .05, respectively). Body weight in patients without transfusion was significantly greater than that in patients with (P < .01). In multiple regression analysis, the determinants of blood transfusion were the bypass time and body weight (odds ratio 1.026, 95% confidence interval 1.011-.040, P < .0001, and odds ratio 0.366, 95% confidence interval 0.171-0.785, P < .01).

CONCLUSIONS

It is possible to do complex transfusion-free procedures safely for patients weighing more than 4 kg by using the low-priming volume circuit. The limiting factors of bloodless heart surgery are not preoperative hematocrit and complexity of procedure but the cardiopulmonary bypass time and the patient's body weight.

Respiratory infection in congenital cardiac disease. Hospitalizations in young children in Spain during 2004 and 2005: the CIVIC Epidemiologic Study

OBJECTIVES

To evaluate the rate of hospitalization for acute respiratory tract infection in children less than 24 months with haemodynamically significant congenital cardiac disease, and to describe associated risk factors, preventive measures, aetiology, and clinical course.

MATERIALS AND METHODS

We followed 760 subjects from October 2004 through April 2005 in an epidemiological, multicentric, observational, follow-up, prospective study involving 53 Spanish hospitals.

RESULTS

Of our cohort, 79 patients (10.4%, 95% CI: 8.2%-12.6%) required a total of 105 admissions to hospital related to respiratory infections. The incidence rate was 21.4 new admissions per 1000 patients-months. Significant associated risk factors for hospitalization included, with odds ratios and 95% confidence intervals shown in parentheses: 22q11 deletion (8.2, 2.5-26.3), weight below the 10th centile (5.2, 1.6-17.4), previous respiratory disease (4.5, 2.3-8.6), incomplete immunoprophylaxis against respiratory syncytial virus (2.2, 1.2-3.9), trisomy 21 (2.1, 1.1-4.2), cardiopulmonary bypass (2.0, 1.1-3.4), and siblings aged less than 11 years old (1.7, 1.1-2.9). Bronchiolitis (51.4%), upper respiratory tract infections (25.7%), and pneumonia (20%) were the main diagnoses. An infectious agent was found in 37 cases (35.2%): respiratory syncytial virus in 25, Streptococcus pneumoniae in 5, and Haemophilus influenzae in 4. The odds ratio for hospitalization due to infection by the respiratory syncytial virus increases by 3.05 (95% CI: 2.14 to 4.35) in patients with incomplete prophylaxis. The median length of hospitalization was 7 days. In 18 patients (17.1%), the clinical course of respiratory infection was complicated and 2 died.

CONCLUSIONS

Hospital admissions for respiratory infection in young children with haemodynamically significant congenital cardiac disease are mainly associated with non-cardiac conditions, which may be genetic, malnutrition, or respiratory, and to cardiopulmonary bypass. Respiratory syncytial virus was the most commonly identified infectious agent. Incomplete immunoprophylaxis against the virus increased the risk of hospitalization.

Complications and Risk Factors for Mortality During Congenital Heart Surgery Admissions

BACKGROUND

We have previously reported a high rate (32%) of complications among congenital heart surgery admissions. The association among reported complications and other risk factors for mortality during congenital heart surgery admissions has not been assessed.

METHODS

We identified congenital heart surgery admissions, ages less than 18 years, within the Kids' Inpatient Database 2000, and applied a complication screening method using "International Classification of Disease, 9th Revision, Clinical Modification." Complication diagnoses were classified into four categories, complications due to the following: (1) drugs; (2) procedures; (3) devices, implants, and grafts; and (4) radiation. We examined the independent effect of a complication diagnosis code and complication subcategory on mortality using generalized estimating equations controlling for case-mix using the Risk Adjustment for Congenital Heart Surgery (RACHS-1) method, as well as other previously reported predictors for mortality.

RESULTS

Among the 10,032 congenital heart surgical admissions, 32% had at least one complication diagnosis. Seventy-eight percent of complication diagnoses were procedure related, 18% device, implant, or graft related, and 4% drug related. There were no radiation complications identified. After adjusting for case-mix, gender, race, insurance, and hospital surgical volume, admissions with a complication diagnosis had a substantially greater odds of death compared with admissions without a complication (odds ratio [OR] 2.4, p < 0.001). Among complication subcategories, procedure (OR 2.3, p < 0.001), and device, implant, or graft (OR 2.7, p < 0.001) related complications contributed to higher death risk.

CONCLUSIONS

Complication diagnoses occur frequently during congenital heart surgery admissions and are associated with an increased risk of death even after controlling for other known mortality risk factors. Identification of complication diagnoses is an important first step. Subsequent efforts must further examine these events to determine their degree of preventability and develop strategies to reduce them. Such an effort may reduce death in this vulnerable population. This study represents preliminary work in an effort to improve outcomes in this complex patient population.

Case Volume and Mortality in Pediatric Cardiac Surgery Patients in California, 1998–2003

Background— Previous reports have found an inverse relationship between pediatric cardiac surgery case volume and in-hospital mortality. This association has been noted recently to be decreasing for coronary artery bypass grafting, possibly because of improved training programs, quality improvement activities, or other innovations to improve outcomes. It is unknown whether the volume-mortality association among pediatric cardiac surgery patients is decreasing similarly.

Methods and Results— We used data from the state of California’s patient discharge data set from the years 1998–2003 to replicate 4 previous research studies of pediatric cardiac surgery volume and mortality. The total number of pediatric surgeries varied from 12 801 to 13 971 depending on the selection criteria applied. Using this larger and more contemporary data set, we found a weaker and less consistent volume-mortality relationship than had been reported previously. We also developed a new model, which incorporated elements of the old models, and found a statistically significant relationship with higher volume and lower mortality (odds ratio=0.86 per 100-patient increase in annual volume; 95% CI, 0.81 to 0.92). Post hoc analyses show that this relationship was related to the performance of the single largest-volume hospital.

Conclusions— With the use of data from California, the volume-mortality relationship among pediatric cardiac surgery patients has changed since previous research, such that the old models no longer describe a clear or consistent association. With the use of a continuous definition of volume and an updated model, an association is observed but is dependent on highly leveraged covariate patterns found in the largest-volume hospital.

Use of administrative data or clinical databases as predictors of risk of death in hospital: comparison of models

OBJECTIVE

To compare risk prediction models for death in hospital based on an administrative database with published results based on data derived from three national clinical databases: the national cardiac surgical database, the national vascular database and the colorectal cancer study.

DESIGN

Analysis of inpatient hospital episode statistics. Predictive model developed using multiple logistic regression.

SETTING

NHS hospital trusts in England.

PATIENTS

All patients admitted to an NHS hospital within England for isolated coronary artery bypass graft (CABG), repair of abdominal aortic aneurysm, and colorectal excision for cancer from 1996-7 to 2003-4.

MAIN OUTCOME MEASURES

Deaths in hospital. Performance of models assessed with receiver operating characteristic (ROC) curve scores measuring discrimination (<0.7=poor, 0.7-0.8=reasonable, >0.8=good) and both Hosmer-Lemeshow statistics and standardised residuals measuring goodness of fit.

RESULTS

During the study period 152 523 cases of isolated CABG with 3247 deaths in hospital (2.1%), 12 781 repairs of ruptured abdominal aortic aneurysm (5987 deaths, 46.8%), 31 705 repairs of unruptured abdominal aortic aneurysm (3246 deaths, 10.2%), and 144,370 colorectal resections for cancer (10,424 deaths, 7.2%) were recorded. The power of the complex predictive model was comparable with that of models based on clinical datasets with ROC curve scores of 0.77 (v 0.78 from clinical database) for isolated CABG, 0.66 (v 0.65) and 0.74 (v 0.70) for repairs of ruptured and unruptured abdominal aortic aneurysm, respectively, and 0.80 (v 0.78) for colorectal excision for cancer. Calibration plots generally showed good agreement between observed and predicted mortality.

CONCLUSIONS

Routinely collected administrative data can be used to predict risk with similar discrimination to clinical databases. The creative use of such data to adjust for case mix would be useful for monitoring healthcare performance and could usefully complement clinical databases. Further work on other procedures and diagnoses could result in a suite of models for performance adjusted for case mix for a range of specialties and procedures.

Glucocorticoid therapy for hypotension in the cardiac intensive care unit

In recent years, it has been our practice to treat persistent hypotension in the cardiac intensive care unit with glucocorticoids. We undertook a retrospective review in an attempt to identify predictors of a hemodynamic response to steroids and of survival in these patients. Patients who had received glucocorticoids for hypotension over a 2-year period were identified retrospectively. Summary measures of blood pressure, heart rate, urine output, inotrope score, and volume of infused fluid were calculated for the 12 hours before and the 24 hours following initiation of glucocorticoid therapy. A hemodynamic response was defined as a > or =20% increase in mean blood pressure without an increase in inotrope score following initiation of steroid therapy. Fifty-one patients were included, of whom 6 (11.8%) died. Serum cortisol was measured in 43 patients (84.3%) and was below the lower limit of normal (<5 microg/dl) in 20 of these (46.5%). Following initiation of steroid therapy, blood pressure and urine output increased, whereas heart rate, inotrope score, and infused volume decreased. There were 21 (41.1%) hemodynamic responders, all of whom survived, whereas 6 of 30 (20%) nonresponders died (p = 0.036). No predictors of a hemodynamic response to steroid were identified. Some critically ill children with cardiac disease and inotrope refractory hypotension demonstrated hemodynamic improvement following glucocorticoid administration. An improvement in blood pressure following administration of glucocorticoid was associated with survival, but we were unable to identify predictors of that response.

Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality

BACKGROUND

We aimed to improve the quality and safety of handover of patients from surgery to intensive care using the analogy of a Formula 1 pit stop and expertise from aviation.

METHODS

A prospective intervention study measured the change in performance before and after the implementation of a new handover protocol that was developed through detailed discussions with a Formula 1 racing team and aviation training captains. Fifty (23 before and 27 after) postsurgery patient handovers were observed. Technical errors and information omissions were measured using checklists, and teamwork was scored using a Likert scale. Duration of the handover was also measured.

RESULTS

The mean number of technical errors was reduced from 5.42 (95% CI +/-1.24) to 3.15 (95% CI +/-0.71), the mean number of information handover omissions was reduced from 2.09 (95% CI +/-1.14) to 1.07 (95% CI +/-0.55), and duration of handover was reduced from 10.8 min (95% CI +/-1.6) to 9.4 min (95% CI +/-1.29). Nine out of twenty-three (39%) precondition patients had more than one error in both technical and information handover prior to the new protocol, compared with three out of twnety-seven (11.5%) with the new handover. Regression analysis showed that the number of technical errors were significantly reduced with the new handover (t = -3.63, P < 0.001), and an interaction suggested that teamwork (t = 3.04, P = 0.004) had a different effect with the new handover protocol.

CONCLUSIONS

The introduction of the new handover protocol lead to improvements in all aspects of the handover. Expertise from other industries can be extrapolated to improve patient safety, and in particular, areas of medicine involving the handover of patients or information.

Case complexity scores in congenital heart surgery: A comparative study of the Aristotle Basic Complexity score and the Risk Adjustment in Congenital Heart Surgery (RACHS-1) system

OBJECTIVE

The Aristotle Basic Complexity score and the Risk Adjustment in Congenital Heart Surgery system were developed by consensus to compare outcomes of congenital cardiac surgery. We compared the predictive value of the 2 systems.

METHODS

Of all index congenital cardiac operations at our institution from 1982 to 2004 (n = 13,675), we were able to assign an Aristotle Basic Complexity score, a Risk Adjustment in Congenital Heart Surgery score, and both scores to 13,138 (96%), 11,533 (84%), and 11,438 (84%) operations, respectively. Models of in-hospital mortality and length of stay were generated for Aristotle Basic Complexity and Risk Adjustment in Congenital Heart Surgery using an identical data set in which both Aristotle Basic Complexity and Risk Adjustment in Congenital Heart Surgery scores were assigned. The likelihood ratio test for nested models and paired concordance statistics were used.

RESULTS

After adjustment for year of operation, the odds ratios for Aristotle Basic Complexity score 3 versus 6, 9 versus 6, 12 versus 6, and 15 versus 6 were 0.29, 2.22, 7.62, and 26.54 (P < .0001). Similarly, odds ratios for Risk Adjustment in Congenital Heart Surgery categories 1 versus 2, 3 versus 2, 4 versus 2, and 5/6 versus 2 were 0.23, 1.98, 5.80, and 20.71 (P < .0001). Risk Adjustment in Congenital Heart Surgery added significant predictive value over Aristotle Basic Complexity (likelihood ratio chi2 = 162, P < .0001), whereas Aristotle Basic Complexity contributed much less predictive value over Risk Adjustment in Congenital Heart Surgery (likelihood ratio chi2 = 13.4, P = .009). Neither system fully adjusted for the child's age. The Risk Adjustment in Congenital Heart Surgery scores were more concordant with length of stay compared with Aristotle Basic Complexity scores (P < .0001).

CONCLUSIONS

The predictive value of Risk Adjustment in Congenital Heart Surgery is higher than that of Aristotle Basic Complexity. The use of Aristotle Basic Complexity or Risk Adjustment in Congenital Heart Surgery as risk stratification and trending tools to monitor outcomes over time and to guide risk-adjusted comparisons may be valuable.

Female gender increases the risk of death during hospitalization for pediatric cardiac surgery

OBJECTIVES

The study objective was to determine whether gender is a determinant of in-hospital mortality after surgery to repair congenital heart disease in patients aged 20 years or less. Secondary objectives were to determine other factors associated with increased risk of death and whether female gender is associated with increased length of stay or total charges.

METHODS

The study included a retrospective cohort consisting of all records indicating cardiac operations within the Healthcare Cost and Utilization Project Kids' Inpatient Database for the year 2000. Logistic regression was used to simultaneously evaluate the effect of gender on the risk of death while adjusting for all other factors being considered. Logistic regression was then used to evaluate possible differences in length of stay or total charges.

RESULTS

Female gender was associated with increased risk of in-hospital death when all of the other measured factors were taken into consideration (odds ratio 1.31, 95% confidence interval 1.02-1.69). Other factors that were significantly associated with increased in-hospital mortality after pediatric cardiac surgery included the number of days between admission and operation; African American race; young age (neonates and infants compared with children aged > or =1 year); pulmonary hypertension; and the Norwood operation. There were no significant gender differences in risk-adjusted length of stay or total charges.

CONCLUSIONS

In-hospital mortality after pediatric cardiac surgery seems to be associated with patient gender but not with the type of insurance or ability to access higher-volume pediatric facilities or teaching hospitals.

Nomenclature and databases - the past, the present, and the future : a primer for the congenital heart surgeon

This review discusses the historical aspects, current state of the art, and potential future advances in the areas of nomenclature and databases for congenital heart disease. Five areas will be reviewed: (1) common language = nomenclature, (2) mechanism of data collection (database or registry) with an established uniform core data set, (3) mechanism of evaluating case complexity, (4) mechanism to ensure and verify data completeness and accuracy, and (5) collaboration between medical subspecialties. During the 1990s, both the Society of Thoracic Surgeons (STS) and the European Association for Cardiothoracic Surgery (EACTS) created congenital heart surgery outcomes databases. Beginning in 1998, the EACTS and STS collaborated in the work of the International Congenital Heart Surgery Nomenclature and Database Project. By 2000, a common congenital heart surgery nomenclature, along with a common core minimal data set, were adopted by the EACTS and the STS and published in the Annals of Thoracic Surgery. In 2000, the International Nomenclature Committee for Pediatric and Congenital Heart Disease was established; this committee eventually evolved into the International Society for Nomenclature of Paediatric and Congenital Heart Disease (ISNPCHD). The working component of ISNPCHD is the International Working Group for Mapping and Coding of Nomenclatures for Paediatric and Congenital Heart Disease, also known as the Nomenclature Working Group (NWG). By 2005, the NWG cross-mapped the EACTS-STS nomenclature with the European Paediatric Cardiac Code of the Association for European Paediatric Cardiology and created the International Paediatric and Congenital Cardiac Code (IPCCC) ( http://www.IPCCC.NET ). This common nomenclature (IPCCC), and the common minimum database data set created by the International Congenital Heart Surgery Nomenclature and Database Project, are now utilized by both EACTS and STS; since 1998, this nomenclature and database have been used by both the STS and EACTS to analyze outcomes of more than 75,000 patients. Two major multi-institutional efforts have attempted to measure case complexity; the Risk Adjustment in Congenital Heart Surgery-1 and the Aristotle Complexity Score. Efforts to unify these two scoring systems are in their early stages but are encouraging. Collaborative efforts involving the EACTS and STS are under way to develop mechanisms to verify data completeness and accuracy. Further collaborative efforts are also ongoing between pediatric and congenital heart surgeons and other subspecialties, including pediatric cardiac anesthesiologists (via the Congenital Cardiac Anesthesia Society), pediatric cardiac intensivists (via the Pediatric Cardiac Intensive Care Society), and pediatric cardiologists (via the Joint Council on Congenital Heart Disease). Clearly, methods of congenital heart disease outcomes analysis continue to evolve, with continued advances in five areas: nomenclature, database, complexity adjustment, data verification, and subspecialty collaboration.

Patient safety and human factors in pediatric cardiac surgery

The patient safety movement and human factors studies are becoming an increasingly important part of everyday clinical practice. Pediatric cardiac surgery is a high-risk field that is very much dependent on safe practices and continuous research into improvement of outcomes. This article reviews the main research frameworks, methods used, and current findings in the area of patient safety and human factors within pediatric cardiac surgery.

Outcome after surgical repair of congenital cardiac malformations at school age

OBJECTIVES

To explore the long-term physical, educational, behavioural, and emotional outcome of patients undergoing surgical correction of congenital cardiac disease at school age, and to investigate the relation, if any, between the outcome and comorbidity, age and sex, and level of complexity of the cardiac surgery.

METHODS

Information was obtained concerning 101 patients who underwent open-heart surgery for correction of congenital cardiac malformations between 1992 and 2000 whilst aged from 6 to 16 years. The patients, and their parents, completed the questionnaire "Outcome of congenital heart disease and surgery", the RAND 36-Item Health Survey, and the Child Behaviour Checklist/Youth Self-Report/Young Adult Self-Report.

RESULTS

Of the patients, 26% had comorbidity. Of those without comorbidity, 39% had frequent physical complaints, and 28% experienced limitations due to the cardiac disease. Nevertheless, the patients reported a good subjective state of health, and did not report any behavioural or emotional problems. Patients did show academic difficulties. They had received special education more frequently than their healthy peers, and many had needed to repeat a grade, or had received remedial teaching. Consequently, the educational level of patients was lower than that of their healthy peers. Patients with comorbidity, female patients, and patients who underwent complex surgery, seemed to be most at risk for physical, behavioural, and emotional problems.

CONCLUSION

It is necessary to distinguish between physical state and its appraisal, and clinicians should be aware of this. Further research is needed to find out the cause and nature of the academic difficulties. Groups of patients at risk should be followed closely to enable early interventions.

Measurement of technical performance in congenital heart surgery: a pilot study

BACKGROUND

Although adequacy of repair after congenital heart surgery is a crucial determinant of clinical outcome, there is no current method of assessment. We sought to develop a process to measure the adequacy of repair for a diverse group of congenital heart procedures.

METHODS

Selected surgical procedures, consisting of repair of ventricular septal defect (VSD), tetralogy of Fallot (TOF), complete common atrioventricular canal (CAVC), and arterial switch operation, were divided into component subprocedures, each of which was assessed separately. Three outcome categories of "optimal," "adequate," and "inadequate" were defined by consensus according to postprocedure echocardiographic assessment. Outcome categories for conduction disturbance were also created. All patients undergoing one of the four procedures in 2004 were identified, and each subprocedure was assessed. Other clinical data were obtained from medical records. Repairs were scored as "optimal" if all attempted subprocedures and conduction were optimal, and "inadequate" if any was inadequate.

RESULTS

A total of 138 procedures were included. VSD repair was done in 46 patients (33%), TOF repair in 33 (24%), arterial switch operation in 36 (26%), and CAVC repair in 23 (17%). Optimal technical score was found in 28 (20%), adequate in 106 (77%), and inadequate in 4 (3%) (2 VSD, 1 TOF, 1 CAVC). Median length of stay was 8 days, and no patients died.

CONCLUSIONS

Despite procedural diversity and complexity, technical adequacy of repair can be assessed for congenital heart surgery.

Rapid Cardiopulmonary Support in Children With Heart Disease: A Nine-Year Experience

BACKGROUND

We developed a novel mechanical rapid cardiopulmonary support system (CPS) in 1996 to eliminate what we believed were shortcomings of conventional extracorporeal membrane oxygenation (ECMO) circuits when used in patients with congenital heart disease. We reviewed the use of this system over a nine year period to determine if we had been successful in improving results compared with ECMO and if outcomes have changed over this time.

METHODS

All children supported with CPS (110 procedures) were reviewed. Noncardiac CPS cases (7) were excluded. The study population was divided into two time periods (1995 to 2000 and 2001 to 2004), which correlate with significant differences in intraoperative, postoperative, and CPS management. Patients were further analyzed by age (< or = 30 days or > 30 days), repair complexity (risk adjusted classification for congenital heart surgery [RACHS]-1 category 6 or categories 1 to 5), and length of support.

RESULTS

Overall thirty day survival of cardiac CPS patients was 55% (57 of 103). Overall survival increased from 45% (23 of 51) during the first period to 65% (34 of 52) during the second period [p < or = 0.005]. Survival rates in neonates improved from 41% (11 of 27) to 56% (15 of 27) and RACHS-1 category 6 survival improved from 38% (5 of 13) to 69% (9 of 13), but neither change reached statistical significance. Intracranial hemorrhage occurred in 6.4% of all CPS patients.

CONCLUSIONS

Cardiopulmonary support is an effective alternative to ECMO for pediatric cardiac support. Further, our experience suggests that patient survival may be improved by CPS compared with reported results for ECMO in cardiac patients.

Postoperative Prophylactic Peritoneal Dialysis in Neonates and Infants After Complex Congenital Cardiac Surgery

Peritoneal dialysis after complex congenital cardiac surgery was introduced to a group of neonates and infants (n = 756; age, 0 to 1 year) between May 1993 and December 2005. Indications of peritoneal dialysis were determined as well as methods, prolonged dialysis, and its outcomes. Demographic characteristics, preoperative risk factors, intraoperative variables, and postoperative complications were compared in 756 cases with ages below 1 year. All cases underwent ultrafiltration during the perioperative stage. One hundred eighty-six cases (24.6% of total) required peritoneal dialysis. The cardiac pathology was transposition of great arteries in 133 cases, tetralogy of Fallot in 37, aorticopulmonary window associated with interrupted aortic arch in 4 and total anomalous pulmonary venous return in 5, and other complex pathology in 7 cases. Prolonged peritoneal dialysis was usually required in infants with low weight, with episodes of pulmonary hypertensive crisis (p < 0.05), and with preoperative renal dysfunction. No major complication was observed related to the peritoneal dialysis catheter. Of 186 patients, 23 (12.3%) had acute renal failure, and 4 of them died (2.15% of all patients underwent operation, 17.3% of those with acute renal failure). It has been demonstrated that the combination of peritoneal dialysis with perioperative ultrafiltration application was effective in providing the required postoperative negative fluid balance in especially complex congenital heart cases and affected survival positively.

Cardiac Troponin T Levels for Risk Stratification in Pediatric Open Heart Surgery

BACKGROUND

Cardiac troponin T has been found to be accurate predictor of complications and adverse clinical events after pediatric cardiac surgery. Contrary to adult cardiac surgery, the relationship of troponin T to patient survival after pediatric heart surgery has not been previously studied. The purpose of this study was to determine whether troponin T could predict death after pediatric open cardiac surgery.

METHODS

This was a retrospective cohort study in which data from 1001 consecutive children having cardiac surgery during a 5-year period were studied. Perioperative variables that could influence death at 30 postoperative days were evaluated.

RESULTS

Multivariate analysis, using a forward stepwise logistic regression, showed that troponin T measured on the first postoperative day was a strong independent predictor of death at 30 days. Level of troponin T greater than 5.9 microg/L on the first postoperative day predicted death (odds ratio, 10.7; 95% confidence interval: 5.2 to 22.1) as did admission lactate level greater than 5.2 mmol/L (odds ratio, 22.2; 95% confidence interval: 9.7 to 50.8) No other variable, including postoperative creatine kinase-MB mass concentration, age, diagnosis, surgical procedure, presence of cyanosis, chromosomal anomaly or ventriculotomy, duration of cardiopulmonary bypass, or aortic cross-clamp, had any independent effect on 30-day survival.

CONCLUSIONS

Cardiac troponin T level on the first postoperative day is a powerful independent risk marker of death in pediatric cardiac surgery.

Interleukin-10 and its role in clinical immunoparalysis following pediatric cardiac surgery

OBJECTIVE

A systemic insult is associated with subsequent hyporesponsiveness to endotoxin (as measured by ex vivo tumor necrosis factor [TNF]-alpha production) and an increased risk of late nosocomial infection in some patients. When combined with low monocyte surface major histocompatibility complex class II expression, this state of altered host defense is now commonly referred to as immunoparalysis. This study was undertaken to delineate the relationship between observed levels of the anti-inflammatory cytokine interleukin-10, common genetic polymorphisms that influence these levels, and the occurrence and severity of endotoxin hyporesponsiveness in children following elective cardiac surgery requiring cardiopulmonary bypass.

DESIGN

A prospective observational clinical study.

SETTING

A tertiary pediatric cardiac center.

PATIENTS

Thirty-six infants and children <2 yrs of age undergoing elective cardiac surgery requiring cardiopulmonary bypass.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We investigated the production of TNF-alpha, interleukin-6, interleukin-8, interleukin-1 receptor antagonist, and interleukin-10 in whole blood in response to lipopolysaccharide (Neisseria meningitides 10 ng/mL) in samples drawn before, during, and up to 48 hrs after surgery. Patients were genotyped for the -1082, -819, and -592 interleukin-10 promoter polymorphisms. Whole blood cytokine response to lipopolysaccharide was reduced postoperatively to </=50% of preoperative levels for all cytokines measured. Stimulated cytokine production was lowest in cases with the highest postoperative plasma interleukin-10 levels, which were in turn associated with the GCC haplotype. Those patients in whom the whole blood response to endotoxin was maintained (TNF-alpha >100 pg/mL) over the first 48 hrs were more likely to have an uncomplicated short stay (odds ratio 4.7, 95% confidence interval 1-22).

CONCLUSIONS

Immediately following cardiac surgery, many children become relatively refractory to lipopolysaccharide stimulation. This immunoparalysis appears to be related in part to high circulating levels of interleukin-10 and places these patients at increased risk of postoperative complications. Interleukin-10 genotype may be a risk factor for immunoparalysis.

Pretransport and posttransport characteristics and outcomes of neonates who were admitted to a cardiac intensive care unit

OBJECTIVE

The objective for this study was to characterize the impact and the safety of transporting neonates with known or suspected cardiac abnormalities.

METHODS

We reviewed retrospectively the charts and computerized records of 192 admissions to a cardiac ICU in 2002. Patients were included when they were < 28 days of age at admission and were transported from adjacent obstetric facilities (local N = 70) or other inpatient medical facilities (transport N = 122). Demographic, clinical, pharmacologic, laboratory, and diagnostic information was obtained before transport (when available) and within 3 hours of arrival. Arrival status was considered optimal when measured metabolic and clinical parameters all were within range. Outcome variables included days on ventilator, days in ICU, days in hospital, and death.

RESULTS

Of local admissions, 31 (44%) patients had 61 suboptimal arrival values, including pH < 7.25 (n = 11), saturation < 70% (n = 12), and temperature < 36 degrees C (n = 9). There were 69 undocumented values in 39 patients. Of transported patients, 55 (45%) had 86 suboptimal arrival values, including pH < 7.25 (n = 8), saturation < 70% (n = 14), and temperature < 36 degrees C (n = 13). There were 98 undocumented values in 53 patients. No in-transport deaths or catastrophic events occurred. Local admissions were more likely to have a prenatal diagnosis of heart disease and had more complex disease and higher mortality. Other outcome parameters were not significantly different between the 2 groups. Low admission arterial saturation, pH, and core temperature were not correlated with adverse outcome measures.

CONCLUSIONS

Although we did not encounter major transport complications, opportunities exist to optimize arrival status and improve surveillance and documentation.

Internet rounds: a congenital heart surgeon's Web log

As the complexity of congenital heart care increases, and expectations for improved outcomes grow, the limitations of current medical information management systems are exposed. Despite advances in information management technology, achieving a state of information resonance within a congenital heart team, where comprehensive patient data and real time program performance can be intuitively accessed on demand, remains an elusive goal. The World Wide Web constitutes a potential platform for a medical information management system capable of overcoming the limitations of traditional medical information exchange. We designed and implemented an Internet based information management system to collect, store and exchange comprehensive patient information, and measure clinical performance in real time. Use of this system has been associated with improved clinical outcomes for a congenital heart team.

Risk factors for deaths occurring within 30 days and 1 year after hospital discharge for cardiac surgery among pediatric patients

BACKGROUND

Little is known regarding the risk factors for early and late death after hospital discharge among pediatric patients undergoing cardiac surgery.

METHODS

Statewide hospital discharge data from California in 1989 to 1999 were used to study outcomes of children <18 years old who had a procedure code (by International Classification of Diseases, Ninth Revision, Clinical Modification) indicating cardiac surgery. The outcome variable was death occurring after hospital discharge. Postdischarge deaths were identified by linking hospital discharge data to statewide death registry data. Cardiac surgical procedures were grouped into 23 categories to adjust for risk involved with the procedures. We used logistic regression to evaluate risk factors for postdischarge mortality, including variables age, sex, race and ethnicity, type of insurance, home income, date and month of surgery, type of admission, hospitals case volume, and the various types of procedures.

RESULTS

There were 25,402 cardiac surgery cases with 1505 inhospital deaths. Of 23,897 hospital discharges, 148 deaths (0.62%) occurred within 365 days after discharge, including 37 deaths within 30 days; 44 deaths at 31 to 90 days; and 67 deaths at 91 to 365 days. Logistic regression showed young age was an important risk factor for postdischarge death with an odds ratio of 4.8 for neonates and 3.5 for infants, compared with children >1 year old. Another significant risk factor was the type of procedure. For death <30 days after discharge, Norwood operation (odds ratio 8.4 compared with closure of ventricular septal defect) was a risk factor. For death that occurred between 31 and 365 days, significant risk factors were truncus arteriosus repair, total anomalous pulmonary vein repair, aortopulmonary shunt, and open valvotomy. Sex, race/ethnicity, home income, and hospital case volume were not significant predictors of postdischarge deaths.

CONCLUSIONS

Many demographic and socioeconomic variables affecting inhospital death were not significant predictors for postdischarge death. Important risk factors for postdischarge death were young age and the type of surgery performed.

Hyperglycemia is a marker for poor outcome in the postoperative pediatric cardiac patient

OBJECTIVE

Hyperglycemia in critical care populations has been shown to be a risk factor for increased morbidity and mortality. Minimal data exist in postoperative pediatric cardiac patients. The goal of this study was to determine whether hyperglycemia in the postoperative period was associated with increased morbidity or mortality.

DESIGN

Retrospective chart review.

SETTING

Tertiary care, free-standing pediatric medical center with a dedicated cardiac intensive care unit.

PATIENTS

We included 184 patients <1 yr of age who underwent cardiac surgery requiring cardiopulmonary bypass from October 2002 to August 2004. Patients with a weight <2 kg, a preoperative diagnosis of diabetes, preoperative extracorporeal membrane oxygenation support, solid organ transplant recipients, and preoperative renal or liver insufficiency were excluded.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Age was 4.3 +/- 3.2 months and weight was 4.9 +/- 1.7 kg at surgery. Duration of hyperglycemia was significantly longer in patients with renal insufficiency (p = .029), liver insufficiency (p = .006), infection (p < .002), central nervous system event (p = .038), extracorporeal membrane oxygenation use (p < .001), and death (p < .002). Duration of hyperglycemia was also significantly associated with increased intensive care (p < .001) and hospital (p < .001) stay and longer ventilator use (p < .001). Peak glucose levels were significantly different in patients with renal insufficiency (p < .001), infection (p = .002), central nervous system event (p = .01), and mortality (p < .001).

CONCLUSIONS

Hyperglycemia in the postoperative period was associated with increased morbidity and mortality in postoperative pediatric cardiac patient. Strict glycemic control may improve outcomes in this patient population.

Current Assessment of Mortality Rates in Congenital Cardiac Surgery

BACKGROUND

The purpose of this study is to evaluate whether published and widely quoted mortality rates for pediatric cardiac surgery accurately reflect current expectations. Our hypotheses are that (1) mortality rates at high-quality pediatric cardiac programs are lower than published national results despite (2) a change in case mix with a shift away from low complexity operations.

METHODS

We requested data for all pediatric cardiac surgical procedures performed between 2001 and 2004 at 29 Congenital Heart Surgeon's Society (CHSS) member institutions (using CHSS as a surrogate for recognized high quality). Procedures were categorized by Risk Adjustment for Congenital Heart Surgery, version 1 (RACHS-1) category. In-hospital mortality rates for each category were calculated and compared with those in the 2002 manuscript of Jenkins and colleagues.

RESULTS

We received data for 16,805 procedures from 11 institutions. In all, 12,672 operations (76%) could be placed into RACHS-1 categories. Overall in-hospital mortality for categorized operations was 2.9% and was most related to case mix. There was a significant decrease in the percentage of category 1 operations, and there were significant increases in category 2, 4, and 6 operations. There were significant decreases in category 2, 3, 4, and 6 mortality rates (Jenkins 2002 [CHSS]): (1) 0.4% [0.7%], (2) 3.8% [0.9%], (3) 8.5% [2.7%], (4) 19.4% [7.7%], (5) not applicable, and (6) 47.7% [17.2%]. There was no significant association between hospital surgical volume and mortality.

CONCLUSIONS

This outcomes "footprint" suggests that we could hold ourselves accountable to higher benchmarks than those reflected by some published standards. Mortality rates declined, despite an increase in case mix complexity. The lack of association between hospital surgical volume and mortality suggests that other factors determine outcomes at high-quality institutions. In addition to continually validating our expectations for treatment, future research needs to identify these factors by understanding the system of care and identifying process measures that influence outcomes.

Racial and ethnic disparities in mortality following congenital heart surgery

Our objective was to assess risk-adjusted racial and ethnic disparities in mortality following congenital heart surgery. We studied 8483 congenital heart surgical cases from the Kids' Inpatient Database 2000. Black sub-analysis was performed using predetermined regional categories. For our Hispanic sub-analyses, we categorized Hispanics into state groups according to a state's predominant Hispanic group: West (Mexican-American), Southeast (Cuban-American), Northeast (Puerto Rican), and Mixed/Heterogeneous. Risk adjustment was performed using the Risk Adjustment for Congenital Heart Surgery method. Multivariate analyses assessed the effect of race/ethnicity and Hispanic state group on mortality and explored the effects of gender, income, insurance type, and region. Black children had a higher risk for death than Whites odds ratio (OR), [1.65; p = 0.003]. Hispanics and the Cuban-American state group showed a trend toward a higher death risk (Hispanic: OR, 1.24; p = 0.16; Southeast Cuban-American: OR 1.55; p = 0.08). Disparities were not influenced by insurance. Among Blacks, disparities were greatest in the Northeast region (OR, 2.25; p = 0.007). After adjusting for gender, income, and region, Blacks (OR, 1.76; p = 0.002) and Hispanics (OR, 1.34; p = 0.05) had a higher death risk. Racial and ethnic disparities in risk-adjusted mortality following congenital heart disease exist for Blacks and Hispanics. These disparities are not due to insurance but are partially explained by gender and region.

Identification of systems failures in successful paediatric cardiac surgery

Patient safety will benefit from an approach to human error that examines systemic causes, rather than blames individuals. This study describes a direct observation methodology, based on a threat and error model, prospectively to identify types and sources of systems failures in paediatric cardiac surgery. Of substantive interest were the range, frequency and types of failures that could be identified and whether minor failures could accumulate to form more serious events, as has been the case in other industries. Check lists, notes and video recordings were employed to observe 24 successful operations. A total of 366 failures were recorded. Coordination and communication problems, equipment problems, a relaxed safety culture, patient-related problems and perfusion-related problems were most frequent, with a smaller number of skill, knowledge and decision-making failures. Longer and more risky operations were likely to generate a greater number of minor failures than shorter and lower risk operations, and in seven higher-risk cases frequently occurring minor failures accumulated to threaten the safety of the patient. Non-technical errors were more prevalent than technical errors and task threats were the most prevalent systemic source of error. Adverse events in surgery are likely to be associated with a number of recurring and prospectively identifiable errors. These may be co-incident and cumulative human errors predisposed by threats embedded in the system, rather than due to individual incompetence or negligence. Prospectively identifying and reducing these recurrent failures would lead to improved surgical standards and enhanced patient safety.

In-hospital mortality for children with hypoplastic left heart syndrome after stage I surgical palliation: teaching versus nonteaching hospitals

OBJECTIVES

Teaching hospitals are perceived to provide a higher quality of care for the treatment of rare disease and complex patients. A substantial proportion of stage I palliation for hypoplastic left heart syndrome (HLHS) may be performed in nonteaching hospitals. This study compares the in-hospital mortality of stage I palliation between teaching and nonteaching hospitals.

METHODS

The authors conducted a retrospective cohort study using the Kids' Inpatient Database 1997 and 2000. Patients with HLHS undergoing stage I palliation were identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes.

RESULTS

Seven hundred fifty-four and 880 discharges of children with HLHS undergoing stage I palliation in 1997 and 2000, respectively, were identified. The in-hospital mortality for the study population was 28% in 1997 and 24% in 2000. Twenty percent of stage I palliation operations were performed in nonteaching hospitals in 1997. Two percent of operations were performed in nonteaching hospitals in 2000. In 1997 only, in-hospital mortality remained higher in nonteaching hospitals after controlling for stage I palliation hospital volume and condition-severity diagnoses. Low-volume hospitals performing stage I palliation were associated with increased in-hospital mortality in 1997 and 2000.

CONCLUSIONS

Patients with HLHS undergoing stage I palliation in nonteaching hospitals experienced increased in-hospital mortality in 1997. A significant reduction in the number of stage I palliation procedures performed in nonteaching hospitals occurred between 1997 and 2000. This centralization of stage I palliation into teaching hospitals, along with advances in postoperative medical and surgical care for these children, was associated with a decrease in mortality. Patients in low-volume hospitals performing stage I palliation continued to experience increased mortality in 2000.

Use of dexmedetomidine in children after cardiac and thoracic surgery

OBJECTIVE

In this report, we describe our experience with the use of dexmedetomidine in spontaneously breathing as well as in mechanically ventilated patients, after congenital cardiac and thoracic surgery.

DESIGN

Retrospective case series.

SETTING

University hospital, pediatric cardiac intensive care unit.

PATIENTS

Thirty-three spontaneously breathing and five mechanically ventilated patients who received dexmedetomidine after cardiothoracic surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Thirty-eight patients, age 8 +/- 1.1 yrs old and weight 29 +/- 3.8 kg, were included. Seven patients (18%) were <1 yr old. Dexmedetomidine was used as a primary sedative and analgesic agent, and when its effect was considered inadequate, despite incremental infusion doses, a rescue agent was administered. The initial dexmedetomidine infusion dose was 0.32 +/- 0.15 microg/kg/hr followed by an average infusion of 0.3 +/- 0.05 microg/kg/hr (range 0.1-0.75 microg/kg/hr). There was a trend toward higher dexmedetomidine infusion requirement in patients <1 yr old compared with older children, 0.4 +/- 0.13 vs. 0.29 +/- 0.17 microg/kg/hr (p = .06). Desired sedation and analgesia were achieved during 93% and 83% of the dexmedetomidine infusion, respectively. According to the intensive care unit sedation scale (score 0-3) and two pain scales (Numeric Visual Analog Scale and Face, Legs, Activity, Cry, and Consolability, score 0-10), the mean sedation score was 1.3 +/- 0.6 (mild sedation) and the mean pain score was 1.5 +/- 0.9 (mild pain). The most frequently rescue drugs administered were fentanyl, morphine, and midazolam. Overall, 49 rescue doses of sedatives/analgesics were given. Patients <1 yr old required more rescue boluses than older children, 22 boluses (3.19 +/- 0.8) vs. 27 boluses (0.8 +/- 0.2, p = .003). Throughout the dexmedetomidine infusion there was no significant change in the systolic and diastolic blood pressure trend. Six patients (15%) had documented hypotension. In three, hypotension resolved with decreasing the dexmedetomidine infusion dose whereas in the other three, hypotension resolved after discontinuing the infusion. Although there was a trend toward lower heart rates, this was not clinically significant. One patient had an episode of considerable bradycardia without hypotension, which resolved shortly after discontinuing the dexmedetomidine infusion. No significant changes in the arterial blood gases or respiratory rates were observed. There was no mortality, and the total intensive care unit length of stay was 19 +/- 2 hrs.

CONCLUSIONS

Our data suggest that dexmedetomidine is a well-tolerated and effective agent for both spontaneously breathing and mechanically ventilated patients following congenital cardiac and thoracic surgery.

Prognostic value of plasma N-terminal pro-brain natriuretic peptide in children with congenital heart defects and open-heart surgery

OBJECTIVE

To assess whether preoperative and postoperative plasma levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) predict postoperative outcome of open-heart surgery in children.

STUDY DESIGN

A prospective observational study was conducted with 40 children with congenital heart defects who were undergoing elective open-heart surgery. Plasma levels of NT-proBNP, troponin T, lactate, C-reactive protein, and total neutrophil cell counts were measured before, during, and 1 and 3 hours after the end of cardiopulmonary bypass grafting (CPB). Outcomes were assessed by means of the kind, dosage, and duration of inotropic drug use during the postoperative period, lactate concentrations, and the duration of mechanical ventilation.

RESULTS

Preoperative levels of NT-proBNP were significantly increased irrespective of the type of congenital heart defect and the age of the patient. Preoperative NT-proBNP levels were higher in patients receiving prolonged postoperative inotropic drug therapy (r = 0.56, P = .0003). By means of multivariate analysis with the duration of inotropic therapy as the dependent variable, a significant impact of preoperative NT-proBNP levels, the presence of a cyanotic heart defect, the risk adjustment for congenital heart surgery score, duration of CPB time, and postoperative lactate levels were demonstrated (R squared = 76.8%, P <.0001).

CONCLUSION

Preoperative NT-proBNP levels were associated with complicated postoperative outcome in children who underwent low-risk open-heart surgery. This marker may therefore be a useful tool in risk stratification of patients with congenital heart defects.

Influence of surgical strategies on outcome after the Norwood procedure

OBJECTIVE

The study objective was to identify how the evolution of surgical strategies influenced the outcome after the Norwood procedure.

METHODS

From 1992 to 2004, 367 patients underwent the Norwood procedure (median age, 4 days). Three surgical strategies were identified on the basis of arch reconstruction and source of pulmonary blood flow. The arch was refashioned without extra material in group A (n = 148). The arch was reconstructed with a pulmonary artery homograft patch in groups B (n = 145) and C (n = 74). Pulmonary blood flow was supplied by a modified Blalock-Taussig shunt in groups A and B. Pulmonary blood flow was supplied by a right ventricle to pulmonary artery conduit in group C. Early mortality, actuarial survival, and freedom from arch reintervention or pulmonary artery patch augmentation were analyzed.

RESULTS

Early mortality was 28% (n = 102). Actuarial survival was 62% +/- 3% at 6 months. Early mortality was lower in group C (15%) than group A (31%) or group B (31%; P <.05). Actuarial survival at 6 months was better in group C (78% +/- 5%) than group A (59% +/- 5%) or group B (58% +/- 4%; P <.05). Fifty-three patients (14%) had arch reintervention. Freedom from arch reintervention was 76% +/- 3% at 1 year, with univariable analysis showing no difference among groups A, B, and C (P =.71). One hundred patients (27%) required subsequent pulmonary artery patch augmentation. Freedom from patch augmentation was 61% +/- 3% at 1 year, and was lower in group C (3% +/- 3%) than group A (80% +/- 4%) or group B (72% +/- 5%; P <.05).

CONCLUSIONS

Survival after the Norwood procedure improved after the introduction of a right ventricle to pulmonary artery conduit, but a greater proportion of patients required subsequent pulmonary artery patch augmentation. The type of arch reconstruction did not affect the incidence of arch reintervention.

Delayed diagnosis of congenital heart disease worsens preoperative condition and outcome of surgery in neonates

OBJECTIVES

To assess whether the route by which neonatal congenital heart disease (CHD) is first recognised influences outcome after surgery.

METHODS

Surgical neonates admitted to a tertiary cardiac unit between March 1999 and February 2002 were retrospectively reviewed with analysis of risk factors for outcome. Three routes to initial recognition of CHD were compared: antenatal diagnosis, detection on the postnatal ward, and presentation after discharge to home. Outcome measures were mortality and duration of perioperative ventilation.

RESULTS

286 neonates had cardiac surgery with a median duration of ventilation of 101 h and in-hospital mortality of 12%. Recognition of CHD was antenatal in 20%, on the postnatal ward in 55% and after discharge to home in 25%. Multiple regression analyses, including the cardiac diagnosis, associated problems and other risk factors, indicated that severe cardiovascular compromise on admission to the cardiac unit was significantly related to mortality and prolonged ventilation. Considered in isolation, the route to recognition of heart disease did not influence mortality or ventilation time. Route to initial recognition did, however, influence the patient's condition on admission to the cardiac unit. Cardiovascular compromise and end organ dysfunction were least likely when recognition was antenatal and most common when presentation followed discharge to home.

CONCLUSION

The setting in which neonatal CHD is first recognised has an impact on preoperative condition, which in turn influences postoperative progress and survival after surgery. Optimal screening procedures and access to specialist care will improve outcome for neonates undergoing cardiac surgery.

Cardiovascular malformations among preterm infants

OBJECTIVE

Preterm birth and cardiovascular malformations are the 2 most common causes of neonatal and infant death, but there are no published population-based reports on the relationship between them. We undertook this study to determine the prevalence and spectrum of cardiovascular malformations in a preterm population, the prevalence of prematurity among infants with cardiovascular malformations, and the influence of prematurity and cardiovascular malformations on outcomes.

METHODS

We based the study on the population of the former Northern Health Region of England. We identified all live-born infants with cardiovascular malformations diagnosed in the first 1 year of life from the regional pediatric cardiology database, which includes the gestational age and details of the diagnosis. We limited ascertainment to malformations diagnosed by the age of 12 months. Infants with isolated patent ductus arteriosus or atrial septal defect were excluded, to avoid ascertainment bias. Infants with ventricular septal defect were classified according to whether they required surgery in the first 1 year. There are no population data on gestational ages for all births in our population for the era of this study; therefore, we used data published in the literature for populations similar to our own to predict that 0.4% of live births occur at <28 weeks of gestation, 0.9% at 28 to 31 weeks, and 6% at 32 to 36 weeks. Overall, 7.3% of live-born infants are preterm.

RESULTS

Of 521619 live-born infants in 1987-2001, 2964 had cardiovascular malformations (prevalence: 5.7 cases per 1000 live births). Cardiovascular malformations were present at 5.1 cases per 1000 term infants and 12.5 cases per 1000 preterm infants. The odds ratio (OR) for a cardiovascular malformation in prematurity was 2.4 (95% confidence interval [CI]: 2.2-2.7). We found that 474 infants (16%) with cardiovascular malformations were born at <37 weeks of gestation, giving an OR for prematurity among infants with a cardiovascular malformation of 2.4 (95% CI: 2.2-2.7). More infants were born preterm with diagnoses of pulmonary atresia with ventricular septal defect (23%), complete atrioventricular septal defect (22%), and coarctation of the aorta, tetralogy of Fallot, and pulmonary valve stenosis (each 20%). Fewer were born preterm with diagnoses of pulmonary atresia and intact ventricular septum (7%), transposition of the great arteries (8%), and single ventricle (9%). We found that 18% of infants with ventricular septal defect requiring surgery were preterm, compared with 13% in the nonsurgical group. Preterm infants with ventricular septal defect required surgery in 30% of cases, compared with 23% of term infants with ventricular septal defect. These figures show that the excess of cardiovascular malformations among preterm infants cannot be explained by greater ascertainment of minor ventricular septal defects. In our denominator population, 646 live-born infants were recognized as having trisomy 21, and gestational age data were available for 609. Of these, 149 (25%; 95% CI: 21-28%) were preterm. Approximately two thirds of infants with complete atrioventricular septal defect have trisomy 21. Complete atrioventricular septal defect was no more common among preterm infants with trisomy 21 (16%) than among term infants with trisomy 21. However, the increased incidence of prematurity among infants with trisomy 21 probably explains some of the excess of preterm births among infants with complete atrioventricular septal defect. Only 4 (11%) of 38 infants with 22q11 deletion were born preterm. None of those infants had pulmonary atresia with ventricular septal defect; therefore, 22q11 deletion does not explain the excess of preterm births in pulmonary atresia with ventricular septal defect. The OR for death in the first 1 year in the presence of a cardiovascular malformation was 4.4 (95% CI: 3.1-5.5) overall; ORs were 1.8 at <28 weeks of gestation, 3.7 at 28 to 31 weeks, 11.0 at 32 to 36 weeks, and 35.6 at term.

CONCLUSIONS

This study showed that preterm infants have more than twice as many cardiovascular malformations as do infants born at term and that 16% of all infants with cardiovascular malformations are preterm. It also showed, not surprisingly, that there is an increased mortality rate among infants born preterm with a cardiovascular malformation. The additional effect of cardiovascular malformations on mortality rates is most marked for term and near-term infants, for whom mortality rates are otherwise low. The excess of cardiovascular malformations among preterm infants is intriguing but not easy to explain. Previous studies of birth weight among infants with cardiovascular malformations reported a significant increase in the likelihood of being small for gestational age among infants with tetralogy of Fallot, complete atrioventricular septal defect, hypoplastic left heart, or large ventricular septal defect. There is an obvious relationship between birth weight and gestational age, and those studies also showed an increased prevalence of prematurity among infants with tetralogy of Fallot, pulmonary stenosis, aortic stenosis, coarctation of the aorta, complete atrioventricular septal defect, or ventricular septal defect. There is also a high prevalence of cardiovascular malformations among late stillbirths, with major differences in the number and spectrum of cardiovascular malformations, compared with those seen in postnatal life. In particular, there is a greater incidence of coarctation of the aorta, double-inlet left ventricle, hypoplastic left heart, truncus arteriosus, double-outlet right ventricle, and atrioventricular septal defect among stillbirths. This spectrum of malformations is similar to that in our study and to those in other reports. Whether the increased prevalence of cardiovascular malformations among preterm infants and the increase in stillbirths suggest clues to the cause is difficult to say. The influence of preterm birth should be taken into account in risk assessment and risk stratification for surgical repair.

High mortality rate after extubation failure after pediatric cardiac surgery

The objective of this study was to evaluate the different causes of extubation failure and the consequent mortality rates in a pediatric population after cardiac surgery. We studied 184 consecutive patients with a median age of 9 months (range, 0-165). In 158 patients, extubation was successful (group A). Nine patients were reintubated for upper airway obstruction and finally extubated successfully (group B). Seventeen patients were reintubated for cardiorespiratory failure, finally leading to death in 11 of 17 patients (65%) (group C). Group B patients were younger and had a longer intubation period compared to group A patients. Group C patients had more reoperations (30% vs 4% in group A patients, p < 0.001), a lower PaO2 on admission at the intensive care unit as well as just prior to extubation, a lower base deficit before extubation, and needed more inotropic support during their stay in the intensive care unit. We conclude that extubation failure after pediatric cardiac surgery due to cardiorespiratory failure is a bad prognostic sign. Patients with high inotropic support and a low PaO2 prior to extubation are especially at risk and probably need careful evaluation before final extubation.

Computerized outcomes analysis for congenital heart disease

PURPOSE OF REVIEW

This paper reviews the past year's literature on computerized outcomes analysis for congenital heart disease.

RECENT FINDINGS

This review focuses on recent advances in four areas of computerized outcomes analysis for congenital heart disease: nomenclature, database, complexity adjustment, and data verification. A common nomenclature, along with a common core minimal dataset, were adopted by the European Association for Cardio-thoracic Surgery and the Society of Thoracic Surgeons and published in 2000 in the Annals of Thoracic Surgery; the thrust towards the establishment of an international nomenclature is now being developed further by the International Society for Nomenclature of Pediatric and Congenital Heart Disease [http://www.IPCCC.net]. This common nomenclature and common minimum database dataset, created by the International Congenital Heart Surgery Nomenclature and Database Project, are now used by the European Association for Cardio-thoracic Surgery and Society of Thoracic Surgeons since 1998, this nomenclature and database have been used to analyze outcomes of over 40 000 patients. Two major multi-institutional efforts have attempted to measure case complexity: the Risk Adjustment in Congenital Heart Surgery-1 and the Aristotle Complexity Score. Collaborative efforts involving the European Association for Cardio-thoracic Surgery and Society of Thoracic Surgeons are underway to develop mechanisms to verify data completeness and accuracy.

SUMMARY

Methods of congenital heart disease outcomes analysis continue to evolve, with continued advances in four areas: nomenclature, database, complexity adjustment, and data verification.

Outcome in neonates with congenital heart disease referred for respiratory extracorporeal membrane oxygenation

AIM

To evaluate the proportion of neonates referred for extracorporeal membrane oxygenation (ECMO) support in the modern era of advanced conventional treatments for respiratory failure who actually had congenital heart disease (CHD), and to assess the impact of this diagnostic route on patient condition and outcome.

METHODS

A retrospective case-note review of neonatal ECMO and cardiac admissions to a single, tertiary ECMO and cardiac intensive care unit (ICU) between March 1999 and February 2002.

RESULTS

287 symptomatic neonates presented to the ICU with previously undiagnosed cardiac or respiratory disease. Eighty-two with presumed respiratory failure were referred for ECMO, and 205 with suspected CHD were referred for cardiac evaluation. Eight (10%) ECMO referrals, all with presumed persistent pulmonary hypertension of the newborn (PPHN), were found to have CHD (transposition: 3; total anomalous pulmonary venous connection: 3; left heart obstructive lesions: 2). Mortality in this group was 50%, compared with 11% for correctly identified CHD patients (odds ratio 8.2, 95% CI 1.92, 35.4, p<0.01). For all neonates with CHD, the risk of death was increased by the presence of cardiovascular collapse and end-organ dysfunction at presentation to the ICU (p<0.01 for both).

CONCLUSION

Neonates with CHD may present as severe "PPHN" via the ECMO service. Poor outcome in these patients relates to the high incidence of cardiovascular collapse and end-organ dysfunction. Early echocardiography is recommended for neonates with presumed PPHN. Neonatal ECMO support should be based in centres with cardiac surgical services.

Factors associated with increased resource utilization for congenital heart disease

OBJECTIVE

To identify patient, institutional, and regional factors that are associated with high resource utilization for congenital heart surgery.

METHODS

We used hospital discharge data from the Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID) year 2000 (data from 27 states). Patients who had congenital heart surgery and were younger than 18 years were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. High resource utilization admissions were defined as those in the highest decile for total hospital charges. Univariate and multivariate analyses with and without deaths were used to determine demographic and hospital predictors for cases of high resource use. Case-mix severity was approximated using Risk Adjustment for Congenital Heart Surgery risk groups. Regional and state differences were also examined.

RESULTS

Among 10,569 cases of congenital heart surgery identified, median total hospital charges were 53,828 dollars. Statewide differences in the number of high resource use admissions were present; California, Colorado, Florida, Hawaii, Pennsylvania, and Texas were more likely to have high resource use cases, and Maine and South Carolina were less likely. Subsequent analyses were performed adjusting for baseline state effects. Multivariate analyses using generalized estimating equations models revealed Risk Adjustment for Congenital Heart Surgery risk category (odds ratio [OR]: 1.66-14.1), age (OR: 3.81), prematurity (OR: 4.85), the presence of other major noncardiac structural anomalies (OR: 2.53), Medicaid insurance (OR: 1.48), and admission during a weekend (OR: 1.62) to be independent predictors of a higher odds of high cost cases. Although some institutional differences were noted in univariate analyses, gender, race, bed size, teaching and children's hospital status, hospital ownership, and hospital volume of cardiac cases were not independently associated with greater odds of high resource utilization.

CONCLUSIONS

States varied in the frequency of high resource utilization for congenital heart surgery. Patients who had greater disease complexity, younger age, prematurity, other anomalies, and Medicaid and were admitted during a weekend were more likely to result in high resource utilization. Institutions of various types did not differ in high cost admissions, regardless of children's hospital or teaching status.