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Alphonso N, Angelini A, Barron DJ, Bellsham-Revell H, Blom NA, Brown K, Davis D, Duncan D, Fedrigo M, Galletti L, Hehir D, Herberg U, Jacobs JP, Januszewska K, Karl TR, Malec E, Maruszewski B, Montgomerie J, Pizzaro C, Schranz D, Shillingford AJ, Simpson JM. Guidelines for the management of neonates and infants with hypoplastic left heart syndrome: The European Association for Cardio-Thoracic Surgery (EACTS) and the Association for European Paediatric and Congenital Cardiology (AEPC) Hypoplastic Left Heart Syndrome Guidelines Task Force. Eur J Cardiothorac Surg 2020; 58:416-499. [DOI: 10.1093/ejcts/ezaa188] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Nelson Alphonso
- Queensland Pediatric Cardiac Service, Queensland Children’s Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Annalisa Angelini
- Department of Cardiac, Thoracic Vascular Sciences and Public health, University of Padua Medical School, Padua, Italy
| | - David J Barron
- Department of Cardiovascular Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Katherine Brown
- Paediatric Intensive Care, Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah Davis
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, USA
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Daniel Duncan
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Marny Fedrigo
- Department of Cardiac, Thoracic Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Lorenzo Galletti
- Unit of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - David Hehir
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | | | - Katarzyna Januszewska
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | | | - Edward Malec
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | - Bohdan Maruszewski
- Department for Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - James Montgomerie
- Department of Anesthesia, Birmingham Children’s Hospital, Birmingham, UK
| | - Christian Pizzaro
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University, Giessen, Germany
| | - Amanda J Shillingford
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Welke KF, Pasquali SK, Lin P, Backer CL, Overman DM, Romano JC, Karamlou T. Theoretical Model for Delivery of Congenital Heart Surgery in the United States. Ann Thorac Surg 2020; 111:1628-1635. [PMID: 32860751 DOI: 10.1016/j.athoracsur.2020.06.057] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/27/2020] [Accepted: 06/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Over 150 hospitals perform congenital heart surgery (CHS) in the United States. Many hospitals are close together, with a median patient travel distance of 38.5 miles. We began with a theoretical blank slate and used objective methodology guided by population density and volume thresholds to estimate the optimal number and locations of hospitals to provide CHS in the United States. METHODS Guided by published data, we estimated the number of CHS operations in the United States in to be 32,500 per year. We distributed patients geographically based on population density. Metropolitan Statistical Areas (population centers and surrounding areas with close economic/social ties) were used as potential hospital locations. Patients were assigned to the closest hospital location such that all hospitals had a CHS volume of ≥300 operations. RESULTS We estimated 57 hospitals could serve the contiguous United States. Median theoretical hospital volume after regionalization was 451 operations (interquartile range, 366-648). Median patient travel distance was 35.1 miles. Some patients (6396/31,895, 20%) traveled more than 100 miles. CONCLUSIONS Our model suggests the United States could be served by approximately 100 fewer CHS hospitals than currently exist. With hospitals optimally placed, patient travel burden would decrease. This model serves as a platform to improve care delivery by regionalization of CHS.
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Affiliation(s)
- Karl F Welke
- Division of Congenital Cardiac Surgery, Levine Children's Hospital/Atrium Health, Charlotte, North Carolina.
| | - Sara K Pasquali
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan C. S. Mott Children's Hospital, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, Michigan
| | - Paul Lin
- Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, Michigan
| | - Carl L Backer
- Division of Cardiovascular-Thoracic Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David M Overman
- Division of Cardiovascular Surgery, The Children's Heart Clinic, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan C. S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery and the Heart and Vascular Institute, The Cleveland Clinic, Cleveland, Ohio
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Johnson JT, Scholtens DM, Kuang A, Feng XY, Eltayeb OM, Post LA, Marino BS. Does Value Vary by Center Surgical Volume for Neonates With Truncus Arteriosus? A Multicenter Study. Ann Thorac Surg 2020; 112:170-177. [PMID: 32768429 DOI: 10.1016/j.athoracsur.2020.05.178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 05/18/2020] [Accepted: 05/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Truncus arteriosus is a congenital heart defect with high resource use, cost, and mortality. Value assessment (outcome relative to cost) can improve quality of care and decrease cost. This study hypothesized that truncus arteriosus repair at a high-volume center would result in better outcomes at lower cost (higher value) compared with a low-volume center. METHODS This study retrospectively analyzed a multicenter cohort of neonates undergoing truncus arteriosus repair (2004 to 2015) by using the Pediatric Health Information Systems database. Multivariate quantile, logistic, and negative binomial regression models were used to evaluate total hospital cost, in-hospital mortality, ventilation days, intensive care unit length of stay (LOS), hospital LOS, and days of inotropic agent use by center volume (high-volume >3/year) and age at repair while adjusting for sex, ethnicity, race, genetic abnormality, prematurity, low birth weight, concurrent interrupted arch repair, and truncal valve repair. RESULTS Of 1024 neonates with truncus arteriosus, 495 (48%) were treated at high-volume centers. Costs at the 75th percentile were lower at high-volume vs low-volume centers by $28,456 (P = .02) at all ages at repair. Patients at high-volume centers had lower median postoperative ventilation days (5 days vs 6 days; P < .001), intensive care unit LOS (13 days vs 19 days; P < .001), hospital LOS (23 days vs 28 days; P = .02), and inotropic agent use (3 days vs 4 days; P = .004). In-hospital mortality did not differ by center volume. CONCLUSIONS In neonates undergoing truncus arteriosus repair, costs are lower and outcomes are better at high-volume centers, thus resulting in higher value at all ages of repair. Value-based interventions should be considered to improve outcomes and decrease cost in truncus arteriosus care.
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Affiliation(s)
- Joyce T Johnson
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Denise M Scholtens
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Alan Kuang
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Xiang Yu Feng
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Osama M Eltayeb
- Division of Cardiothoracic Surgery, Department of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Lori A Post
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Bradley S Marino
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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The final reason paediatric Cardiac ICU patients require care prior to discharge to the floor: a single-centre survey. Cardiol Young 2020; 30:1109-1117. [PMID: 32631466 DOI: 10.1017/s104795112000164x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine the Final ICU Need in the 24 hours prior to ICU discharge for children with cardiac disease by utilising a single-centre survey. METHODS A cross-sectional survey was utilised to determine Final ICU Need, which was categorised as "Cardiovascular", "Respiratory", "Feeding", "Sedation", "Systems Issue", or "Other" for each encounter. Survey responses were obtained from attending physicians who discharged children (≤18 years of age with ICU length of stay >24 hours) from the Cardiac ICU between April 2016 and July 2018. MEASUREMENTS AND RESULTS Survey response rate was 99% (n = 1073), with 667 encounters eligible for analysis. "Cardiovascular" (61%) and "Respiratory" (26%) were the most frequently chosen Final ICU Needs. From a multivariable mixed effects logistic regression model fitted to "Cardiovascular" and "Respiratory", operations with significantly reduced odds of having "Cardiovascular" Final ICU Need included Glenn palliation (p = 0.003), total anomalous pulmonary venous connection repair (p = 0.024), truncus arteriosus repair (p = 0.044), and vascular ring repair (p < 0.001). Short lengths of stay (<7.9 days) had significantly higher odds of "Cardiovascular" Final ICU Need (p < 0.001). "Cardiovascular" and "Respiratory" Final ICU Needs were also associated with provider and ICU discharge season. CONCLUSIONS Final ICU Need is a novel metric to identify variations in Cardiac ICU utilisation and clinical trajectories. Final ICU Need was significantly influenced by benchmark operation, length of stay, provider, and season. Future applications of Final ICU Need include targeting quality and research initiatives, calibrating provider and family expectations, and identifying provider-level variability in care processes and mental models.
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O'Byrne ML, DeCost G, Katcoff H, Savla JJ, Chang J, Goldmuntz E, Groeneveld PW, Rossano JW, Faerber JA, Mercer-Rosa L. Resource Utilization in the First 2 Years Following Operative Correction for Tetralogy of Fallot: Study Using Data From the Optum's De-Identified Clinformatics Data Mart Insurance Claims Database. J Am Heart Assoc 2020; 9:e016581. [PMID: 32691679 PMCID: PMC7792257 DOI: 10.1161/jaha.120.016581] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Despite excellent operative survival, correction of tetralogy of Fallot frequently is accompanied by residual lesions that may affect health beyond the incident hospitalization. Measuring resource utilization, specifically cost and length of stay, provides an integrated measure of morbidity not appreciable in traditional outcomes. Methods and Results We conducted a retrospective cohort study, using de‐identified commercial insurance claims data, of 269 children who underwent operative correction of tetralogy of Fallot from January 2004 to September 2015 with ≥2 years of continuous follow‐up (1) to describe resource utilization for the incident hospitalization and subsequent 2 years, (2) to determine whether prolonged length of stay (>7 days) in the incident hospitalization was associated with increased subsequent resource utilization, and (3) to explore whether there was regional variation in resource utilization with both direct comparisons and multivariable models adjusting for known covariates. Subjects with prolonged incident hospitalization length of stay demonstrated greater resource utilization (total cost as well as counts of outpatient visits, hospitalizations, and catheterizations) after hospital discharge (P<0.0001 for each), though the number of subsequent operative and transcatheter interventions were not significantly different. Regional differences were observed in the cost of incident hospitalization as well as subsequent hospitalizations, outpatient visits, and the costs associated with each. Conclusions This study is the first to report short‐ and medium‐term resource utilization following tetralogy of Fallot operative correction. It also demonstrates that prolonged length of stay in the initial hospitalization is associated with increased subsequent resource utilization. This should motivate research to determine whether these differences are because of modifiable factors.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA.,Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA
| | - Grace DeCost
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Hannah Katcoff
- Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA
| | - Jill J Savla
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Joyce Chang
- Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA.,Division of Rheumatology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Elizabeth Goldmuntz
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Peter W Groeneveld
- Division of General Internal Medicine Department of Medicine Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,Corporal Michael J. Crescenz VA Medical Center Philadelphia PA
| | - Joseph W Rossano
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA
| | - Jennifer A Faerber
- Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA
| | - Laura Mercer-Rosa
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
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Gaies M, Pasquali SK, Banerjee M, Dimick JB, Birkmeyer JD, Zhang W, Alten JA, Chanani N, Cooper DS, Costello JM, Gaynor JW, Ghanayem N, Jacobs JP, Mayer JE, Ohye RG, Scheurer MA, Schwartz SM, Tabbutt S, Charpie JR. Improvement in Pediatric Cardiac Surgical Outcomes Through Interhospital Collaboration. J Am Coll Cardiol 2020; 74:2786-2795. [PMID: 31779793 DOI: 10.1016/j.jacc.2019.09.046] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/01/2019] [Accepted: 09/05/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Patients undergoing complex pediatric cardiac surgery remain at considerable risk of mortality and morbidity, and variation in outcomes exists across hospitals. The Pediatric Cardiac Critical Care Consortium (PC4) was formed to improve the quality of care for these patients through transparent data sharing and collaborative learning between participants. OBJECTIVES The purpose of this study was to determine whether outcomes improved over time within PC4. METHODS The study analyzed 19,600 hospitalizations (18 hospitals) in the PC4 clinical registry that included cardiovascular surgery from August 2014 to June 2018. The primary exposure was 2 years of PC4 participation; this provided adequate time for hospitals to accrue data and engage in collaborative learning. Aggregate case mix-adjusted outcomes were compared between the first 2 years of participation (baseline) and all months post-exposure. We also evaluated outcomes from the same era in a cohort of similar, non-PC4 hospitals. RESULTS During the baseline period, there was no evidence of improvement. We observed significant improvement in the post-exposure period versus baseline for post-operative intensive care unit mortality (2.1% vs. 2.7%; 22% relative reduction [RR]; p = 0.001), in-hospital mortality (2.5% vs. 3.3%; 24% RR; p = 0.001), major complications (10.1% vs. 11.5%; 12% RR; p < 0.001), intensive care unit length of stay (7.3 days vs. 7.7 days; 5% RR; p < 0.001), and duration of ventilation (61.3 h vs. 70.6 h; 13% RR; p = 0.01). Non-PC4 hospitals showed no significant improvement in mortality, complications, or hospital length of stay. CONCLUSIONS This analysis demonstrates improving cardiac surgical outcomes at children's hospitals participating in PC4. This change appears unrelated to secular improvement trends, and likely reflects PC4's commitment to transparency and collaboration.
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Affiliation(s)
- Michael Gaies
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Justin B Dimick
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Wenying Zhang
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Jeffrey A Alten
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Nikhil Chanani
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - David S Cooper
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - John M Costello
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - J William Gaynor
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nancy Ghanayem
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | | | - John E Mayer
- Department of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts
| | - Richard G Ohye
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Mark A Scheurer
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Steven M Schwartz
- Departments of Pediatrics and Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Tabbutt
- Department of Pediatrics, University of California, San Francisco School of Medicine, San Francisco, California
| | - John R Charpie
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
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Hornik CP. Commentary: Outcomes of truncus arteriosus repair: Insights from time and numbers. J Thorac Cardiovasc Surg 2020; 161:S0022-5223(20)31242-3. [PMID: 32591207 DOI: 10.1016/j.jtcvs.2020.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 05/09/2020] [Accepted: 05/11/2020] [Indexed: 11/21/2022]
Affiliation(s)
- Christoph P Hornik
- Department of Pediatrics and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
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Alamri RM, Dohain AM, Arafat AA, Elmahrouk AF, Ghunaim AH, Elassal AA, Jamjoom AA, Al-Radi OO. Surgical repair for persistent truncus arteriosus in neonates and older children. J Cardiothorac Surg 2020; 15:83. [PMID: 32393289 PMCID: PMC7216609 DOI: 10.1186/s13019-020-01114-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 04/27/2020] [Indexed: 11/21/2022] Open
Abstract
Objectives Persistent truncus arteriosus represents less than 3% of all congenital heart defects. We aim to analyze mid-term outcomes after primary Truncus arteriosus repair at different ages and to identify the risk factors contributing to mortality and the need for intervention after surgical repair. Methods This retrospective cohort study included 36 children, underwent repair of Truncus arteriosus in the period from January 2011 to December 2018 in two institutions. We recorded the clinical and echocardiographic data for the patients preoperatively, early postoperative, 6 months postoperative, then every year until their last documented follow-up appointment. Results Thirty-six patients had truncus arteriosus repair during the study period. Thirty-one patients had open sternum post-repair, and two patients required extracorporeal membrane oxygenation. Bleeding occurred in 15 patients (41.67%), and operative mortality occurred in 5 patients (14.7%). Patients with truncus arteriosus type 2 (p = 0.008) and 3 (p = 0.001) and who were ventilated preoperatively (p < 0.001) had a longer hospital stay. Surgical re-intervention was required in 8 patients (22.86%), and 11 patients (30.56%) had catheter-based reintervention. Freedom from reintervention was 86% at 1 year, 75% at 2 years and 65% at 3 years. Survival at 1 year was 81% and at 3 years was 76%. High postoperative inotropic score predicted mortality (p = 0.013). Conclusion Repair of the truncus arteriosus can be performed safely with low morbidity and mortality, both in neonates, infants, and older children. Re-intervention is common, preferably through a transcatheter approach.
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Affiliation(s)
- Rawan M Alamri
- Cardiac Surgery Division, Department of Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ahmed M Dohain
- Pediatric Cardiology Division, Department of Pediatrics, King Abdulaziz University, Jeddah, Saudi Arabia.,Pediatric Cardiology Division, Department of Pediatrics, Cairo University, Giza, Egypt
| | - Amr A Arafat
- Department of Cardiothoracic Surgery, Tanta University, Tanta, Egypt
| | - Ahmed F Elmahrouk
- Department of Cardiothoracic Surgery, Tanta University, Tanta, Egypt. .,Department of Cardiothoracic Surgery, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia.
| | - Abdullah H Ghunaim
- Cardiac Surgery Division, Department of Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ahmed A Elassal
- Cardiac Surgery Division, Department of Surgery, King Abdulaziz University, Jeddah, Saudi Arabia.,Department of Cardiothoracic Surgery, Zagazig University, Zagazig, Egypt
| | - Ahmed A Jamjoom
- Department of Cardiothoracic Surgery, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Osman O Al-Radi
- Cardiac Surgery Division, Department of Surgery, King Abdulaziz University, Jeddah, Saudi Arabia.,Department of Cardiothoracic Surgery, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
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Predicting the Future: Tetralogy of Fallot Will Be Primarily Treated with Catheter Based Intervention Within Two Decades. Surgeon's Perspective. Pediatr Cardiol 2020; 41:546-552. [PMID: 32198582 DOI: 10.1007/s00246-020-02298-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/17/2020] [Indexed: 10/24/2022]
Abstract
Interventional cardiology has made extraordinary advances over recent years, but most are still limited to addressing single intracardiac or valvular lesions. This debate considers whether complete interventional repair of more complex congenital defects might become achievable. Tetralogy of Fallot (ToF) is probably the first candidate where complete interventional repair might be achieved-given that various components of the defect have already been successfully addressed-albeit as either a palliative intervention (RVOT stenting) or to address the sequelae of standard surgery (percutaneous PVR). This article considers the challenges that would need to be overcome in terms of the morphology of the condition, the age limitations, and the necessary technological advancements that would be required-while setting these against the benchmark of current surgical outcomes and the parallel progress that is being developed in surgical correction. While complete interventional repair of ToF may still be beyond current techniques, a hybrid approach between surgeons and intentional cardiologists can strive to create a life-long paradigm of care that minimizes the need for surgery and focuses on the maintenance of a healthy right ventricle, such that patients born with ToF can achieve normal life expectancy.
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Intensive Care Unit and Acute Care Unit Length of Stay After Congenital Heart Surgery. Ann Thorac Surg 2020; 110:1396-1403. [PMID: 32114048 DOI: 10.1016/j.athoracsur.2020.01.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 01/02/2020] [Accepted: 01/13/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Postoperative length of stay (LOS) is an important quality metric and is known to vary widely across hospitals after congenital heart surgery. Whether this variability is explained by factors associated with the intensive care unit (ICU) or acute care unit (ACU) remains unclear. We evaluated the relationship between ICU and ACU LOS and the impact of ACU characteristics on postoperative LOS. METHODS Hospitalizations for congenital heart surgery within the Pediatric Cardiac Critical Care Consortium (PC4) registry (August 2014 to February 2018) were included. Models were developed for ICU, ACU, and postoperative LOS by adjusting for differences in case-mix across hospitals. PC4 hospitals participating in the Pediatric Acute Care Cardiology Collaborative (PAC3) were also surveyed on ACU organizational factors and practice patterns. RESULTS Overall, 19,674 hospitalizations across 27 hospitals were included. There was significant variation in ICU and ACU LOS. Postperative LOS appeared to be most closely related to ICU LOS; 75% (6 of 8) of hospitals with shorter than expected postoperative LOS also had shorter than expected ICU LOS. A clear relationship between postoperative and ACU LOS was not observed. Hospitals with an ACU able to provide higher-acuity care as indexed according to the PAC3 survey were more likely to have shorter postoperative LOS (P < .01). CONCLUSIONS For hospitals that achieve shorter than expected postoperative LOS after congenital heart surgery, ICU LOS appears to be the primary driver. Higher-acuity resources in the ACU may be an important factor facilitating earlier transfer from the ICU. These data are key to informing quality improvement initiatives geared toward reducing postoperative LOS.
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Pasquali SK, Banerjee M, Romano JC, Normand SLT. Hospital Performance Assessment in Congenital Heart Surgery: Where Do We Go From Here? Ann Thorac Surg 2020; 109:621-626. [PMID: 31962112 DOI: 10.1016/j.athoracsur.2020.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 01/01/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Sara K Pasquali
- Department of Pediatrics, C.S. Mott Children's Hospital, and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
| | - Mousumi Banerjee
- Department of Biostatistics, School of Public Health, and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Jennifer C Romano
- Department of Cardiac Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Sharon-Lise T Normand
- Department of Health Care Policy, Harvard Medical School, and Department of Biostatistics, Harvard Chan School of Public Health, Boston, Massachusetts
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Woo JL, Anderson BR, Gruenstein D, Conti R, Chua KP. Minimum Travel Distance Among Publicly Insured Infants with Severe Congenital Heart Disease: Potential Impact of In-state Restrictions. Pediatr Cardiol 2019; 40:1599-1608. [PMID: 31463514 PMCID: PMC6851488 DOI: 10.1007/s00246-019-02193-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 08/23/2019] [Indexed: 11/30/2022]
Abstract
Travel distance to surgical centers may be increased when coverage restrictions prevent children with congenital heart disease (CHD) from receiving care at out-of-state congenital heart surgery centers. We estimated the minimum travel distance to congenital heart surgery centers among publicly insured infants with time-sensitive CHD surgical needs, under two different scenarios: if they were and were not restricted to in-state centers. Using 2012 Medicaid Analytic eXtract data from 40 states, we identified 4598 infants with CHD that require surgery in the first year of life. We calculated the minimum travel distance between patients' homes and the nearest cardiac surgery center, assuming patients were and were not restricted to in-state centers. We used linear regression to identify demographic predictors of distance under both scenarios. When patients were not restricted to in-state centers, mean minimum travel distance was 43.7 miles, compared to 54.1 miles when they were restricted. For 5.9% of patients, the difference in travel distance under the two scenarios exceeded 50 miles. In six states, the difference in mean minimum travel distance exceeded 20 miles. Under both scenarios, distance was positively predicted by rural status, residence in middle-income zip codes, and white/non-Hispanic or American Indian/Alaskan Native race/ethnicity. For some publicly insured infants with severe CHD, facilitating the receipt of out-of-state care could mitigate access barriers. Existing efforts to regionalize care at fewer centers should be designed to avoid exacerbating access barriers among publicly insured CHD patients.
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Affiliation(s)
- Joyce L Woo
- Division of Pediatric Cardiology, Columbia University Medical Center, 3959 Broadway, CHN-253, New York, NY, 10032, USA.
| | - Brett R Anderson
- Division of Pediatric Cardiology, Columbia University Medical Center, 3959 Broadway, CHN-253, New York, NY, 10032, USA
| | - Daniel Gruenstein
- Department of Pediatrics, Section of Cardiology, University of Chicago Medical Center, 5839 S. Maryland Ave, MC 4051, Chicago, IL, 60637, USA
| | - Rena Conti
- Institute of Health System Innovation and Policy Markets, Public Policy, and Law, Boston University, 595 Commonwealth Ave, Boston, MA, 02215, USA
| | - Kao-Ping Chua
- Department of Pediatrics, University of Michigan Medical Center, 300 North Ingalls, SPC 5456, Room 6E18, Ann Arbor, MI, 48109, USA
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Center Variation in Chest Tube Duration and Length of Stay After Congenital Heart Surgery. Ann Thorac Surg 2019; 110:221-227. [PMID: 31760054 DOI: 10.1016/j.athoracsur.2019.09.078] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/18/2019] [Accepted: 09/23/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Nearly every child undergoing congenital heart surgery has chest tubes placed intraoperatively. Center variation in removal practices and impact on outcomes has not been well described. This study evaluated variation in chest tube management practices and outcomes across centers. METHODS The study included patients undergoing any of 10 benchmark operations from June 2017 to May 2018 at participating Pediatric Acute Care Cardiology Collaborative (PAC3) and Pediatric Cardiac Critical Care Consortium (PC4) centers. Clinical data from PC4 centers were merged with chest tube data from PAC3 centers. Practices and outcomes were compared across centers in univariate and multivariable analysis. RESULTS The cohort included 1029 patients (N = 9 centers). Median chest tube duration varied significantly across centers for 9 of 10 benchmark operations (all P ≤ .03), with a "model" center noted to have the shortest duration for 9 of 10 operations (range, 27.9% to 87.4% shorter duration vs other centers across operations). This effect persisted in multivariable analysis (P < .0001). The model center had higher volumes of chest tube output before removal (median, 8.5 mL/kg/24 h [model] vs 2.2 mL/kg/24 h [other centers]; P < .001], but it did not have higher rates of chest tube reinsertion (model center 1.3% vs 2.1%; P = .59) or readmission for pleural effusion (model center 4.4% vs 3.0%; P = .31), and had the shortest length of stay for 7 of 10 operations. CONCLUSIONS This study suggests significant center variation in chest tube removal practices and associated outcomes after congenital heart surgery. Best practices used at the model center have informed the design of an ongoing collaborative learning project aimed at reducing chest tube duration and length of stay.
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Bobillo-Perez S, Sanchez-de-Toledo J, Segura S, Girona-Alarcon M, Mele M, Sole-Ribalta A, Cañizo Vazquez D, Jordan I, Cambra FJ. Risk stratification models for congenital heart surgery in children: Comparative single-center study. CONGENIT HEART DIS 2019; 14:1066-1077. [PMID: 31545015 DOI: 10.1111/chd.12846] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 08/21/2019] [Accepted: 09/11/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Three scores have been proposed to stratify the risk of mortality for each cardiac surgical procedure: The RACHS-1, the Aristotle Basic Complexity (ABC), and the STS-EACTS complexity scoring model. The aim was to compare the ability to predict mortality and morbidity of the three scores applied to a specific population. DESIGN Retrospective, descriptive study. SETTING Pediatric and neonatal intensive care units in a referral hospital. PATIENTS Children under 18 years admitted to the intensive care unit after surgery. INTERVENTIONS None. OUTCOME MEASURES Demographic, clinical, and surgical data were assessed. Morbidity was considered as prolonged length of stay (LOS > 75 percentile), high respiratory (>72 hours of mechanical ventilation), and high hemodynamic support (inotropic support >20). RESULTS One thousand and thirty-seven patients were included, in which 205 were newborns (18%). The category 2 was the most frequent in the three scores: In RACHS-1, ABC, 44.9%, and STS-EACTS, 40.8%. Newborns presented significant higher categories. Children required cardiopulmonary bypass in more occasions (P < .001) but the times of bypass and aortic cross-clamp were significantly higher in newborns (P < .001 and P = .016). Thirty-two patients died (2.8%). A quarter of patients had a prolonged LOS, 17%, a high respiratory support, and 7.1%, a high hemodynamic support. RACHS-1 (AUC 0.760) and STS-EACTS (AUC 0.763) were more powerful for predicting mortality and STS-EACTS for predicting prolonged LOS (AUC 0.733) and the need for high respiratory support (AUC 0.742). CONCLUSIONS STS-EACTS seems to stratify better risk of mortality, prolonged LOS, and need for respiratory support after surgery.
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Affiliation(s)
- Sara Bobillo-Perez
- Disorders of Immunity and Respiration of the Pediatric Critical Patient Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain.,Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, Universitat de Barcelona, Spain
| | - Joan Sanchez-de-Toledo
- Pediatric Cardiology Department, Hospital Sant Joan de Déu, University of Barcelona, Spain.,Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Susana Segura
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, Universitat de Barcelona, Spain
| | - Monica Girona-Alarcon
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, Universitat de Barcelona, Spain
| | - Maria Mele
- Pediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Anna Sole-Ribalta
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, Universitat de Barcelona, Spain
| | - Debora Cañizo Vazquez
- Neonatal Intensive Care Unit, Maternal, Fetal and Neonatology Center Barcelona (BCNatal), Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Iolanda Jordan
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, Universitat de Barcelona, Spain.,Pediatric Infectious Diseases Research Group, Institut Recerca Hospital Sant Joan de Déu, CIBERESP, Barcelona, Spain
| | - Francisco Jose Cambra
- Disorders of Immunity and Respiration of the Pediatric Critical Patient Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain.,Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, Universitat de Barcelona, Spain
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65
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Spector LG, Menk JS, Knight JH, McCracken C, Thomas AS, Vinocur JM, Oster ME, St Louis JD, Moller JH, Kochilas L. Trends in Long-Term Mortality After Congenital Heart Surgery. J Am Coll Cardiol 2019; 71:2434-2446. [PMID: 29793633 DOI: 10.1016/j.jacc.2018.03.491] [Citation(s) in RCA: 126] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/21/2018] [Accepted: 03/06/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Congenital heart surgery has improved the survival of patients with even the most complex defects, but the long-term survival after these procedures has not been fully described. OBJECTIVES The purpose of this study was to evaluate the long-term survival of patients (age <21 years) who were operated on for congenital heart defects (CHDs). METHODS This study used the Pediatric Cardiac Care Consortium data, a U.S.-based, multicenter registry of pediatric cardiac surgery. Survival analysis included 35,998 patients who survived their first congenital heart surgery at <21 years of age and had adequate identifiers for linkage with the National Death Index through 2014. Survival was compared to that in the general population using standardized mortality ratios (SMRs). RESULTS After a median follow-up of 18 years (645,806 person-years), 3,191 deaths occurred with an overall SMR of 8.3 (95% confidence interval [CI]: 8.0 to 8.7). The 15-year SMR decreased from 12.7 (95% CI: 11.9 to 13.6) in the early era (1982 to 1992) to 10.0 (95% CI: 9.3 to 10.8) in the late era (1998 to 2003). The SMR remained elevated even for mild forms of CHD such as patent ductus arteriosus (SMR 4.5) and atrial septal defects (SMR 4.9). The largest decreases in SMR occurred for patients with transposition of great arteries (early: 11.0 vs. late: 3.8; p < 0.05), complete atrioventricular canal (31.3 vs. 15.3; p < 0.05), and single ventricle (53.7 vs. 31.3; p < 0.05). CONCLUSIONS In this large U.S. cohort, long-term mortality after congenital heart surgery was elevated across all forms of CHD. Survival has improved over time, particularly for severe defects with significant changes in their management strategy, but still lags behind the general population.
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Affiliation(s)
- Logan G Spector
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Jeremiah S Menk
- Biostatistical Design and Analysis Center, University of Minnesota, Minneapolis, Minnesota
| | - Jessica H Knight
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Courtney McCracken
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Amanda S Thomas
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Jeffrey M Vinocur
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Matthew E Oster
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - James D St Louis
- Department of Pediatric Surgery, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - James H Moller
- Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Lazaros Kochilas
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia.
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66
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Anderson BR, Kumar SR, Gottlieb-Sen D, Liava'a MH, Hill KD, Jacobs JP, Moga FX, Overman DM, Newburger JW, Glied SA, Bacha EA. The Congenital Heart Technical Skill Study: Rationale and Design. World J Pediatr Congenit Heart Surg 2019; 10:137-144. [PMID: 30841825 DOI: 10.1177/2150135118822689] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We report the rationale and design for a peer-evaluation protocol of attending congenital heart surgeon technical skill using direct video observation. METHODS All surgeons contributing data to The Society of Thoracic Surgeons-Congenital Heart Surgery Database (STS-CHSD) are invited to submit videos of themselves operating, to rate peers, or both. Surgeons may submit Norwood procedures, complete atrioventricular canal repairs, and/or arterial switch operations. A HIPPA-compliant website allows secure transmission/evaluation. Videos are anonymously rated using a modified Objective Structured Assessment of Technical Skills score. Ratings are linked to five years of contemporaneous outcome data from the STS-CHSD and surgeon questionnaires. The primary outcome is a composite for major morbidity/mortality. RESULTS Two hundred seventy-six surgeons from 113 centers are eligible for participation: 83 (30%) surgeons from 53 (45%) centers have agreed to participate, with recruitment ongoing. These surgeons vary considerably in years of experience and outcomes. Participants, both early and late in their careers, describe the process as "very rewarding" and "less time consuming than anticipated." An initial subset of 10 videos demonstrated excellent interrater reliability (interclass correlation = 0.85). CONCLUSIONS This study proposes to evaluate the technical skills of attending pediatric cardiothoracic surgeons by video observation and peer-review. It is notable that over a quarter of congenital heart surgeons, across a range of experiences, from almost half of United States centers have already agreed to participate. This study also creates a mechanism for peer feedback; we hypothesize that feedback could yield broad and meaningful quality improvement.
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Affiliation(s)
- Brett R Anderson
- 1 Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - S Ram Kumar
- 2 Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Danielle Gottlieb-Sen
- 3 Section of Pediatric Surgery, Children's Hospital of New Orleans, New Orleans, LA, USA
| | - Matthew H Liava'a
- 4 Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Kevin D Hill
- 5 Department of Pediatrics, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey P Jacobs
- 6 Division of Cardiac Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, FL, USA
| | - Francis X Moga
- 7 Division of Cardiac Surgery, The Children's Heart Clinic, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | - David M Overman
- 7 Division of Cardiac Surgery, The Children's Heart Clinic, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | - Jane W Newburger
- 8 Department of Cardiology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Sherry A Glied
- 9 The Robert F. Wagner Graduate School of Public Service, New York University, New York, NY, USA
| | - Emile A Bacha
- 4 Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, NY, USA
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67
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Affiliation(s)
- David Bichell
- 1 Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, TN, USA
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68
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Overman DM. The data show it: Size matters. J Thorac Cardiovasc Surg 2019; 157:1144-1145. [PMID: 33197995 DOI: 10.1016/j.jtcvs.2018.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 12/03/2018] [Indexed: 11/17/2022]
Affiliation(s)
- David M Overman
- Division of Cardiac Surgery, The Children's Heart Clinic, Minneapolis, Minn; Division of Cardiovascular Surgery, Children's Minnesota, Minneapolis, Minn.
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69
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Jacobs JP, Mayer JE, Pasquali SK, Hill KD, Overman DM, St. Louis JD, Kumar SR, Backer CL, Tweddell JS, Dearani JA, Jacobs ML. The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2019 Update on Outcomes and Quality. Ann Thorac Surg 2019; 107:691-704. [DOI: 10.1016/j.athoracsur.2018.12.016] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 12/10/2018] [Indexed: 12/20/2022]
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Mastropietro CW, Amula V, Sassalos P, Buckley JR, Smerling AJ, Iliopoulos I, Riley CM, Jennings A, Cashen K, Narasimhulu SS, Narayana Gowda KM, Bakar AM, Wilhelm M, Badheka A, Moser EAS, Costello JM. Characteristics and operative outcomes for children undergoing repair of truncus arteriosus: A contemporary multicenter analysis. J Thorac Cardiovasc Surg 2019; 157:2386-2398.e4. [PMID: 30954295 DOI: 10.1016/j.jtcvs.2018.12.115] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 11/20/2018] [Accepted: 12/22/2018] [Indexed: 01/29/2023]
Abstract
OBJECTIVE We sought to describe characteristics and operative outcomes of children who underwent repair of truncus arteriosus and identify risk factors for the occurrence of major adverse cardiac events (MACE) in the immediate postoperative period in a contemporary multicenter cohort. METHODS We conducted a retrospective review of children who underwent repair of truncus arteriosus between 2009 and 2016 at 15 centers within the United States. Patients with associated interrupted or obstructed aortic arch were excluded. MACE was defined as the need for postoperative extracorporeal membrane oxygenation, cardiopulmonary resuscitation, or operative mortality. Risk factors for MACE were identified using multivariable logistic regression analysis and reported as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS We reviewed 216 patients. MACE occurred in 44 patients (20%) and did not vary significantly over time. Twenty-two patients (10%) received postoperative extracorporeal membrane oxygenation, 26 (12%) received cardiopulmonary resuscitation, and 15 (7%) suffered operative mortality. With multivariable logistic regression analysis (which included adjustment for center effect), factors independently associated with MACE were failure to diagnose truncus arteriosus before discharge from the nursery (OR, 3.1; 95% CI, 1.3-7.4), cardiopulmonary bypass duration >150 minutes (OR, 3.5; 95% CI, 1.5-8.5), and right ventricle-to-pulmonary artery conduit diameter >50 mm/m2 (OR, 4.7; 95% CI, 2.0-11.1). CONCLUSIONS In a contemporary multicenter analysis, 20% of children who underwent repair of truncus arteriosus experienced MACE. Early diagnosis, shorter duration of cardiopulmonary bypass, and use of smaller diameter right ventricle-to-pulmonary artery conduits represent potentially modifiable factors that could decrease morbidity and mortality in this fragile patient population.
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Affiliation(s)
- Christopher W Mastropietro
- Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Ind.
| | - Venu Amula
- Division of Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah
| | - Peter Sassalos
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Mich
| | - Jason R Buckley
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina Children's Hospital, Charleston, SC
| | - Arthur J Smerling
- Division of Critical Care, Department of Pediatrics, Columbia University College of Physicians & Surgeons, Morgan Stanley Children's Hospital of New York, New York, NY
| | - Ilias Iliopoulos
- Division of Cardiac Critical Care, Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Christine M Riley
- Division of Cardiac Critical Care, Department of Pediatrics, Children's National Health System, Washington, DC
| | - Aimee Jennings
- Division of Critical Care, Department of Pediatrics, Seattle Children's Hospital, Seattle, Wash
| | - Katherine Cashen
- Division of Critical Care, Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, Mich
| | - Sukumar Suguna Narasimhulu
- Division of Cardiac Intensive Care, Department of Pediatrics, University of Central Florida College of Medicine, The Heart Center at Arnold Palmer Hospital for Children, Orlando, Fla
| | | | - Adnan M Bakar
- Division of Cardiac Critical Care, Department of Pediatrics, Zucker School of Medicine at Hofstra/Northwell, Cohen Children's Medical Center of NY, New Hyde Park, NY
| | - Michael Wilhelm
- Division of Cardiac Intensive Care, Department of Pediatrics, University of Wisconsin, Madison, Wis
| | - Aditya Badheka
- Division of Critical Care Medicine, Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa
| | - Elizabeth A S Moser
- Department of Biostatistics, Indiana University School of Medicine and Richard M. Fairbanks School of Public Health, Indianapolis, Ind
| | - John M Costello
- Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill
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71
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Welke KF, Pasquali SK, Lin P, Backer CL, Overman DM, Romano JC, Jacobs JP, Karamlou T. Hospital Distribution and Patient Travel Patterns for Congenital Cardiac Surgery in the United States. Ann Thorac Surg 2019; 107:574-581. [DOI: 10.1016/j.athoracsur.2018.07.047] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 07/12/2018] [Accepted: 07/16/2018] [Indexed: 10/28/2022]
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Alsoufi B. Commentary: Assessing risk factors after truncus arteriosus repair-The devil is in the details. J Thorac Cardiovasc Surg 2019; 157:2399-2401. [PMID: 30846262 DOI: 10.1016/j.jtcvs.2019.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 01/16/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Ky.
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73
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Gardiner HM. In utero intervention for severe congenital heart disease. Best Pract Res Clin Obstet Gynaecol 2019; 58:42-54. [PMID: 30772145 DOI: 10.1016/j.bpobgyn.2019.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 01/11/2019] [Indexed: 10/27/2022]
Abstract
The aim of foetal cardiac therapy is to treat an abnormality at the developmental stage so that the process of cardiac growth, which is complex and relies on the volume and direction of circulating blood as well as genetic determinants, can continue. In reality, most cardiac interventions are palliative; hence, major abnormalities are still present at birth. Nevertheless, tangible benefits following successful foetal intervention include improved haemodynamics and reduction in secondary damage leading to better postnatal outcomes. In cases of semilunar valve stenosis, or atresia, foetal valvuloplasty aims to achieve a biventricular, rather than univentricular, circulation. Opening and stenting a restrictive atrial foramen may preserve the pulmonary function in cases of hypoplastic left heart syndrome, thereby increasing the chances of successful postnatal surgery. More recent endeavours include percutaneous implantation of a miniaturised pacemaker to treat complete heart block and the promotion of left-sided heart growth by chronic maternal hyperoxygenation. The true clinical benefit of these interventions over natural history remains uncertain because of the paucity of appropriate randomised controlled trials (RCTs). Foetal cardiac therapy must now move from a pioneering approach to one that is supported by evidence, as has been done successfully for other foetal therapies.
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Affiliation(s)
- Helena M Gardiner
- The Fetal Center, Children's Memorial Hermann Hospital and the Department of Obstetrics and Gynecology, McGovern Medical School, UTHealth, Houston, TX, USA.
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74
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St Louis JD, Timkovich N, Lenderman S, Jonas RA, Guleserian KJ, Tchervenkov CI, Jacobs JP, Austin EH, Plunkett MD, Myers JL, Hraska V, Sinha P, O'Brien JE, Jacobs ML, Kirklin JK. The World Database for Pediatric and Congenital Heart Surgery "A Call to Service for North American Congenital Heart Surgery Programs". Semin Thorac Cardiovasc Surg 2019; 31:230-233. [PMID: 30616005 DOI: 10.1053/j.semtcvs.2019.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 01/02/2019] [Indexed: 11/11/2022]
Abstract
The World Society for Pediatric and Congenital Heart Surgery has endorsed the establishment of an international platform for the exchange of knowledge and experience for those that treat patients with a congenital heart defect. On January 1, 2017, the release of the World Database for Pediatric and Congenital Heart Surgery opened a new era in evaluation of treatment with congenital heart defects. The contribution of data from countries with established congenital surgical databases will greatly enhance the efforts to provide the most accurate measure of overall surgical outcomes across the globe.
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Affiliation(s)
- James D St Louis
- Department of Surgery, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.
| | - Nick Timkovich
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Richard A Jonas
- Department of Cardiovascular Surgery, Children's National Medical Center, Washington DC
| | | | - Christo I Tchervenkov
- Division of Pediatric Cardiovascular Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Jeffery P Jacobs
- Division of Cardiovascular of Surgery, Johns Hopkins All Children's Heart Institute, Johns Hopkins All Children's Hospital and Florida Hospital for Children, John Hopkins University, Saint Petersburg, Tampa, and Orlando, Florida
| | - Erle H Austin
- University of Louisville, Norton Children's Hospital, Louisville, Kentucky
| | - Mark D Plunkett
- Congenital Heart Center at Children's Hospital of Illinois, Peoria, Illinois
| | - John L Myers
- Penn State Children's Hospital, Hershey, Pennsylvania
| | - Viktor Hraska
- Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pranava Sinha
- Department of Cardiovascular Surgery, Children's National Medical Center, Washington DC
| | - James E O'Brien
- Department of Surgery, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Marshall L Jacobs
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Maryland
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75
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Cost Savings Analysis of Early Extubation Following Congenital Heart Surgery. Pediatr Cardiol 2019; 40:138-146. [PMID: 30203291 DOI: 10.1007/s00246-018-1970-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 08/28/2018] [Indexed: 10/28/2022]
Abstract
The clinical benefit of early extubation following congenital heart surgery has been demonstrated; however, its effect on resource utilization has not been rigorously evaluated. We sought to determine the cost savings of implementing an early extubation pathway for children undergoing surgery for congenital heart disease. We performed a cost savings analysis after implementation of an early extubation strategy among children undergoing congenital heart surgery at British Columbia Children's Hospital (BCCH) over a 2.5-year period. All patients undergoing one of the eight Society of Thoracic Surgeons (STS) benchmark operations, ASD repair, or bidirectional cavopulmonary anastomosis were included in the analysis (n = 370). We compared our data to aggregate STS multi-institutional data from a contemporary cohort. We estimated daily costs for ICU care, ward care, medications, imaging, additional procedures, and allied health care using an administrative database. Direct costs, indirect costs, and cost savings were estimated. Simulation methods, Monte Carlo, and bootstrapping were used to calculate the 95% credible intervals for all estimates. The mean cost savings per procedure was $12,976 and the total estimated cost savings over the study period at BCCH was $4.8 million with direct costs accounting for 91% of cost savings. Sensitivity analysis demonstrated a mean cost savings range of $11,934-$14,059 per procedure. Early extubation is associated with substantial cost savings due to reduced hospital resource utilization. Implementation of an early extubation strategy following congenital heart surgery may contribute to improved resource utilization.
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Impact of genetic studies on comprehension and treatment of congenital heart disease. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2018.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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77
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Abstract
Centers with higher surgical and extracorporeal membrane oxygenation (ECMO) volumes have improved survival for children undergoing pediatric cardiac surgery and ECMO, respectively. We examined the relationship between both cardiac surgical and cardiac ECMO volumes, with survival. Using data from the Pediatric Health Information System, we reviewed patients who underwent ECMO during the hospitalization for cardiac surgery or heart transplantation from January 2003 to June 2014. Among 106,967 patients in 43 centers undergoing a Risk Adjustment for Congenital Heart Surgery-1 1-6 procedure (n = 104,951) or cardiac transplantation (n = 2,016), 2.9% (n = 3,069) underwent ECMO support. Centers were categorized into volume quartiles based on annual ECMO and cardiac surgical volumes. Multivariable logistic regression models controlling for clustering by center and adjusting for factors associated with mortality were constructed. Although mortality was lower in ECMO centers that performed ≥7 ECMO runs (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.22-0.88)] and centers performing ≥158 cardiac surgical cases (OR: 0.37, 95% CI: 0.22-0.63), surgical volume was more strongly associated with ECMO mortality. Centers with higher cardiac surgical volume had fewer ECMO complications. Cardiac surgical volume, compared with ECMO volume, is more strongly associated with cardiac ECMO survival.
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78
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Takahashi A, Kumamaru H, Tomotaki A, Matsumura G, Fukuchi E, Hirata Y, Murakami A, Hashimoto H, Ono M, Miyata H. Verification of Data Accuracy in Japan Congenital Cardiovascular Surgery Database Including Its Postprocedural Complication Reports. World J Pediatr Congenit Heart Surg 2018; 9:150-156. [DOI: 10.1177/2150135117745871] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Japan Congenital Cardiovascluar Surgical Database (JCCVSD) is a nationwide registry whose data are used for health quality assessment and clinical research in Japan. We evaluated the completeness of case registration and the accuracy of recorded data components including postprocedural mortality and complications in the database via on-site data adjudication. Methods: We validated the records from JCCVSD 2010 to 2012 containing congenital cardiovascular surgery data performed in 111 facilities throughout Japan. We randomly chose nine facilities for site visit by the auditor team and conducted on-site data adjudication. We assessed whether the records in JCCVSD matched the data in the source materials. Results: We identified 1,928 cases of eligible surgeries performed at the facilities, of which 1,910 were registered (99.1% completeness), with 6 cases of duplication and 1 inappropriate case registration. Data components including gender, age, and surgery time (hours) were highly accurate with 98% to 100% concordance. Mortality at discharge and at 30 and 90 postoperative days was 100% accurate. Among the five complications studied, reoperation was the most frequently observed, with 16 and 21 cases recorded in the database and source materials, respectively, having a sensitivity of 0.67 and a specificity of 0.99. Conclusions: Validation of JCCVSD database showed high registration completeness and high accuracy especially in the categorical data components. Adjudicated mortality was 100% accurate. While limited in numbers, the recorded cases of postoperative complications all had high specificities but had lower sensitivity (0.67-1.00). Continued activities for data quality improvement and assessment are necessary for optimizing the utility of these registries.
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Affiliation(s)
- Arata Takahashi
- Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
| | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ai Tomotaki
- Informatics, National College of Nursing, Tokyo, Japan
| | - Goki Matsumura
- Cardiovascular Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Eriko Fukuchi
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasutaka Hirata
- Department of Cardiac Surgery, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | | | - Hideki Hashimoto
- Health and Social Behavior, School of Public Health, the University of Tokyo, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Hiroaki Miyata
- Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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79
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Russell MW, Chung WK, Kaltman JR, Miller TA. Advances in the Understanding of the Genetic Determinants of Congenital Heart Disease and Their Impact on Clinical Outcomes. J Am Heart Assoc 2018; 7:e006906. [PMID: 29523523 PMCID: PMC5907537 DOI: 10.1161/jaha.117.006906] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Mark W Russell
- Division of Pediatric Cardiology, University of Michigan, Ann Arbor, MI
| | - Wendy K Chung
- Departments of Pediatrics and Medicine, Columbia University, New York, NY
| | - Jonathan R Kaltman
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Thomas A Miller
- Department of Pediatrics, University of Utah, Salt Lake City, UT
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80
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Jacobs JP, Mayer JE, Pasquali SK, Hill KD, Overman DM, St. Louis JD, Kumar SR, Backer CL, Fraser CD, Tweddell JS, Jacobs ML. The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2018 Update on Outcomes and Quality. Ann Thorac Surg 2018; 105:680-689. [DOI: 10.1016/j.athoracsur.2018.01.001] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 01/03/2018] [Indexed: 11/15/2022]
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81
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Jantzen DW, He X, Jacobs JP, Jacobs ML, Gaies MG, Hall M, Mayer JE, Shah SS, Hirsch-Romano J, Gaynor JW, Peterson ED, Pasquali SK. The Impact of Differential Case Ascertainment in Clinical Registry Versus Administrative Data on Assessment of Resource Utilization in Pediatric Heart Surgery. World J Pediatr Congenit Heart Surg 2017; 5:398-405. [PMID: 24958042 DOI: 10.1177/2150135114534274] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 04/07/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Resource utilization in congenital heart surgery is typically assessed using administrative data sets. Recent analyses have called into question the accuracy of coding of cases in administrative data; however, it is unclear whether miscoding impacts assessment of associated resource use. METHODS We merged data coded within both an administrative data set and clinical registry on children undergoing heart surgery (2004-2010) at 33 hospitals. The impact of differences in coding of operations between data sets on reporting of postoperative length of stay (PLOS) and total hospital costs associated with these operations was assessed. RESULTS For each of the eight operations of varying complexity evaluated (total n = 57,797), there were differences in coding between data sets, which translated into differences in the reporting of associated resource utilization for the cases coded in either data set. There were statistically significant differences in PLOS and cost for seven of the eight operations, although most PLOS differences were relatively small with the exception of the Norwood operation and truncus repair (differences of two days, P < .001). For cost, there was a >5% difference for three of the eight operations and >10% difference for truncus repair (US$10,570; P < .01). Grouping of operations into categories of similar risk appeared to mitigate many of these differences. CONCLUSION Differences in coding of cases in administrative versus clinical registry data can translate into differences in assessment of associated PLOS and cost for certain operations. This may be minimized through evaluating larger groups of operations when using administrative data or using clinical registry data to accurately identify operations of interest.
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Affiliation(s)
- David W Jantzen
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Xia He
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Jeffrey P Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael G Gaies
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Matt Hall
- Children's Hospital Association, Overland Park, KS, USA
| | - John E Mayer
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Samir S Shah
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jennifer Hirsch-Romano
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - J William Gaynor
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Sara K Pasquali
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
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82
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Tume S, Checchia PA. Extracorporeal Membrane Oxygenation After Congenital Heart Surgery: Does One Database Fit All? Pediatr Crit Care Med 2017; 18:809-810. [PMID: 28796708 DOI: 10.1097/pcc.0000000000001244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Sebastian Tume
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
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83
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Metrics to Assess Extracorporeal Membrane Oxygenation Utilization in Pediatric Cardiac Surgery Programs. Pediatr Crit Care Med 2017; 18:779-786. [PMID: 28498231 DOI: 10.1097/pcc.0000000000001205] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Only a small fraction of pediatric cardiac surgical patients are supported with extracorporeal membrane oxygenation following cardiac surgery, but extracorporeal membrane oxygenation use is more common among those undergoing higher complexity surgery. We evaluated extracorporeal membrane oxygenation metrics indexed to annual cardiac surgical volume to better understand extracorporeal membrane oxygenation use among U.S. cardiac surgical programs. DESIGN Retrospective analysis SETTING:: Forty-three U.S. Children's Hospitals in the Pediatric Health Information System that performed cardiac surgery and used extracorporeal membrane oxygenation. PATIENTS All patients (< 19 yr) undergoing cardiac surgery during January 2003 to July 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Both extracorporeal membrane oxygenation use and surgical mortality were risk adjusted using Risk Adjustment for Congenital Heart Surgery 1. Extracorporeal membrane oxygenation metrics indexed to annual cardiac surgery cases were calculated for each hospital and the metric values divided into quintiles for comparison across hospitals. Among 131,786 cardiac surgical patients, 3,782 (2.9%) received extracorporeal membrane oxygenation. Median case mix adjusted rate of extracorporeal membrane oxygenation use was 2.8% (interquartile range, 1.6-3.4%). Median pediatric cardiac case mix adjusted surgical mortality was 3.5%. Extracorporeal membrane oxygenation-associated surgical mortality was 1.3% (interquartile range, 0.7-1.6%); without extracorporeal membrane oxygenation, median case mix adjusted surgical mortality would increase from 3.5% to 5.0%. Among patients who died, 36.7% (median) were supported with extracorporeal membrane oxygenation. The median reduction in case mix adjusted surgical mortality from extracorporeal membrane oxygenation surgical survival was 30.1%. The median extracorporeal membrane oxygenation free surgical survival was 95% (interquartile range, 94-96%). Centers with less than 150 annual surgical cases had significantly lower median extracorporeal membrane oxygenation use (0.78%) than centers with greater than 275 cases (≥ 2.8% extracorporeal membrane oxygenation use). Extracorporeal membrane oxygenation use and mortality varied within quintiles and across quintiles of center annual surgical case volume. CONCLUSIONS Risk adjusted extracorporeal membrane oxygenation metrics indexed to annual surgical volume provide potential for benchmarking as well as a greater understanding of extracorporeal membrane oxygenation utilization, efficacy, and impact on cardiac surgery mortality.
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84
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Schidlow DN, Jenkins KJ, Gauvreau K, Croti UA, Giang DTC, Konda RK, Novick WM, Sandoval NF, Castañeda A. Transposition of the Great Arteries in the Developing World: Surgery and Outcomes. J Am Coll Cardiol 2017; 69:43-51. [PMID: 28057249 DOI: 10.1016/j.jacc.2016.10.051] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 09/01/2016] [Accepted: 10/04/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Little has been published regarding surgery for transposition of the great arteries (TGA) in the developing world. OBJECTIVES This study sought to identify patient characteristics, surgical interventions, institutional characteristics, risk factors for mortality, and outcomes among patients undergoing surgery for TGA in this setting. METHODS Developing world congenital heart surgical programs submitted de-identified data to a novel international collaborative database as part of a quality improvement project. We conducted a retrospective cohort study that included all cases of TGA with intact ventricular septum and TGA with ventricular septal defect performed from 2010 to 2013. Demographic, surgical, and institutional characteristics and their associations with in-hospital mortality were identified. RESULTS There were 778 TGA operations performed at 26 centers, 480 (62%) for TGA with intact ventricular septum and 298 (38%) for TGA with ventricular septal defect. Most (80%) were single-stage arterial switch operations, but 20% were atrial baffling procedures (atrial switch operation) or 2-stage repairs (pulmonary artery band followed by arterial switch operation). Age at operation was >30 days in one-half of the cases and did not vary significantly with operation type. Survival was 85% and did not significantly vary with age at operation or operation type. Preceding septostomy was infrequently reported (16%) and was not associated with surgical mortality. Mortality was associated with lower World Health Organization weight/body mass index-for-age percentile and lower institutional volume of TGA repair. CONCLUSIONS Surgical repair of TGA performed in the developing world is associated with an early survival of 85%. Type of surgical repair and age at operation varied considerably, but no associations with mortality were identified. In contrast, poor nutrition and small surgical volume were most strongly associated with mortality. Multicenter collaborative quality improvement efforts may benefit patients with TGA in the developing world.
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Affiliation(s)
- David N Schidlow
- Children's National Heart Institute, Children's National Medical Center, George Washington University, Washington, DC.
| | - Kathy J Jenkins
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Ulisses A Croti
- Hospital da Criança e Maternidade de São José do Rio Preto, São José do Rio Preto, Brazil
| | | | | | - William M Novick
- Department of Surgery, University of Tennessee Health Science Center and William Novick Global Cardiac Alliance, Memphis, Tennessee
| | | | - Aldo Castañeda
- UNICAR and the Fundación Aldo Castañeda, Guatemala City, Guatemala
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85
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Holst KA, Said SM, Nelson TJ, Cannon BC, Dearani JA. Current Interventional and Surgical Management of Congenital Heart Disease: Specific Focus on Valvular Disease and Cardiac Arrhythmias. Circ Res 2017; 120:1027-1044. [PMID: 28302746 DOI: 10.1161/circresaha.117.309186] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 02/20/2017] [Accepted: 02/20/2017] [Indexed: 01/15/2023]
Abstract
Successful outcome in the care of patients with congenital heart disease depends on a comprehensive multidisciplinary team. Surgery is offered for almost every heart defect, despite complexity. Early mortality for cardiac surgery in the neonatal period is ≈10% and beyond infancy is <5%, with 90% to 95% of patients surviving with a good quality of life into the adult years. Advances in imaging have facilitated accurate diagnosis and planning of interventions and surgical procedures. Similarly, advances in the perioperative medical management of patients, particularly with intensive care, has also contributed to improving outcomes. Arrhythmias and heart failure are the most common late complications for the majority of defects, and reoperation for valvar problems is common. Lifelong surveillance for monitoring of recurrent or residual structural heart defects, as well as periodic assessment of cardiac function and arrhythmia monitoring, is essential for all patients. The field of congenital heart surgery is poised to incorporate new innovations such as bioengineered cells and scaffolds that will iteratively move toward bioengineered patches, conduits, valves, and even whole organs.
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Affiliation(s)
- Kimberly A Holst
- From the Department of Cardiovascular Surgery (K.A.H., S.M.S., J.A.D.), Departments of Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics (T.J.N., B.C.C.), and Division of Pediatric Cardiology (T.J.N., B.C.C.), Mayo Clinic, Rochester, MN
| | - Sameh M Said
- From the Department of Cardiovascular Surgery (K.A.H., S.M.S., J.A.D.), Departments of Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics (T.J.N., B.C.C.), and Division of Pediatric Cardiology (T.J.N., B.C.C.), Mayo Clinic, Rochester, MN
| | - Timothy J Nelson
- From the Department of Cardiovascular Surgery (K.A.H., S.M.S., J.A.D.), Departments of Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics (T.J.N., B.C.C.), and Division of Pediatric Cardiology (T.J.N., B.C.C.), Mayo Clinic, Rochester, MN
| | - Bryan C Cannon
- From the Department of Cardiovascular Surgery (K.A.H., S.M.S., J.A.D.), Departments of Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics (T.J.N., B.C.C.), and Division of Pediatric Cardiology (T.J.N., B.C.C.), Mayo Clinic, Rochester, MN
| | - Joseph A Dearani
- From the Department of Cardiovascular Surgery (K.A.H., S.M.S., J.A.D.), Departments of Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics (T.J.N., B.C.C.), and Division of Pediatric Cardiology (T.J.N., B.C.C.), Mayo Clinic, Rochester, MN.
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86
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Jacobs JP, Mayer JE, Mavroudis C, O’Brien SM, Austin EH, Pasquali SK, Hill KD, Overman DM, St. Louis JD, Karamlou T, Pizarro C, Hirsch-Romano JC, McDonald D, Han JM, Becker S, Tchervenkov CI, Lacour-Gayet F, Backer CL, Fraser CD, Tweddell JS, Elliott MJ, Walters H, Jonas RA, Prager RL, Shahian DM, Jacobs ML. The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2017 Update on Outcomes and Quality. Ann Thorac Surg 2017; 103:699-709. [DOI: 10.1016/j.athoracsur.2017.01.004] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 01/08/2017] [Accepted: 01/10/2017] [Indexed: 11/16/2022]
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87
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Karl TR, Jacobs JP. Is experience the best teacher? Eur J Cardiothorac Surg 2017; 51:299-300. [PMID: 28082468 DOI: 10.1093/ejcts/ezw287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 07/29/2016] [Indexed: 11/14/2022] Open
Affiliation(s)
- Tom R Karl
- Discipline of Surgery, University of Queensland School of Medicine, Brisbane, Australia
| | - Jeffrey P Jacobs
- Johns Hopkins School of Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
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89
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Jacobs JP. The Society of Thoracic Surgeons Congenital Heart Surgery Database Public Reporting Initiative. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2017; 20:43-48. [PMID: 28007064 DOI: 10.1053/j.pcsu.2016.09.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Accepted: 09/14/2016] [Indexed: 06/06/2023]
Abstract
Three basic principles provide the rationale for the Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database (CHSD) public reporting initiative: (1) Variation in congenital and pediatric cardiac surgical outcomes exist. (2) Patients and their families have the right to know the outcomes of the treatments that they will receive. (3). It is our professional responsibility to share this information with them in a format they can understand. The STS CHSD public reporting initiative facilitates the voluntary transparent public reporting of congenital and pediatric cardiac surgical outcomes using the STS CHSD Mortality Risk Model. The STS CHSD Mortality Risk Model is used to calculate risk-adjusted operative mortality and adjusts for the following variables: age, primary procedure, weight (neonates and infants), prior cardiothoracic operations, non-cardiac congenital anatomic abnormalities, chromosomal abnormalities or syndromes, prematurity (neonates and infants), and preoperative factors (including preoperative/preprocedural mechanical circulatory support [intraaortic balloon pump, ventricular assist device, extracorporeal membrane oxygenation, or cardiopulmonary support], shock [persistent at time of surgery], mechanical ventilation to treat cardiorespiratory failure, renal failure requiring dialysis and/or renal dysfunction, preoperative neurological deficit, and other preoperative factors). Operative mortality is defined in all STS databases as (1) all deaths, regardless of cause, occurring during the hospitalization in which the operation was performed, even if after 30 days (including patients transferred to other acute care facilities); and (2) all deaths, regardless of cause, occurring after discharge from the hospital, but before the end of the 30th postoperative day. The STS CHSD Mortality Risk Model has good model fit and discrimination with an overall C statistics of 0.875 and 0.858 in the development sample and the validation sample, respectively. These C statistics are the highest C statistics ever seen in a pediatric cardiac surgical risk model. Therefore, the STS CHSD Mortality Risk Model provides excellent adjustment for case mix and should mitigate against risk aversive behavior. The STS CHSD Mortality Risk Model is the best available model to date for measuring outcomes after pediatric cardiac surgery. As of March 2016, 60% of participants in STS CHSD have agreed to publicly report their outcomes through the STS Public Reporting Online website (http://www.sts.org/quality-research-patient-safety/sts-public-reporting-online). Although several opportunities exist to improve our risk models, the current STS CHSD public reporting initiative provides the tools to report publicly, and with meaning and accuracy, the outcomes of congenital and pediatric cardiac surgery.
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Affiliation(s)
- Jeffrey P Jacobs
- Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, Johns Hopkins All Children's Hospital and Florida Hospital for Children, Saint Petersburg, Tampa, and Orlando, FL; Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
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90
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Design and initial results of a programme for routine standardised longitudinal follow-up after congenital heart surgery. Cardiol Young 2016; 26:1590-1596. [PMID: 28148316 DOI: 10.1017/s1047951116001669] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND With improvements in early survival following congenital heart surgery, it has become increasingly important to understand longer-term outcomes; however, routine collection of these data is challenging and remains very limited. We describe the development and initial results of a collaborative programme incorporating standardised longitudinal follow-up into usual care at the Children's Hospital of Philadelphia (CHOP) and University of Michigan (UM). METHODS We included children undergoing benchmark operations of the Society of Thoracic Surgeons. Considerations regarding personnel, patient/parent engagement, funding, regulatory issues, and annual data collection are described, and initial follow-up rates are reported. RESULTS The present analysis included 1737 eligible patients undergoing surgery at CHOP from January 2007 to December 2014 and 887 UM patients from January 2010 to December 2014. Overall, follow-up data, of any type, were obtained from 90.8% of patients at CHOP (median follow-up 4.3 years, 92.2% survival) and 98.3% at UM (median follow-up 2.8 years, 92.7% survival), with similar rates across operations and institutions. Most patients lost to follow-up at CHOP had undergone surgery before 2010. Standardised questionnaires assessing burden of disease/quality of life were completed by 80.2% (CHOP) and 78.4% (UM) via phone follow-up. In subsequent pilot testing of an automated e-mail system, 53.4% of eligible patients completed the follow-up questionnaire through this system. CONCLUSIONS Standardised follow-up data can be obtained on the majority of children undergoing benchmark operations. Ongoing efforts to support automated electronic systems and integration with registry data may reduce resource needs, facilitate expansion across centres, and support multi-centre efforts to understand and improve long-term outcomes in this population.
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91
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Ethical considerations of transparency, informed consent, and nudging in a patient with paediatric aortic stenosis and symptomatic left ventricular endocardial fibroelastosis. Cardiol Young 2016; 26:1573-1580. [PMID: 28148333 DOI: 10.1017/s1047951116002456] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A 9-year-old boy who was born with bicuspid aortic stenosis underwent two unsuccessful aortic valvuloplasty interventions, and by 2 years of age he developed restrictive cardiomyopathy caused by left ventricular endocardial fibroelastosis and diastolic dysfunction. The attending cardiologist referred the patient to a high-volume, high-profile congenital cardiac surgical programme 1000 miles away that has a team with considerable experience with left ventricular endocardial fibroelastosis resection and a reputation of achieving good results. Owing to problems with insurance coverage, the parents sought other options for the care of their child in their home state. Dr George Miller is a well-respected local congenital and paediatric cardiac surgeon with considerable experience with the Ross operation as well as with right ventricular endocardial fibroelastosis resection. When talking with Dr Miller, he implied that there is little difference between right ventricular endocardial fibroelastosis and left ventricular endocardial fibroelastosis resection, and stated that he would perform the operation with low mortality based on his overall experience. Dr Miller stated that the local institution could provide an equivalent surgical procedure with comparable outcomes, without the patient and family having to travel out of state. A fundamental dilemma that often arises in clinical surgical practice concerns the conduct of assessing and performing new procedures, especially in rare cases, for which the collective global experience is scant. Although Dr Miller has performed right ventricular endocardial fibroelastosis resection, this procedure differs from left ventricular endocardial fibroelastosis resection, and he cannot be sure that he will indeed be able to perform the procedure better than the high-volume surgeon. This ethical situation is best understood in terms of the principles of respect for patient autonomy, beneficence, non-maleficence, and justice. The tension between the imperatives of beneficence and the obligation to respect the autonomy of the patient by acting only with the patient's best interest in mind is discussed.
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92
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Hill GD, Rudd NA, Ghanayem NS, Hehir DA, Bartz PJ. Center Variability in Timing of Stage 2 Palliation and Association with Interstage Mortality: A Report from the National Pediatric Cardiology Quality Improvement Collaborative. Pediatr Cardiol 2016; 37:1516-1524. [PMID: 27558553 DOI: 10.1007/s00246-016-1465-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 08/16/2016] [Indexed: 11/27/2022]
Abstract
For infants with single-ventricle lesions with aortic arch hypoplasia, the interstage period from discharge following stage 1 palliation (S1P) until stage 2 palliation (S2P) remains high risk. Significant variability among institutions exists around the timing of S2P. We sought to describe institutional variation in timing of S2P, determine the association between timing of S2P and interstage mortality, and determine the impact of earlier S2P on hospital morbidity and mortality. The National Pediatric Cardiology Quality Improvement Collaborative registry was queried. Centers were divided based on median age at S2P into early (n = 15) and late (n = 16) centers using a cutoff of 153 days. Groups were compared using Chi-squared or Wilcoxon rank-sum test. Multivariable logistic regression was used to determine risk factors for interstage mortality. The final cohort included 789 patients from 31 centers. There was intra- and inter-center variability in timing of S2P, with the median age by center ranging from 109 to 214 days. Late centers had a higher mortality (9.9 vs. 5.7 %, p = 0.03) than early centers. However, the event rate (late: 8.2 vs. early: 5.8 deaths per 10,000 interstage days) was not different by group (p = 0.26). Survival to hospital discharge and hospital length of stay following S2P were similar between groups. In conclusion, in a large multi-institution collaborative, the median age at S2P varies among centers. Although optimal timing of S2P remains unclear, centers performing early S2P did not experience worse S2P outcomes and experienced less interstage mortality.
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Affiliation(s)
- Garick D Hill
- Divison of Cardiology, Department of Pediatrics, Medical College of Wisconsin, 9000 W Wisconsin Ave, Milwaukee, WI, 53226, USA.
| | - Nancy A Rudd
- Divison of Cardiology, Department of Pediatrics, Medical College of Wisconsin, 9000 W Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Nancy S Ghanayem
- Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David A Hehir
- Division of Cardiac Critical Care, Department of Pediatrics, Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - Peter J Bartz
- Divison of Cardiology, Department of Pediatrics, Medical College of Wisconsin, 9000 W Wisconsin Ave, Milwaukee, WI, 53226, USA
- Division of Adult Cardiovascular Medicine, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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93
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Mortality Trends in Pediatric and Congenital Heart Surgery: An Analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database. Ann Thorac Surg 2016; 102:1345-52. [DOI: 10.1016/j.athoracsur.2016.01.071] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 12/24/2015] [Accepted: 01/11/2016] [Indexed: 11/21/2022]
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Gaies M, Pasquali SK, Donohue JE, Dimick JB, Limbach S, Burnham N, Ravishankar C, Ohye RG, Gaynor JW, Mascio CE. Seminal Postoperative Complications and Mode of Death After Pediatric Cardiac Surgical Procedures. Ann Thorac Surg 2016; 102:628-35. [PMID: 27154145 PMCID: PMC4958574 DOI: 10.1016/j.athoracsur.2016.02.043] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 01/12/2016] [Accepted: 02/09/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND Understanding the seminal complications leading to death after pediatric cardiac surgical procedures may provide opportunities to reduce mortality. This study analyzed all deaths at two pediatric cardiac surgical programs and developed a method to identify the seminal complications and modes of death. METHODS Trained nurses abstracted all cases of in-hospital mortality meeting inclusion criteria from each site over 5 years (2008 to 2012). Complication definitions were consistent with those of a multicenter clinical registry. An adjudication committee assigned a seminal complication in each case (the complication initiating the cascade of events leading to death). Seminal complications were grouped into categories to designate "mode of death." The epidemiology of seminal complications and of mode of death was described. RESULTS In 191 subjects, low cardiac output syndrome (71% of all subjects), cardiac arrest (52%), and arrhythmia (48%) were the most common complications. The committee assigned low cardiac output syndrome (30%), failure to separate from bypass (16%), and cardiac arrest (12%) most frequently as seminal complications. Seminal complications occurred a median 2 hours (interquartile range [IQR], 0 to 35 hours) postoperatively. Patients experienced a median of seven (IQR, 3 to 12) additional complications before death at a median of 15 days (IQR, 4 to 46). Systemic circulatory failure was the most common mode of death (51%), followed by inadequate pulmonary blood flow (13%) and cardiac arrest (12%). CONCLUSIONS Seminal complications occurred early postoperatively, and systemic circulatory failure was the most common mode of death. Our classification system is likely scalable for subsequent multicenter analysis to understand cause-specific mortality variation across hospitals and to drive quality improvement.
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Affiliation(s)
- Michael Gaies
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Sara K Pasquali
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan
| | - Janet E Donohue
- Michigan Congenital Heart Outcomes Research and Discovery Unit, Ann Arbor, Michigan
| | - Justin B Dimick
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Sarah Limbach
- Division of Cardiac Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nancy Burnham
- Division of Cardiac Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chitra Ravishankar
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Richard G Ohye
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - J William Gaynor
- Division of Cardiac Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christopher E Mascio
- Division of Cardiac Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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96
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Pasquali SK, Wallace AS, Gaynor JW, Jacobs ML, O'Brien SM, Hill KD, Gaies MG, Romano JC, Shahian DM, Mayer JE, Jacobs JP. Congenital Heart Surgery Case Mix Across North American Centers and Impact on Performance Assessment. Ann Thorac Surg 2016; 102:1580-1587. [PMID: 27457827 DOI: 10.1016/j.athoracsur.2016.04.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/05/2016] [Accepted: 04/11/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Performance assessment in congenital heart surgery is challenging due to the wide heterogeneity of disease. We describe current case mix across centers, evaluate methodology inclusive of all cardiac operations versus the more homogeneous subset of Society of Thoracic Surgeons benchmark operations, and describe implications regarding performance assessment. METHODS Centers (n = 119) participating in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2010 through 2014) were included. Index operation type and frequency across centers were described. Center performance (risk-adjusted operative mortality) was evaluated and classified when including the benchmark versus all eligible operations. RESULTS Overall, 207 types of operations were performed during the study period (112,140 total cases). Few operations were performed across all centers; only 25% were performed at least once by 75% or more of centers. There was 7.9-fold variation across centers in the proportion of total cases comprising high-complexity cases (STAT 5). In contrast, the benchmark operations made up 36% of cases, and all but 2 were performed by at least 90% of centers. When evaluating performance based on benchmark versus all operations, 15% of centers changed performance classification; 85% remained unchanged. Benchmark versus all operation methodology was associated with lower power, with 35% versus 78% of centers meeting sample size thresholds. CONCLUSIONS There is wide variation in congenital heart surgery case mix across centers. Metrics based on benchmark versus all operations are associated with strengths (less heterogeneity) and weaknesses (lower power), and lead to differing performance classification for some centers. These findings have implications for ongoing efforts to optimize performance assessment, including choice of target population and appropriate interpretation of reported metrics.
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Affiliation(s)
- Sara K Pasquali
- Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, Ann Arbor, Michigan.
| | - Amelia S Wallace
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - J William Gaynor
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Marshall L Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, All Children's Hospital and Florida Hospital for Children, St. Petersburg, Tampa, and Orlando, Florida
| | - Sean M O'Brien
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Kevin D Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Michael G Gaies
- Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - David M Shahian
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John E Mayer
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Jeffrey P Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, All Children's Hospital and Florida Hospital for Children, St. Petersburg, Tampa, and Orlando, Florida
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97
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Jacobs JP, Mayer JE, Mavroudis C, O'Brien SM, Austin EH, Pasquali SK, Hill KD, He X, Overman DM, St Louis JD, Karamlou T, Pizarro C, Hirsch-Romano JC, McDonald D, Han JM, Dokholyan RS, Tchervenkov CI, Lacour-Gayet F, Backer CL, Fraser CD, Tweddell JS, Elliott MJ, Walters H, Jonas RA, Prager RL, Shahian DM, Jacobs ML. The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2016 Update on Outcomes and Quality. Ann Thorac Surg 2016; 101:850-62. [PMID: 26897186 DOI: 10.1016/j.athoracsur.2016.01.057] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 01/09/2016] [Accepted: 01/12/2016] [Indexed: 11/19/2022]
Abstract
The Society of Thoracic Surgeons Congenital Heart Surgery Database is the largest congenital and pediatric cardiac surgical clinical data registry in the world. It is the platform for all activities of The Society of Thoracic Surgeons related to the analysis of outcomes and the improvement of quality in this subspecialty. This article summarizes current aggregate national outcomes in congenital and pediatric cardiac surgery and reviews related activities in the areas of quality measurement, performance improvement, and transparency. The reported data about aggregate national outcomes are exemplified by an analysis of 10 benchmark operations performed from January 2011 to December 2014 and documenting overall discharge mortality (interquartile range among programs with more than 9 cases): off-bypass coarctation, 1.0% (0.0% to 0.9%); ventricular septal defect repair, 0.7% (0.0% to 1.1%); tetralogy of Fallot repair, 1.0% (0.0% to 1.7%); complete atrioventricular canal repair, 3.2% (0.0% to 6.5%); arterial switch operation, 2.7% (0.0% to 5.6%); arterial switch operation plus ventricular septal defect, 5.3% (0.0% to 6.7%); Glenn/hemiFontan, 2.1% (0.0% to 3.8%); Fontan operation, 1.4% (0.0% to 2.4%); truncus arteriosus repair, 9.6% (0.0 % to 11.8%); and Norwood procedure, 15.6% (10.0% to 21.4%).
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Affiliation(s)
- Jeffrey P Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, All Children's Hospital and Florida Hospital for Children, Saint Petersburg, Tampa, and Orlando, Florida.
| | - John E Mayer
- Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts
| | - Constantine Mavroudis
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, All Children's Hospital and Florida Hospital for Children, Saint Petersburg, Tampa, and Orlando, Florida
| | | | - Erle H Austin
- Kosair Children's Hospital, University of Louisville, Louisville, Kentucky
| | - Sara K Pasquali
- C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | | | - Xia He
- Duke University, Durham, North Carolina
| | - David M Overman
- The Children's Heart Clinic at Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - James D St Louis
- Department of Surgery, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery, Benioff Children's Hospital, University of California, San Francisco, San Francisco, California
| | | | | | | | - Jane M Han
- The Society of Thoracic Surgeons, Chicago, Illinois
| | | | | | | | - Carl L Backer
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Charles D Fraser
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - James S Tweddell
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Martin J Elliott
- The Great Ormond Street Hospital, London, England, United Kingdom
| | - Hal Walters
- Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, Michigan
| | | | | | - David M Shahian
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marshall L Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, All Children's Hospital and Florida Hospital for Children, Saint Petersburg, Tampa, and Orlando, Florida
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Crowe S, Ridout DA, Knowles R, Tregay J, Wray J, Barron DJ, Cunningham D, Parslow RC, Utley M, Franklin R, Bull C, Brown KL. Death and Emergency Readmission of Infants Discharged After Interventions for Congenital Heart Disease: A National Study of 7643 Infants to Inform Service Improvement. J Am Heart Assoc 2016; 5:JAHA.116.003369. [PMID: 27207967 PMCID: PMC4889202 DOI: 10.1161/jaha.116.003369] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Improvements in hospital‐based care have reduced early mortality in congenital heart disease. Later adverse outcomes may be reducible by focusing on care at or after discharge. We aimed to identify risk factors for such events within 1 year of discharge after intervention in infancy and, separately, to identify subgroups that might benefit from different forms of intervention. Methods and Results Cardiac procedures performed in infants between 2005 and 2010 in England and Wales from the UK National Congenital Heart Disease Audit were linked to intensive care records. Among 7976 infants, 333 (4.2%) died before discharge. Of 7643 infants discharged alive, 246 (3.2%) died outside the hospital or after an unplanned readmission to intensive care (risk factors were age, weight‐for‐age, cardiac procedure, cardiac diagnosis, congenital anomaly, preprocedural clinical deterioration, prematurity, ethnicity, and duration of initial admission; c‐statistic 0.78 [0.75–0.82]). Of the 7643, 514 (6.7%) died outside the hospital or had an unplanned intensive care readmission (same risk factors but with neurodevelopmental condition and acquired cardiac diagnosis and without preprocedural deterioration; c‐statistic 0.78 [0.75–0.80]). Classification and regression tree analysis were used to identify 6 subgroups stratified by the level (3–24%) and nature of risk for death outside the hospital or unplanned intensive care readmission based on neurodevelopmental condition, cardiac diagnosis, congenital anomaly, and duration of initial admission. An additional 115 patients died after planned intensive care admission (typically following elective surgery). Conclusions Adverse outcomes in the year after discharge are of similar magnitude to in‐hospital mortality, warrant service improvements, and are not confined to diagnostic groups currently targeted with enhanced monitoring.
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Affiliation(s)
- Sonya Crowe
- Clinical Operational Research Unit, University College London, London, UK
| | - Deborah A Ridout
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
| | - Rachel Knowles
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
| | - Jenifer Tregay
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Jo Wray
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David J Barron
- Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - David Cunningham
- NICOR: National Institute for Cardiovascular Outcomes Research, UCL, London, UK
| | | | - Martin Utley
- Clinical Operational Research Unit, University College London, London, UK
| | - Rodney Franklin
- Royal Brompton and Harefield Hospitals NHS Trust, London, UK
| | - Catherine Bull
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
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Jenkins KJ, Koch Kupiec J, Owens PL, Romano PS, Geppert JJ, Gauvreau K. Development and Validation of an Agency for Healthcare Research and Quality Indicator for Mortality After Congenital Heart Surgery Harmonized With Risk Adjustment for Congenital Heart Surgery (RACHS-1) Methodology. J Am Heart Assoc 2016; 5:e003028. [PMID: 27207997 PMCID: PMC4889177 DOI: 10.1161/jaha.115.003028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 03/23/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The National Quality Forum previously approved a quality indicator for mortality after congenital heart surgery developed by the Agency for Healthcare Research and Quality (AHRQ). Several parameters of the validated Risk Adjustment for Congenital Heart Surgery (RACHS-1) method were included, but others differed. As part of the National Quality Forum endorsement maintenance process, developers were asked to harmonize the 2 methodologies. METHODS AND RESULTS Parameters that were identical between the 2 methods were retained. AHRQ's Healthcare Cost and Utilization Project State Inpatient Databases (SID) 2008 were used to select optimal parameters where differences existed, with a goal to maximize model performance and face validity. Inclusion criteria were not changed and included all discharges for patients <18 years with International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes for congenital heart surgery or nonspecific heart surgery combined with congenital heart disease diagnosis codes. The final model includes procedure risk group, age (0-28 days, 29-90 days, 91-364 days, 1-17 years), low birth weight (500-2499 g), other congenital anomalies (Clinical Classifications Software 217, except for 758.xx), multiple procedures, and transfer-in status. Among 17 945 eligible cases in the SID 2008, the c statistic for model performance was 0.82. In the SID 2013 validation data set, the c statistic was 0.82. Risk-adjusted mortality rates by center ranged from 0.9% to 4.1% (5th-95th percentile). CONCLUSIONS Congenital heart surgery programs can now obtain national benchmarking reports by applying AHRQ Quality Indicator software to hospital administrative data, based on the harmonized RACHS-1 method, with high discrimination and face validity.
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Affiliation(s)
| | | | - Pamela L Owens
- Agency for Healthcare Research and Quality, Rockville, MD
| | - Patrick S Romano
- University of California Davis School of Medicine, Sacramento, CA
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