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Stephens SB, Benjamin RH, Lopez KN, Anderson BR, Lin AE, Shumate CJ, Nembhard WN, Morris SA, Agopian AJ. Enhancing the Classification of Congenital Heart Defects for Outcome Association Studies in Birth Defects Registries. Birth Defects Res 2024; 116:e2393. [PMID: 39169811 PMCID: PMC11421657 DOI: 10.1002/bdr2.2393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 07/10/2024] [Accepted: 07/25/2024] [Indexed: 08/23/2024]
Abstract
INTRODUCTION Traditional strategies for grouping congenital heart defects (CHDs) using birth defect registry data do not adequately address differences in expected clinical consequences between different combinations of CHDs. We report a lesion-specific classification system for birth defect registry-based outcome studies. METHODS For Core Cardiac Lesion Outcome Classifications (C-CLOC) groups, common CHDs expected to have reasonable clinical homogeneity were defined. Criteria based on combinations of Centers for Disease and Control-modified British Pediatric Association (BPA) codes were defined for each C-CLOC group. To demonstrate proof of concept and retention of reasonable case counts within C-CLOC groups, Texas Birth Defect Registry data (1999-2017 deliveries) were used to compare case counts and neonatal mortality between traditional vs. C-CLOC classification approaches. RESULTS C-CLOC defined 59 CHD groups among 62,262 infants with CHDs. Classifying cases into the single, mutually exclusive C-CLOC group reflecting the highest complexity CHD present reduced case counts among lower complexity lesions (e.g., 86.5% of cases with a common atrium BPA code were reclassified to a higher complexity group for a co-occurring CHD). As expected, C-CLOC groups had retained larger sample sizes (i.e., representing presumably better-powered analytic groups) compared to cases with only one CHD code and no occurring CHDs. DISCUSSION This new CHD classification system for investigators using birth defect registry data, C-CLOC, is expected to balance clinical outcome homogeneity in analytic groups while maintaining sufficiently large case counts within categories, thus improving power for CHD-specific outcome association comparisons. Future outcome studies utilizing C-CLOC-based classifications are planned.
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Affiliation(s)
- Sara B Stephens
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Renata H Benjamin
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Keila N Lopez
- Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Brett R Anderson
- Division of Pediatric Cardiology, New York-Presbyterian and Columbia University Irving Medical Center, New York, New York, USA
| | - Angela E Lin
- Department of Pediatrics, Medical Genetics Unit, Mass General for Children and Harvard University School of Medicine, Boston, Massachusetts, USA
| | | | - Wendy N Nembhard
- Arkansas Center for Birth Defects Research and Prevention and Arkansas Reproductive Health Monitoring System, Fay Boozman College of Public Health, Department of Epidemiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Shaine A Morris
- Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - A J Agopian
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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Lubarsky D, Van Driest SL, Crum K, Fountain D, Kannankeril PJ. Association Between Neighborhood Socioeconomic Factors and Length of Stay After Surgery for Congenital Heart Disease. Pediatr Crit Care Med 2024; 25:547-553. [PMID: 38299943 DOI: 10.1097/pcc.0000000000003455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
OBJECTIVES Neighborhood socioeconomic status, as measured by area deprivation index (ADI) is associated with longer length of stay (LOS) after surgery for hypoplastic left heart syndrome. We tested the hypothesis that LOS is associated with ADI in a large cohort of congenital heart disease (CHD) surgical cases of varying severity and sought to determine which other components of the ADI accounted for any associations. DESIGN Retrospective analysis of a curated dataset. The Brokamp ADI was determined using residential addresses. Overall, ADI and each of its six individual components were dichotomized, and LOS compared between groups above versus below the median for the entire cohort and after stratifying by surgical The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) severity category. SETTING Single-center academic pediatric teaching hospital. PATIENTS CHD patients who underwent surgical repair/palliation between September 2007 and August 2022. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 2462 patients (52.7% male) were included. Median age was 254 (interquartile range [IQR] 95-1628) days and median LOS in the hospital was 8 (IQR 5-18) days. We failed to identify an association between Brokamp ADI, above versus below the median for the entire cohort, and LOS; nor in STAT categories 1-4. However, in STAT category 5 ( n = 129) those with ADI above the median (more deprived) had a significantly longer LOS (48 [20-88] vs. 36 [18-49] d, p = 0.034). Of the individual components of the ADI, only percent below poverty level and percent vacant houses were associated with LOS in STAT category 5. CONCLUSIONS LOS after CHD surgery is associated with Brokamp ADI in STAT category 5 cases, we failed to identify an association in lower-risk cardiac operations.
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Affiliation(s)
- Daniel Lubarsky
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN
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Balasubramanian S, Yu S, Behera SK, Bhat AH, Camarda JA, Choueiter NF, Jone P, Lopez L, Natarajan SS, Parra DA, Parthiban A, Sachdeva R, Srivastava S, Tierney ESS. Consensus-Based Development of a Pediatric Echocardiography Complexity Score: Design, Rationale, and Results of a Quality Improvement Collaborative. J Am Heart Assoc 2024; 13:e029798. [PMID: 38390878 PMCID: PMC10944062 DOI: 10.1161/jaha.123.029798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 11/07/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND The complexity of congenital heart disease has been primarily stratified on the basis of surgical technical difficulty, specific diagnoses, and associated outcomes. We report on the refinement and validation of a pediatric echocardiography complexity (PEC) score. METHODS AND RESULTS The American College of Cardiology Quality Network assembled a panel from 12 centers to refine a previously published PEC score developed in a single institution. The panel refined complexity categories and included study modifiers to account for complexity related to performance of the echocardiogram. Each center submitted data using the PEC scoring tool on 15 consecutive inpatient and outpatient echocardiograms. Univariate and multivariate analyses were performed to assess for independent predictors of longer study duration. Among the 174 echocardiograms analyzed, 68.9% had underlying congenital heart disease; 44.8% were outpatient; 34.5% were performed in an intensive care setting; 61.5% were follow-up; 46.6% were initial or preoperative; and 9.8% were sedated. All studies had an assigned PEC score. In univariate analysis, longer study duration was associated with several patient and study variables (age <2 years, PEC 4 or 5, initial study, preoperative study, junior or trainee scanner, and need for additional imaging). In multivariable analysis, a higher PEC score of 4 or 5 was independently associated with longer study duration after controlling for study variables and center variation. CONCLUSIONS The PEC scoring tool is feasible and applicable in a variety of clinical settings and can be used for correlation with diagnostic errors, allocation of resources, and assessment of physician and sonographer effort in performing, interpreting, and training in pediatric echocardiography.
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Affiliation(s)
| | - Sunkyung Yu
- Department of PediatricsUniversity of MichiganAnn ArborMIUSA
| | | | - Aarti H. Bhat
- Department of PediatricsUniversity of Washington and Seattle Children’s HospitalSeattleWAUSA
| | - Joseph A. Camarda
- Department of PediatricsNorthwestern University Feinberg School of MedicineChicagoILUSA
| | | | - Pei‐Ni Jone
- Department of PediatricsLurie Children’s HospitalChicagoILUSA
| | - Leo Lopez
- Department of PediatricsStanford School of MedicinePalo AltoCAUSA
| | - Shobha S. Natarajan
- Department of PediatricsPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPAUSA
| | - David A. Parra
- Department of PediatricsVanderbilt University Medical CenterNashvilleTNUSA
| | - Anitha Parthiban
- Texas Children’s Hospital, Baylor College of MedicineHoustonTXUSA
| | - Ritu Sachdeva
- Emory University and Children’s Healthcare of AtlantaAtlantaGAUSA
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AlAshgar TM, AlDawsari NH, AlSanea NY, AlSalamah NA, AlSugair NS, Ardah HI, Kabbani MS. The Outcomes of Cardiac Surgery in Children With DiGeorge Syndrome in a Single Center Experience: A Retrospective Cohort Study. Cureus 2024; 16:e55186. [PMID: 38562270 PMCID: PMC10983060 DOI: 10.7759/cureus.55186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
Background DiGeorge syndrome, a common genetic microdeletion syndrome, is associated with multiple congenital anomalies, including congenital cardiac diseases. This study aims to identify the short and midterm outcomes of cardiac surgery performed on children with DiGeorge syndrome. Methods A retrospective cohort study was conducted between the period of 2018-2022, which included children divided into two groups with a 1:2 ratio. Group one included DiGeorge syndrome patients who were diagnosed using fluorescence in situ hybridization (FISH). Group two included the control group of patients who were clear of genetic syndromes. The two groups were matched based on similar cardiac surgery, age of surgery, and Risk Adjustment in Congenital Heart Surgery (RACHS-1) score. The two groups were compared based on the demographical data and postoperative complications. Results The study consisted of 81 children; 27 were DiGeorge syndrome patients, and 54 were in the control group. DiGeorge syndrome patients showed an increase in mechanical ventilation duration (p=0.0047), intensive care unit (ICU) length of stay (p=0.0012), and hospital length of stay (p=0.0391). Moreover, they showed an increased risk for bacteremia (p=0.0414), ventilator-associated pneumonia (VAP; p=0.0036), urinary tract infections (UTI; p=0.0064), and surgical site infection (SSI; p≤0.0001). They were also more susceptible to postoperative seizures (p=0.0049). Furthermore, patients with DiGeorge syndrome had a higher prevalence of congenital renal anomalies. However, there was no mortality in either group. Conclusion This study shows a variability in the postoperative outcomes between the two groups. The study demonstrates that patients with DiGeorge syndrome have higher risks of infections and longer hospital stay during the postoperative period. Further research with a larger sample is needed to confirm our findings.
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Affiliation(s)
- Tala M AlAshgar
- Medicine and Surgery, King Saud Bin Abdulaziz University for Health Sciences College of Medicine, Riyadh, SAU
| | - Norah H AlDawsari
- Medicine and Surgery, King Saud Bin Abdulaziz University for Health Sciences College of Medicine, Riyadh, SAU
| | - Nasreen Y AlSanea
- Medicine and Surgery, King Saud Bin Abdulaziz University for Health Sciences College of Medicine, Riyadh, SAU
| | - Noura A AlSalamah
- Medicine and Surgery, King Saud Bin Abdulaziz University for Health Sciences College of Medicine, Riyadh, SAU
| | - Nada S AlSugair
- Medicine and Surgery, King Saud Bin Abdulaziz University for Health Sciences College of Medicine, Riyadh, SAU
| | - Husam I Ardah
- Biostatistics and Epidemiology, King Abdullah International Medical Research Center, Riyadh, SAU
| | - Mohamed S Kabbani
- Pediatric Critical Care, Department of Cardiac Sciences, Ministry of the National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
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Danford DA, Yetman AT, Haynatzki G. Derivation and Validation of a General Predictive Model for Long Term Risks for Mortality and Invasive Interventions in Congenital and Acquired Cardiac Conditions Encountered in the Young. Pediatr Cardiol 2023; 44:1763-1777. [PMID: 37069273 DOI: 10.1007/s00246-023-03154-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 03/20/2023] [Indexed: 04/19/2023]
Abstract
Accurate prognostic assessment is a key driver of clinical decision making in heart disease in the young (HDY). This investigation aims to derive, validate, and calibrate multivariable predictive models for time to surgical or catheter-mediated intervention (INT) and for time to death in HDY. 4108 unique subjects were prospectively and consecutively enrolled, and randomized to derivation and validation cohorts. Total follow-up was 26,578 patient-years, with 102 deaths and 868 INTs. Accelerated failure time multivariable predictive models for the outcomes, based on primary and secondary diagnoses, pathophysiologic severity, age, sex, genetic comorbidities, and prior interventional history, were derived using piecewise exponential methodology. Model predictions were validated, calibrated, and evaluated for sensitivity to changes in the independent variables. Model validity was excellent for predicting mortality and INT at 4 months, 1, 5, 10, and 22 years (areas under receiver operating characteristic curves 0.813-0.915). Model calibration was better for INT than for mortality. Age, sex, and genetic comorbidities were significant independent factors, but predicted outcomes were most sensitive to variations in composite predictors incorporating primary diagnosis, pathophysiologic severity, secondary diagnosis, and prior intervention. Despite 22 years of data acquisition, no significant cohort effects were identified in which predicted mortality and intervention varied by study entry date. A piecewise exponential model predicting survival and freedom from INT is derived which demonstrates excellent validity, and performs well on a clinical sample of HDY outpatients. Objective model-based predictions could educate both patient and provider, and inform clinical decision making in HDY.
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Affiliation(s)
- David A Danford
- University of Nebraska Medical Center, Omaha, NE, USA.
- Criss Heart Center at Children's Hospital and Medical Center, Omaha, NE, USA.
- , 804 S. 129th Ave, Omaha, NE, 68154, USA.
| | - Anji T Yetman
- University of Nebraska Medical Center, Omaha, NE, USA
- Criss Heart Center at Children's Hospital and Medical Center, Omaha, NE, USA
| | - Gleb Haynatzki
- School of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
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Kalfa D, Karamichalis JM, Singh SK, Jiang P, Anderson BR, Vargas D, Choudhury T, Habib A, Bacha E. Operative mortality after Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1 to 3 procedures: Deficiencies and opportunities for quality improvement. J Thorac Cardiovasc Surg 2023; 166:325-333.e3. [PMID: 36621456 DOI: 10.1016/j.jtcvs.2022.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 11/08/2022] [Accepted: 11/12/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVES We examined cases of operative mortality at a single quaternary academic center for patients undergoing relatively lower-risk (Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1-3) procedures, as a means of identifying systemic weaknesses and opportunities for quality improvement. METHODS A retrospective review of all operative mortality events for patients who underwent a Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1, 2, or 3 index procedure (2009-2020) at our institution was performed. After a detailed chart review was performed by 2 independent faculty for each case, factors and system deficiencies that contributed to mortality were identified. RESULTS A total of 42 mortalities were identified. A total of 37 patients (88%) had at least 1 Society of Thoracic Surgeons-designated risk factor, including prior cardiac operations (48%), extracardiac malformations (43%), and preoperative ventilation (33%). Eight patients (19%) had non-Society of Thoracic Surgeons-designated preoperative patient-level variables considered as at potential risk, including severe ventricular dysfunction, pulmonary hypertension, lung hypoplasia, and undiagnosed severe coronary abnormalities. Four patients (10%) had no identified preoperative risk factors. After detailed chart review, 5 broad categories were identified: patient-related factors (n = 33; 78%), postoperative infection (n = 13; 31%), postoperative residual lesions (n = 7; 17%), Fontan physiology failure (n = 4; 10%), and unexplained left ventricular failure after tetralogy of Fallot repair (n = 3; 7%). A total of 74% of patients had at least 1 preoperative, intraoperative, or postoperative system deficiency. A total of 50% of surgeries were urgent or emergency. CONCLUSIONS Operative mortality after Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1 to 3 procedures is related to the presence of multifactorial risk patterns (Society of Thoracic Surgeons and non-Society of Thoracic Surgeons-designated patient-level risk factors and variables, broad risk categories, system deficiencies, emergency surgery). A multidisciplinary approach to care, with early recognition and treatment of modifiable additional burdens, could reduce this risk.
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Affiliation(s)
- David Kalfa
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY.
| | - John M Karamichalis
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Sameer K Singh
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Pengfei Jiang
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Brett R Anderson
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Diana Vargas
- Division of Pediatrics, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Tarif Choudhury
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Anthony Habib
- Division of Anesthesiology, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Emile Bacha
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
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7
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Hasan BS, Bhatti A, Mohsin S, Barach P, Ahmed E, Ali S, Amanullah M, Ansong A, Banu T, Beaton A, Bolman RM, Borim BC, Breinholt JP, Callus E, Caputo M, Cardarelli M, Hernandez TC, Croti UA, Ejigu YM, Fenton K, Gomanju A, Harahsheh AS, Hesslein P, Hugo-Hamman C, Khan S, Kpodonu J, Kumar RK, Jenkins KJ, Lakhoo K, Malik M, Nichani S, Novick WM, Overman D, Quenot APM, Patton Bolman C, Pearson D, Raju V, Ross S, Sandoval NF, Sholler G, Sharma R, Shidhika F, Sivalingam S, Verstappen A, Vervoort D, Zühlke LJ, Zheleva B. Recommendations for developing effective and safe paediatric and congenital heart disease services in low-income and middle-income countries: a public health framework. BMJ Glob Health 2023; 8:e012049. [PMID: 37142298 PMCID: PMC10163477 DOI: 10.1136/bmjgh-2023-012049] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/03/2023] [Indexed: 05/06/2023] Open
Abstract
The global burden of paediatric and congenital heart disease (PCHD) is substantial. We propose a novel public health framework with recommendations for developing effective and safe PCHD services in low-income and middle-income countries (LMICs). This framework was created by the Global Initiative for Children's Surgery Cardiac Surgery working group in collaboration with a group of international rexperts in providing paediatric and congenital cardiac care to patients with CHD and rheumatic heart disease (RHD) in LMICs. Effective and safe PCHD care is inaccessible to many, and there is no consensus on the best approaches to provide meaningful access in resource-limited settings, where it is often needed the most. Considering the high inequity in access to care for CHD and RHD, we aimed to create an actionable framework for health practitioners, policy makers and patients that supports treatment and prevention. It was formulated based on rigorous evaluation of available guidelines and standards of care and builds on a consensus process about the competencies needed at each step of the care continuum. We recommend a tier-based framework for PCHD care integrated within existing health systems. Each level of care is expected to meet minimum benchmarks and ensure high-quality and family centred care. We propose that cardiac surgery capabilities should only be developed at the more advanced levels on hospitals that have an established foundation of cardiology and cardiac surgery services, including screening, diagnostics, inpatient and outpatient care, postoperative care and cardiac catheterisation. This approach requires a quality control system and close collaboration between the different levels of care to facilitate the journey and care of every child with heart disease. This effort was designed to guide readers and leaders in taking action, strengthening capacity, evaluating impact, advancing policy and engaging in partnerships to guide facilities providing PCHD care in LMICs.
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Affiliation(s)
- Babar S Hasan
- Division of Cardiothoracic Sciences, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Areesh Bhatti
- Medical College, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Shazia Mohsin
- Division of Cardiothoracic Sciences, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Paul Barach
- Department of Public Health and Anesthesiology, Thomas Jefferson School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Medicine, Sigmund Freud University, Vienna, Austria
| | | | - Sulafa Ali
- Department of Pediatrics and Child Health, University of Khartoum, Khartoum, Sudan
- Department of Pediatrics and Child Health, Sudan Heart Center, Khartoum, Sudan
| | - Muneer Amanullah
- Division of Cardiothoracic Sciences, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Annette Ansong
- Division of Cardiology, Department of Pediatrics, Children's National Hospital, The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
| | - Tahmina Banu
- Department of Pediatric Surgery, Chittagong Research Institute for Children, Chittagong, Bangladesh
| | - Andrea Beaton
- The Heart Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ralph Morton Bolman
- University of Minnesota, Minneapolis, Minnesota, USA
- Team Heart Inc, Newton Highlands, Massachusetts, USA
| | - Bruna Cury Borim
- Department of Pediatrics and Pediatric Surgery, Hospital da Criança e Maternidade, CardioPedBrazil, São José do Rio Preto, Brazil
| | - John P Breinholt
- Division Chief, Pediatric Cardiology, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
| | - Edward Callus
- Clinical Psychology Service, IRCCS Policlinico San Danato, San Donato Milanese, Lombardia, Italy
- Department of Biomedical Sciences, University of Milan, Milan, Italy
| | - Massimo Caputo
- Translational Health Science, University of Bristol, Bristol, UK
| | | | | | - Ulisses Alexandre Croti
- Department of Pediatrics and Pediatric Surgery, Hospital da Criança e Maternidade, CardioPedBrazil, São José do Rio Preto, Brazil
| | - Yayehyirad M Ejigu
- Department of Cardiothoracic Surgery, King Faisal Hospital, Kigali, Rwanda
| | - Kathleen Fenton
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
- NIH, Bethesda, Maryland, USA
| | - Anu Gomanju
- Kathmandu Institute of Child Health, Kathmandu, Nepal
- Global Alliance for Rheumatic and Congenital Hearts, Philadelphia, Pennsylvania, USA
| | - Ashraf S Harahsheh
- Division of Cardiology, Department of Pediatrics, Children's National Hospital, The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
| | | | - Christopher Hugo-Hamman
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Sohail Khan
- Department of Cardiology, National Institute of Cardiovascular Diseases, Karachi, Pakistan
| | - Jacques Kpodonu
- Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Raman Krishna Kumar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Kathy J Jenkins
- Department of Cardiology, Children's Hospital Boston, Boston, Massachusetts, USA
| | - Kokila Lakhoo
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Mahim Malik
- Department of Cardiac Surgery, Rawalpindi Institute of Cardiology, Rawalpindi, Punjab, Pakistan
| | - Sanjiv Nichani
- Leicester Children's Hospital, Leicester, East Midlands, UK
- Healing Little Hearts Global Foundation, Leicester, UK
| | - William M Novick
- University of Tennessee Health Science Center-Global Surgery Institute, Memphis, Tennessee, USA
- William Novick Global Cardiac Alliance, Memphis, Tennessee, USA
| | - David Overman
- Division of Cardiac Surgery, The Children's Heart Clinic, Children's Minnesota, Minneapolis, Minnesota, USA
- Division of Cardiovascular Surgery, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, Minnesota, USA
| | | | | | - Dorothy Pearson
- Global Alliance for Rheumatic and Congenital Hearts, Philadelphia, Pennsylvania, USA
| | | | - Shelagh Ross
- Global Alliance for Rheumatic and Congenital Hearts, Philadelphia, Pennsylvania, USA
| | - Nestor F Sandoval
- Department of Cardiac Surgery, Fundacion cardioinfantil -la Cardio.Instituto de cardiopatías Congenitas, Universidad del Rosario, Bogota, Colombia
| | - Gary Sholler
- Heart Center for Children, Sydney Children's Hospital Network, University of Sydney, Sydney, New South Wales, Australia
| | | | - Fenny Shidhika
- Windhoek Central Hospital, Ministry of Health and Social Services, Windhoek, Namibia
| | | | - Amy Verstappen
- President, Global Alliance for Rheumatic and Congenital Hearts, Memphis, Tennessee, USA
| | - Dominique Vervoort
- Division of Cardiac Surgery, University of Toronto Institute of Health Policy Management and Evaluation, Toronto, Ontario, Canada
| | - Liesl J Zühlke
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- South African Medical Research Council, SAMRC Francie Van Zil Drive Parow, Cape Town, South Africa
- Division of Paediatric Cardiology, Department of Paediatrics Red Cross War Memorial Hospital, University of Cape Town, Cape Town, South Africa
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8
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Comparison of Intraoperative and Discharge Residual Lesion Severity in Congenital Heart Surgery. Ann Thorac Surg 2022; 114:1731-1737. [PMID: 35398038 DOI: 10.1016/j.athoracsur.2022.02.081] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/10/2022] [Accepted: 02/22/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND While the predischarge technical performance score (DC-TPS) is significantly associated with outcomes after congenital cardiac surgery, the utility of the intraoperative TPS (IO-TPS) remains unknown. METHODS This was a single-center retrospective review of consecutive patients who underwent congenital cardiac surgery from January 2011 to December 2019. Intraoperative and predischarge echocardiograms were used to assign IO-TPS and DC-TPS, respectively, for each index operation (class 1, no residua; class 2, minor residua; class 3, major residua). Anatomic modules identifying the principal residual lesion were assigned to all class 2/3 patients. Overall and module-specific TPS comparisons were made. Multivariable regression models with IO-TPS and DC-TPS as separate predictors of postoperative outcomes were compared. RESULTS Of 6201 patients, overall agreement between IO-TPS and DC-TPS was observed in 4251 patients (68.6%); scores were likelier to be worse at discharge (P < .001). Paired comparative analyses revealed that among patients with at least class 2 atrioventricular and semilunar valve residua, IO-TPS was likelier to worsen than improve (both P < .001). Class 3 patients had a higher risk of in-hospital/early mortality (IO-TPS: odds ratio, 7.5; 95% CI, 2.4-23; DC-TPS: odds ratio, 6.6; 95% CI, 3.0-15), postdischarge/late mortality (IO-TPS: hazard ratio [HR], 3.1, 95% CI, 1.3-7.1; DC-TPS: HR, 2.3; 95% CI, 1.2-4.4), and late unplanned reintervention (IO-TPS: HR, 2.8; 95% CI, 1.9-4.0; DC-TPS: HR, 3.4; 95% CI, 2.8-4.2) vs class 1 (all P < .05). IO- and DC-TPS models were equivalent fits for predicting early and late mortality; the latter was a marginally better fit for late reintervention. CONCLUSIONS IO-TPS and DC-TPS are both important adjuncts for quality improvement in congenital cardiac surgery.
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Neutrophil Count as Atrioventricular Block (AVB) Predictor following Pediatric Heart Surgery. Int J Mol Sci 2022; 23:ijms232012409. [PMID: 36293263 PMCID: PMC9604473 DOI: 10.3390/ijms232012409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/07/2022] [Accepted: 10/15/2022] [Indexed: 11/23/2022] Open
Abstract
Neutrophils play a significant role in immune and inflammatory reactions. The preoperative inflammatory activation may have a detrimental effect on postoperative outcomes. The aim of the study was to investigate the relation between preoperative hematological indices on postoperative complications’ risk in pediatric cardiac congenital surgery. The retrospective single center analysis included 93 pediatric patients (48 (65%) males and 45 (35%) females), mean age of 7 (3−30) months referred for cardiac surgery in cardiopulmonary bypass due to functional single ventricle disease (26 procedures), shunts lesions (40 procedures) and cyanotic disease (27 procedures). Among simple hematological indices, the receiver-operating-characteristic curve showed that a neutrophil count below 2.59 K/uL was found as an optimal cut-off point for predicting postoperative atrioventricular block following pediatric cardiac surgery (AUC = 0.845, p < 0.0001) yielding a sensitivity of 100% and a specificity of 65.62%. Preoperative values of neutrophil count below 2.59 K/uL in whole blood analysis can be regarded as a predictive factor (AUC = 0.845, p < 0.0001) for postoperative atrioventricular block in pediatric cardiac surgery.
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10
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Steroid Use for Management of Vasoactive Resistant Shock in Pediatric Cardiac Intensive Care Patients: Experience of the Consortium of Congenital Cardiac Care-Measurement of Nursing Practice. Dimens Crit Care Nurs 2022; 41:151-156. [PMID: 36749864 DOI: 10.1097/dcc.0000000000000520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Although a variety of doses and duration of hydrocortisone have been reported as a treatment modality for congenital heart surgery patients with refractory hypotension, there remains a lack of understanding of the clinical use in pediatric cardiac programs. OBJECTIVES The aim of this study was to describe the current practice of steroid use for refractory hypotension in postoperative congenital heart surgery patients. METHOD Survey participants were recruited from the Consortium of Congenital Cardiac Care-Measurement of Nursing Practice. The survey focused on 4 areas: diagnosis, intervention, duration of therapy, and clinical decision making. Data were summarized using descriptive statistics. RESULTS Among the programs, 24 of 31 (77%) responded, with 21 (95%) using hydrocortisone as a treatment modality. Most, 20 (83%), reported no written clinical guideline for the use of hydrocortisone. Variation in dosing existed as 3 centers (14%) use 50 mg/m2/d, 6 (29%) use 100 mg/m2/d, and 8 (38%) indicated that dosing varies by provider. DISCUSSION Nearly all centers reported using hydrocortisone for the treatment of hypotension refractory to fluid resuscitation and vasoactive medications. Substantial variation in practice exists in areas of diagnosis, dosing, and duration of hydrocortisone. More research is needed to develop a clinical practice guideline to standardize practice.
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11
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Risk Stratification for Congenital Heart Surgery for ICD-10 Administrative Data (RACHS-2). J Am Coll Cardiol 2022; 79:465-478. [PMID: 35115103 PMCID: PMC8962919 DOI: 10.1016/j.jacc.2021.11.036] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/01/2021] [Accepted: 11/08/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND As the cardiac community strives to improve outcomes, accurate methods of risk stratification are imperative. Since adoption of International Classification of Disease-10th Revision (ICD-10) in 2015, there is no published method for congenital heart surgery risk stratification for administrative data. OBJECTIVES This study sought to develop an empirically derived, publicly available Risk Stratification for Congenital Heart Surgery (RACHS-2) tool for ICD-10 administrative data. METHODS The RACHS-2 stratification system was iteratively and empirically refined in a training dataset of Pediatric Health Information Systems claims to optimize sensitivity and specificity compared with corresponding locally held Society of Thoracic Surgeons-Congenital Heart Surgery (STS-CHS) clinical registry data. The tool was validated in a second administrative data source: New York State Medicaid claims. Logistic regression was used to compare the ability of RACHS-2 in administrative data to predict operative mortality vs STAT Mortality Categories in registry data. RESULTS The RACHS-2 system captured 99.6% of total congenital heart surgery registry cases, with 1.0% false positives. RACHS-2 predicted operative mortality in both training and validation administrative datasets similarly to STAT Mortality Categories in registry data. C-statistics for models for operative mortality in training and validation administrative datasets-adjusted for RACHS-2-were 0.76 and 0.84 (95% CI: 0.72-0.80 and 0.80-0.89); C-statistics for models for operative mortality-adjusted for STAT Mortality Categories-in corresponding clinical registry data were 0.75 and 0.84 (95% CI: 0.71-0.79 and 0.79-0.89). CONCLUSIONS RACHS-2 is a risk stratification system for pediatric cardiac surgery for ICD-10 administrative data, validated in 2 administrative-registry-linked datasets. Statistical code is publicly available upon request.
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Rhinovirus Detection in the Nasopharynx of Children Undergoing Cardiac Surgery Is Not Associated With Longer PICU Length of Stay: Results of the Impact of Rhinovirus Infection After Cardiac Surgery in Kids (RISK) Study. Pediatr Crit Care Med 2021; 22:e79-e90. [PMID: 33027243 DOI: 10.1097/pcc.0000000000002522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine whether children with asymptomatic carriage of rhinovirus in the nasopharynx before elective cardiac surgery have an increased risk of prolonged PICU length of stay. STUDY DESIGN Prospective, single-center, blinded observational cohort study. SETTING PICU in a tertiary hospital in The Netherlands. PATIENTS Children under 12 years old undergoing elective cardiac surgery were enrolled in the study after informed consent of the parents/guardians. INTERVENTIONS The parents/guardians filled out a questionnaire regarding respiratory symptoms. On the day of the operation, a nasopharyngeal swab was obtained. Clinical data were collected during PICU admission, and PICU/hospital length of stay were reported. If a patient was still intubated 3 days after operation, an additional nasopharyngeal swab was collected. Nasopharyngeal swabs were tested for rhinovirus and other respiratory viruses with polymerase chain reaction. MEASUREMENTS AND MAIN RESULTS Of the 163 included children, 74 (45%) tested rhinovirus positive. Rhinovirus-positive patients did not have a prolonged PICU length of stay (median 2 d each; p = 0.257). Rhinovirus-positive patients had a significantly shorter median hospital length of stay compared with rhinovirus-negative patients (8 vs 9 d, respectively; p = 0.006). Overall, 97 of the patients (60%) tested positive for one or more respiratory virus. Virus-positive patients had significantly shorter PICU and hospital length of stay, ventilatory support, and nonmechanical ventilation. Virus-negative patients had respiratory symptoms suspected for a respiratory infection more often. In 31% of the children, the parents reported mild upper respiratory complaints a day prior to the cardiac surgery, this was associated with postextubation stridor, but no other clinical outcome measures. CONCLUSIONS Preoperative rhinovirus polymerase chain reaction positivity is not associated with prolonged PICU length of stay. Our findings do not support the use of routine polymerase chain reaction testing for respiratory viruses in asymptomatic children admitted for elective cardiac surgery.
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Extubation Failure and Major Adverse Events Secondary to Extubation Failure Following Neonatal Cardiac Surgery. Pediatr Crit Care Med 2020; 21:e1119-e1125. [PMID: 32804741 DOI: 10.1097/pcc.0000000000002470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the prevalence and consequences of major adverse events secondary to extubation failure after neonatal cardiac surgery. DESIGN A single-center cohort study. SETTING A medical-surgical, 30-bed PICU in Victoria, Australia. PATIENTS One thousand one hundred eighty-eight neonates less than or equal to 28 days old who underwent cardiac surgery from January 2007 to December 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Extubation failure was defined as unplanned reintubation within 72 hours after a planned extubation. Major adverse event was defined as one or more of cardiac arrest, emergency chest reopening, extracorporeal membrane oxygenation, or death within 72 hours after extubation. One hundred fifteen of 1,188 (9.7%) neonates had extubation failure. Hospital mortality was 17.4% and 2.0% in neonates with and without extubation failure. Major adverse event occurred in 12 of 115 reintubated neonates (10.4%). major adverse event included cardiac arrest (n = 10), chest reopening (n = 8), extracorporeal membrane oxygenation (n = 5), and death (n = 0). Cardiovascular compromise accounted for major adverse event in eight: ventricular dysfunction (n = 3), pulmonary overcirculation (n = 2), coronary ischemia (n = 2), cardiac tamponade (n = 1). In a multivariable logistic regression, factors associated with major adverse event were high complexity in cardiac surgery (odds ratio 5.9; 95% CI: 1.1-32.2) and airway anomaly (odds ratio 6.0; 95% CI: 1.1-32.6). Hospital morality was 25% and 17% in reintubated neonates with and without major adverse event. CONCLUSIONS Around 10% of reintubated neonates suffered major adverse event within 72 hours of extubation. Neonates suffering major adverse event had high mortality. Major adverse event should be monitored and reported in future studies of extubation failure. Along with tracking of extubation failure rates, major adverse event secondary to extubation failure may also serve as a key performance indicator for ICUs and registries.
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McSharry B, Straney L, Alexander J, Gentles T, Winlaw D, Beca J, Millar J, Shann F, Wilkins B, Numa A, Stocker C, Erickson S, Slater A. RACHS - ANZ : A Modified Risk Adjustment in Congenital Heart Surgery Model for Outcome Surveillance in Australia and New Zealand. J Am Heart Assoc 2020; 8:e011390. [PMID: 31039662 PMCID: PMC6512128 DOI: 10.1161/jaha.118.011390] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Outcomes for pediatric cardiac surgery are commonly reported from international databases compiled from voluntary data submissions. Surgical outcomes for all children in a country or region are less commonly reported. We aimed to describe the bi‐national population‐based outcome for children undergoing cardiac surgery in Australia and New Zealand and determine whether the Risk Adjustment for Congenital Heart Surgery (RACHS) classification could be used to create a model that accurately predicts in‐hospital mortality in this population. Methods and Results The study was conducted in all children's hospitals performing cardiac surgery in Australia and New Zealand between January 2007 and December 2015. The performance of the original RACHS‐1 model was assessed and compared with an alternative RACHS‐ANZ (Australia and New Zealand) model, developed balancing discrimination with parsimonious variable selection. A total of 14 324 hospital admissions were analyzed. The overall hospital mortality was 2.3%, ranging from 0.5% for RACHS category 1 procedures, to 17.0% for RACHS category 5 or 6 procedures. The original RACHS‐1 model was poorly calibrated with death overpredicted (1161 deaths predicted, 289 deaths observed). The RACHS‐ANZ model had better performance in this population with excellent discrimination (Az‐ROC of 0.830) and acceptable Hosmer and Lemeshow goodness‐of‐fit (P=0.216). Conclusions The original RACHS‐1 model overpredicts mortality in children undergoing heart surgery in the current era. The RACHS‐ANZ model requires only 3 risk variables in addition to the RACHS procedure category, can be applied to a wider range of patients than RACHS‐1, and is suitable to use to monitor regional pediatric cardiac surgery outcomes.
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Affiliation(s)
- Brent McSharry
- 1 Paediatric Intensive Care Unit Starship Children's Hospital Auckland New Zealand
| | - Lahn Straney
- 3 Department of Epidemiology and Preventive Medicine Monash University Melbourne Australia
| | - Janet Alexander
- 4 Australian and New Zealand Intensive Care Society Melbourne Australia
| | - Tom Gentles
- 2 Green Lane Paediatric and Congenital Cardiac Service Starship Children's Hospital Auckland New Zealand
| | - David Winlaw
- 5 Heart Centre for Children The Children's Hospital Westmead Sydney Australia.,7 School of Medicine University of Sydney Australia
| | - John Beca
- 1 Paediatric Intensive Care Unit Starship Children's Hospital Auckland New Zealand
| | - Johnny Millar
- 8 Intensive Care Unit Royal Children's Hospital Melbourne Australia.,9 Department of Paediatrics University of Melbourne Australia
| | - Frank Shann
- 8 Intensive Care Unit Royal Children's Hospital Melbourne Australia.,9 Department of Paediatrics University of Melbourne Australia
| | - Barry Wilkins
- 6 Paediatric Intensive Care Unit The Children's Hospital Westmead Sydney Australia
| | - Andrew Numa
- 10 Paediatric Intensive Care Unit Sydney Children's Hospital Sydney Australia
| | - Christian Stocker
- 11 Paediatric Intensive Care Unit Queensland Children's Hospital Brisbane Australia
| | - Simon Erickson
- 12 Paediatric Intensive Care Unit Perth Children's Hospital Perth Australia
| | - Anthony Slater
- 11 Paediatric Intensive Care Unit Queensland Children's Hospital Brisbane Australia
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15
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Shin HJ, Park YH, Cho BK. Recent Surgical Outcomes of Congenital Heart Disease according to Korea Heart Foundation Data. Korean Circ J 2020; 50:677-690. [PMID: 32212426 PMCID: PMC7390722 DOI: 10.4070/kcj.2019.0364] [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] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/12/2020] [Accepted: 02/26/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES This study presents an update of the surgical outcomes of congenital heart disease (CHD) according to Korea Heart Foundation (KHF) data. METHODS We investigated the data of the 7,305 patients who were economically supported by KHF in 2000-2014. Of them, we analyzed surgical outcomes of the 6,599 patients who underwent CHD surgery. RESULTS The median patient age was 1.9 years (range, 0-71.5 years). Of the 6,599 patients, 5,616 (85.1%) underwent biventricular repair and 983 (14.9%) underwent palliative procedures. The mean Basic Aristotle Score was 6.6±2.2. A complex procedure (defined as Basic Aristotle Score above 6) was performed in 3,368 patients (51.0%). The early mortality rate was 3.8%, while the late mortality rate was 1.8%. Previous reports of the KHF (1984-1999) showed that the early surgical and late mortality rates were 8.6%, and 5.3%, respectively. There were 491 neonates (7.4%); among them, the early mortality rate was 12.2% and late mortality rate was 3.7%. There were 2,617 infants (40.0%); among them, the early mortality rate was 6.0% and the late mortality rate was 2.3%. A total of 591 patients from 30 countries were helped by the KHF. CONCLUSIONS More neonatal surgeries (491 vs. 74 patients) were performed than those in the past (1984-1999). The surgical outcomes were much better than before. Our surgical outcomes revealed that the Republic of Korea has been transformed from a country receiving help to a country that helps other low socioeconomic status countries.
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Affiliation(s)
- Hong Ju Shin
- Department of Thoracic and Cardiovascular Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Young Hwan Park
- Division of Cardiovascular Surgery, Congenital Heart Disease Center, Severance Cardiovascular Hospital, Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea.
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Hornik CP, Gonzalez D, Dumond J, Wu H, Graham EM, Hill KD, Cohen-Wolkowiez M. Population Pharmacokinetic/Pharmacodynamic Modeling of Methylprednisolone in Neonates Undergoing Cardiopulmonary Bypass. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2019; 8:913-922. [PMID: 31646767 PMCID: PMC6930860 DOI: 10.1002/psp4.12470] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 08/21/2019] [Indexed: 12/11/2022]
Abstract
Methylprednisolone is used in neonates to modulate cardiopulmonary bypass (CPB)–induced inflammation, but optimal dosing and exposure are unknown. We used plasma methylprednisolone and interleukin (IL)‐6 and IL‐10 concentrations from neonates enrolled in a randomized trial comparing one vs. two doses of methylprednisolone to develop indirect response population pharmacokinetic/pharmacodynamic models characterizing the exposure–response relationships. We applied the models to simulate methylprednisolone dosages resulting in the desired IL‐6 and ‐10 exposures, known mediators of CPB‐induced inflammation. A total of 64 neonates (median weight 3.2 kg, range 2.2–4.3) contributed 290 plasma methylprednisolone concentrations (range 1.07–12,700 ng/mL) and IL‐6 (0–681 pg/mL) and IL‐10 (0.1–1125 pg/mL). Methylprednisolone plasma exposure following a single 10 mg/kg intravenous dose inhibited IL‐6 and stimulated IL‐10 production when compared with placebo. Higher (30 mg/kg) or more frequent (twice) dosing did not confer additional benefit. Clinical efficacy studies are needed to evaluate the effect of optimized dosing on outcomes.
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Affiliation(s)
- Christoph P Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Julie Dumond
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Huali Wu
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Eric M Graham
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kevin D Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
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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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Fuchs SR, Smith AH, Van Driest SL, Crum KF, Edwards TL, Kannankeril PJ. Incidence and effect of early postoperative ventricular arrhythmias after congenital heart surgery. Heart Rhythm 2018; 16:710-716. [PMID: 30528449 DOI: 10.1016/j.hrthm.2018.11.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Postoperative arrhythmias after pediatric congenital heart disease (CHD) surgery are a known cause of morbidity and are associated with mortality. A comprehensive evaluation of early postoperative ventricular arrhythmias (VAs) after CHD surgery has not been reported. OBJECTIVES We sought to determine the incidence of in-hospital VAs after CHD surgery and assess the clinical relevance of this arrhythmia during the postoperative hospital course. METHODS Patients undergoing CHD surgery at our center from September 2007 through December 2016 were prospectively enrolled. Univariate and multivariate analysis was used to assess the association between postoperative VAs and in-hospital mortality, adjusting for postoperative extracorporeal membrane oxygenation and stage 1 single ventricle palliation operations. RESULTS A total of 2503 postoperative courses in 1835 patients were included. In all, 464 (18.5%) had VAs, of whom 135 (29.1%) received treatment. Monomorphic ventricular tachycardia was the most frequently treated ventricular arrhythmia (TVA; n=91 [62.3%]). TVAs were associated with increased postoperative extracorporeal membrane oxygenation (13.3% vs 5.5%; P < .001) and in-hospital mortality (14.9% vs 4.0%; P < .001). In multivariate analysis, TVA was an independent risk factor for in-hospital mortality (adjusted odds ratio 2.44; 95% confidence interval 1.21-4.92). CONCLUSION Early postoperative VAs after CHD surgery are more common than previously reported. Postoperative VAs are associated with increased in-hospital mortality, and the subgroup of TVAs is an independent risk factor for in-hospital mortality.
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Affiliation(s)
- Sarah R Fuchs
- Department of Pediatrics, Thomas P. Graham Jr. Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Andrew H Smith
- Department of Pediatrics, Thomas P. Graham Jr. Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Pediatrics, Division of Pediatric Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sara L Van Driest
- Department of Pediatrics, Division of General Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kim F Crum
- Department of Pediatrics, Thomas P. Graham Jr. Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd L Edwards
- Department of Medicine, Division of Epidemiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Prince J Kannankeril
- Department of Pediatrics, Thomas P. Graham Jr. Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Garisto C, Ricci Z, Tofani L, Benegni S, Pezzella C, Cogo P. Use of low-dose dexmedetomidine in combination with opioids and midazolam in pediatric cardiac surgical patients: randomized controlled trial. Minerva Anestesiol 2018. [DOI: 10.23736/s0375-9393.18.12213-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Cardiac reoperation: Should that be a marker of quality? J Thorac Cardiovasc Surg 2018; 156:1959-1960. [PMID: 30093151 DOI: 10.1016/j.jtcvs.2018.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 07/10/2018] [Indexed: 11/21/2022]
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Analysis of congenital heart surgery results: A comparison of four risk scoring systems. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2018; 26:200-206. [PMID: 32082735 DOI: 10.5606/tgkdc.dergisi.2018.15083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 02/19/2018] [Indexed: 11/21/2022]
Abstract
Background This study aims to evaluate the surgical results of our clinic according to presumption systems of Risk Adjustment in Congenital Heart Surgery, Aristotle Basic Complexity score, Aristotle Comprehensive Complexity score, and Society of Thoracic Surgeons and European Association for Cardiothoracic Surgery mortality categories and to compare the efficiency of these systems in predicting morbidity and mortality. Methods In the study, classification and the risk scoring were performed with the four different systems for 1,950 patients (1,038 males, 912 females; mean age 5.5 months; range, 1 day to 18 years) who were administered congenital heart surgery between 1 October 2012 and 31 December 2016. The hospital mortality and morbidity were calculated for each category from the four models. The discriminatory ability of the models was determined by calculating the area under the receiver operating characteristic curve and the receiver operating characteristic curves of the four models were compared. Results Median weight of the patients was 7.2 kg (range, 1.8-80 kg). Among the patients, 53% were males and 47.5% were younger than one year of age. Of totally 1,950 operations, mortality was observed in 149 (7.6%) and morbidity was observed in 541 (27.7%). Areas under the receiver operating characteristic curve for mortality were 0.803, 0.795, 0.729, and 0.712 for the Society of Thoracic Surgeons and European Association for Cardiothoracic Surgery mortality categories, Aristotle Comprehensive Complexity, Risk Adjustment in Congenital Heart Surgery, and Aristotle Basic Complexity scores, respectively. Areas under the receiver operating characteristic curve for morbidity were 0.732, 0.731, 0.730, and 0.685 for the Society of Thoracic Surgeons and European Association for Cardiothoracic Surgery mortality categories, Risk Adjustment in Congenital Heart Surgery, Aristotle Comprehensive Complexity, and Aristotle Basic Complexity scores, respectively. Conclusion Society of Thoracic Surgeons and European Association for Cardiothoracic Surgery mortality categories, Risk Adjustment in Congenital Heart Surgery, Aristotle Basic Complexity, and Aristotle Comprehensive Complexity score systems were effective in predicting the morbidities and mortalities of patients who underwent congenital heart surgery and evaluating the performance of the surgical centers. Society of Thoracic Surgeons and European Association for Cardiothoracic Surgery mortality categories were on the forefront due to high feasibility and performance. Aristotle Basic Complexity score system had the lowest performance. Combinations of systems will provide the most benefit during evaluation of results.
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Alam S, Shalini A, Hegde RG, Mazahir R, Jain A. A comparative study of the risk stratification models for pediatric cardiac surgery. EGYPTIAN JOURNAL OF CRITICAL CARE MEDICINE 2018. [DOI: 10.1016/j.ejccm.2018.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Wallen TJ, Arnaoutakis GJ, Blenden R, Soto R. Programmatic Changes to Reduce Mortality and Morbidity in Humanitarian Congenital Cardiac Surgery. World J Pediatr Congenit Heart Surg 2018; 9:47-53. [DOI: 10.1177/2150135117737686] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: This report documents the outcomes of cardiac surgical mission trips organized by the International Children's Heart Foundation (ICHF), a nongovernmental organization that provides congenital heart surgery services to the developing world, and discusses factors associated with a reduction of mortality and morbidity in this setting. Methods: A retrospective review of a prospectively maintained database was conducted to identify any patient who underwent surgical intervention during the course of an ICHF mission trip. Results: From 2008 to 2016, a total of 223 trips were made to 23 countries and 3,783 operations were performed. Over 40 unique types of operations were performed with repairs of atrial septal defects (ASDs; n = 479), ventricular septal defects (VSDs; n = 760), teratology of Fallot (n = 473), and ligation of patient ductus arteriosus (PDA; n = 242), comprising the majority of cases. Several organizational policy changes were instituted in 2015. These include the requirement of the host site to have a fully functional blood bank and access to medical subspecialties, the ICHF providing 24-hour intensivist coverage, and not performing surgery on patients weighing less than 10 kg until local capacity has been developed. The overall mortality rate fell to 2.3% from 8.1% after the implementation of these policies. The mortality for ASD repair, VSD repair, PDA ligation, and the repair of tetralogy of Fallot fell from 1.2% to 0%, 1.8% to 0%, 0% to 0%, and 5.6% to 5.1%, respectively. The reoperation rate fell from 11% to 3% and reoperation for a bleeding indication fell from 6% to 2%. Conclusions: Programmatic-level changes have been associated with reduced rates of mortality and morbidity in humanitarian congenital cardiac surgery.
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Affiliation(s)
- Tyler J. Wallen
- Department of Surgery, Mercy Catholic Medical Center, Philadelphia, PA, USA
| | | | - Randa Blenden
- The International Children’s Heart Foundation, Memphis, TN, USA
| | - Rodrigo Soto
- The International Children’s Heart Foundation, Memphis, TN, USA
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Peterson JK, Chen Y, Nguyen DV, Setty SP. Current trends in racial, ethnic, and healthcare disparities associated with pediatric cardiac surgery outcomes. CONGENIT HEART DIS 2017; 12:520-532. [PMID: 28544396 DOI: 10.1111/chd.12475] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/10/2017] [Accepted: 04/22/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Despite overall improvements in congenital heart disease outcomes, racial and ethnic disparities have continued. The purpose of this study is to examine the effect of race and ethnicity, as well as other risk factors on congenital heart surgery length of stay and in-hospital mortality. DESIGN From the 2012 Healthcare Cost and Utilization Project Kids Inpatient Database (KID), we identified 13 130 records with Risk Adjustment in Congenital Heart Surgery complexity score-eligible procedures. Multivariate logistic and linear regression modeling with survey weights, stratification and clustering was used to examine the relationships between predictor variables and length of stay as well as in-hospital mortality. RESULTS No significant mortality differences were found among all race and ethnicity groups across each age group. Black neonates and black infants had a longer length of stay (neonatal estimate = 8.73 days, P = .0034; infant estimate 1.10 days, P = .0253), relative to whites. Government-sponsored insurance was associated with increased odds of neonatal mortality (odds ratio = 1.51, P = .0055), increased length of stay in neonates (estimate = 4.26 days, P = .0009) and infants (estimate = 1.52 days, P = .0181), relative to private insurance. Government-sponsored insurance was associated with increased number of chronic conditions, which were also associated with increased LOS (estimate 8.39 days, P < .001 in neonates; estimate 3.60 days, P < .001 in infants; estimate 1.87 days, P < .001 children). CONCLUSIONS Racial/ethnic disparities in congenital heart surgical outcomes may be changing compared with previous studies using the KID database. Increased length of stay in children with government-sponsored insurance may reflect expansion of individual states government-sponsored insurance eligibility criteria for children with complex chronic medical conditions. These findings warrant cautious optimism regarding racial and ethnic disparities in congenital heart surgery outcomes.
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Affiliation(s)
- Jennifer K Peterson
- Long Beach Memorial Hospital/Miller Children's and Women's Hospital, Long Beach, California, USA
| | - Yanjun Chen
- Biostatistics, Epidemiology, and Research Design Unit, University of California, Irvine, California, USA
| | - Danh V Nguyen
- Department of Medicine, University of California, Irvine School of Medicine, Orange, California, USA
| | - Shaun P Setty
- Long Beach Memorial Hospital/Miller Children's and Women's Hospital, Long Beach, California, USA
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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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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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Balasubramanian S, Kipps AK, Smith SN, Tacy TA, Selamet Tierney ES. Pediatric Echocardiography by Work Relative Value Units: Is Study Complexity Adequately Captured? J Am Soc Echocardiogr 2016; 29:1084-1091. [DOI: 10.1016/j.echo.2016.05.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Indexed: 11/27/2022]
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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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Ramachandran P, Woo JG, Ryan TD, Bryant R, Heydarian HC, Jefferies JL, Towbin JA, Lorts A. The Impact of Concomitant Left Ventricular Non-compaction with Congenital Heart Disease on Perioperative Outcomes. Pediatr Cardiol 2016; 37:1307-12. [PMID: 27357002 DOI: 10.1007/s00246-016-1435-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 06/17/2016] [Indexed: 10/21/2022]
Abstract
Left ventricular non-compaction (LVNC) is a heterogeneous myocardial disorder characterized by prominent trabeculations and inter-trabecular recesses which may occur in association with congenital heart disease (CHD). To date, few studies have been performed to assess whether the concomitant diagnosis of LVNC affects the outcomes of CHD surgery. A retrospective review of patients with LVNC with CHD (LVNC-CHD), 0-5 years of age, was conducted. Patients with CHD without LVNC (CHD-only) and 0-5 years of age with similar diagnosis distribution were selected for comparison. Perioperative data, including CHD diagnosis, operative course, and postoperative complications were collected and compared between groups. LVNC-CHD was diagnosed in 26 children. Of the 26 with LVNC-CHD, 20 underwent surgery and these patients were compared with 276 CHD-only controls. Median total length of stay in the hospital was 12.5 days (IQR 5.5-63 days) in LVNC-CHD compared to 5 days (IQR 3-10 days) in CHD-only (p < 0.005). Postoperative death, cardiac arrest, or need for ECMO or transplantation occurred in 6/20 (30 %) of the LVNC-CHD patients compared to 3/276 (1 %) of the CHD-only group (p < 0.0001). LVNC-CHD patients had significantly longer hospital length of stay and higher perioperative complications compared to CHD-only patients without myocardial abnormalities. Pediatric cardiac care teams should be cognizant of the possibility of the increased perioperative risk associated with concomitant LVNC. Future prospective studies are warranted.
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Affiliation(s)
- Preeti Ramachandran
- The Heart Institute, Cincinnati Children's Hospital, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
| | - Jessica G Woo
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Thomas D Ryan
- The Heart Institute, Cincinnati Children's Hospital, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Roosevelt Bryant
- Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Haleh C Heydarian
- The Heart Institute, Cincinnati Children's Hospital, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - John L Jefferies
- The Heart Institute, Cincinnati Children's Hospital, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Jeffrey A Towbin
- The Heart Institute, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
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Jacobs JP, Jacobs ML. Transparency and Public Reporting of Pediatric and Congenital Heart Surgery Outcomes in North America. World J Pediatr Congenit Heart Surg 2016; 7:49-53. [PMID: 26714994 DOI: 10.1177/2150135115619161] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Health care is embarking on a new era of increased transparency. In January 2015, the Society of Thoracic Surgeons (STS) began to publicly report outcomes of pediatric and congenital cardiac surgery using the 2014 Society of Thoracic Surgeons Congenital Heart Surgery Database (STS CHSD) Mortality Risk Model. Because the 2014 STS CHSD Mortality Risk Model adjusts for procedural factors and patient-level factors, it is critical that centers are aware of the important impact of incomplete entry of data in the fields for patient-level factors. These factors are used to estimate expected mortality, and incomplete coding of these factors can lead to inaccurate assessment of case mix and estimation of expected mortality. In order to assure an accurate assessment of case mix and estimate of expected mortality, it is critical to assure accurate completion of the fields for patient factors, including preoperative factors. It is crucial to document variables such as whether the patient was preoperatively ventilated or had an important noncardiac congenital anatomic abnormality. The lack of entry of these variables will lead to an underestimation of expected mortality. The art and science of assessing outcomes of pediatric and congenital cardiac surgery continues to evolve. In the future, when models have been developed that encompass other outcomes in addition to mortality, pediatric and congenital cardiac surgical performance may be able to be assessed using a multidomain composite metric that incorporates both mortality and morbidity, adjusting for the operation performed and for patient-specific factors. It is our expectation that in the future, this information will also be publicly reported. In this era of increased transparency, the complete and accurate coding of both patient-level factors and procedure-level factors is critical.
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Affiliation(s)
- Jeffrey P Jacobs
- 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, FL, USA Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Marshall L Jacobs
- 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, FL, USA Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Outcomes Analysis and Quality Improvement in Children With Congenital and Acquired Cardiovascular Disease. Pediatr Crit Care Med 2016; 17:S362-6. [PMID: 27490624 DOI: 10.1097/pcc.0000000000000785] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES In this review, the current state of outcomes analysis and quality improvement in children with acquired and congenital cardiovascular disease will be discussed, with an emphasis on defining and measuring outcomes and quality in pediatric cardiac critical care medicine and risk stratification systems. DATA SOURCE MEDLINE and PubMed CONCLUSION : Measuring quality and outcomes in the pediatric cardiac critical care environment is challenging owing to many inherent obstacles, including a diverse patient mix, difficulty in determining how the care of the ICU team contributes to outcomes, and the lack of an adequate risk-adjustment method for pediatric cardiac critical care patients. Despite these barriers, new solutions are emerging that capitalize on lessons learned from other quality improvement initiatives, providing opportunities to build upon previous successes.
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O'Connor AM, Wray J, Tomlinson RS, Cassedy A, Jacobs JP, Jenkins KJ, Brown KL, Franklin RCG, Mahony L, Mussatto K, Newburger JW, Wernovsky G, Ittenbach RF, Drotar D, Marino BS. Impact of Surgical Complexity on Health-Related Quality of Life in Congenital Heart Disease Surgical Survivors. J Am Heart Assoc 2016; 5:e001234. [PMID: 27451455 PMCID: PMC5015349 DOI: 10.1161/jaha.114.001234] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 05/03/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Surgical complexity and related morbidities may affect long-term patient quality of life (QOL). Aristotle Basic Complexity (ABC) score and Risk Adjustment in Congenital Heart Surgery (RACHS-1) category stratify the complexity of pediatric cardiac operations. The purpose of this study was to examine the relationship between surgical complexity and QOL and to investigate other demographic and clinical variables that might explain variation in QOL in pediatric cardiac surgical survivors. METHODS AND RESULTS Pediatric Cardiac Quality of Life (PCQLI) study participants who had undergone cardiac surgery were included. The PCQLI database provided sample characteristics and QOL scores. Surgical complexity was defined by the highest ABC raw score or RACHS-1 category. Relationships among surgical complexity and demographic, clinical, and QOL variables were assessed using ordinary least squares regression. A total of 1416 patient-parent pairs were included. Although higher ABC scores and RACHS-1 categories were associated with lower QOL scores (P<0.005), correlation with QOL scores was poor to fair (r=-0.10 to -0.29) for all groups. Ordinary least squares regression showed weak association with R(2)=0.06 to R(2)=0.28. After accounting for single-ventricle anatomy, number of doctor visits, and time since last hospitalization, surgical complexity scores added no additional explanation to the variance in QOL scores. CONCLUSIONS ABC scores and RACHS-1 categories are useful tools for morbidity and mortality predictions prior to cardiac surgery and quality of care initiatives but are minimally helpful in predicting a child's or adolescent's long-term QOL scores. Further studies are warranted to determine other predictors of QOL variation.
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Affiliation(s)
- Amy M O'Connor
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jo Wray
- Cardiorespiratory Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK Department of Pediatric Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Ryan S Tomlinson
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Amy Cassedy
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jeffrey P Jacobs
- Division of Thoracic and Cardiovascular Surgery, The Congenital Heart Institute of Florida, All Children's Hospital and Children's Hospital of Tampa, University of South Florida College of Medicine, Cardiac Surgical Associates, St. Petersburg and Tampa, FL
| | - Kathy J Jenkins
- Department of Cardiology, Children's Hospital Boston, Harvard Medical School, Boston, MA Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kate L Brown
- Cardiorespiratory Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Rodney C G Franklin
- Department of Pediatric Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Lynn Mahony
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kathleen Mussatto
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Wisconsin, Milwaukee, WI
| | - Jane W Newburger
- Department of Cardiology, Children's Hospital Boston, Harvard Medical School, Boston, MA Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Gil Wernovsky
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, PA Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, PA
| | - Richard F Ittenbach
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Dennis Drotar
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Bradley S Marino
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Fuller S, Jacobs JP. Congenital Heart Surgery in Adults: The Challenge of Estimation of Risk of Mortality. World J Pediatr Congenit Heart Surg 2016; 7:436-9. [PMID: 27358297 DOI: 10.1177/2150135116656122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 06/02/2016] [Indexed: 11/15/2022]
Affiliation(s)
- Stephanie Fuller
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, Johns Hopkins All Children's Hospital, St Petersburg, FL, USA Florida Hospital for Children, Orlando, FL, USA Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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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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Cavalcante CTDMB, de Souza NMG, Pinto Júnior VC, Branco KMPC, Pompeu RG, Teles ACDO, Cavalcante RC, de Andrade GV. Analysis of Surgical Mortality for Congenital Heart Defects Using RACHS-1 Risk Score in a Brazilian Single Center. Braz J Cardiovasc Surg 2016; 31:219-225. [PMID: 27737404 PMCID: PMC5062711 DOI: 10.5935/1678-9741.20160022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 02/11/2016] [Indexed: 11/29/2022] Open
Abstract
Introduction Risk Adjustment for Congenital Heart Surgery 1 (RACHS-1) score is a simple model that can be easily applied and has been widely used for mortality comparison among pediatric cardiovascular services. It is based on the categorization of several surgical palliative or corrective procedures, which have similar mortality in the treatment of congenital heart disease. Objective To analyze the in-hospital mortality in pediatric patients (<18 years) submitted to cardiac surgery for congenital heart disease based on RACHS-1 score, during a 12-year period. Methods A retrospective date analysis was performed from January 2003 to December 2014. The survey was divided in two periods of six years long each, to check for any improvement in the results. We evaluated the numbers of procedures performed, complexity of surgery and hospital mortality. Results Three thousand and two hundred and one surgeries were performed. Of these, 3071 were able to be classified according to the score RACHS-1. Among the patients, 51.7% were male and 47.5% were younger than one year of age. The most common RACHS-1 category was 3 (35.5%). The mortality was 1.8%, 5.5%, 14.9%, 32.5% and 68.6% for category 1, 2, 3, 4 and 6, respectively. There was a significant increase in the number of surgeries (48%) and a significant reduction in the mortality in the last period analysed (13.3% in period I and 10.4% in period II; P=0.014). Conclusion RACHS-1 score was a useful score for mortality risk in our service, although we are aware that other factors have an impact on the total mortality.
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Goldsworthy M, Franich-Ray C, Kinney S, Shekerdemian L, Beca J, Gunn J. Relationship between Social-Emotional and Neurodevelopment of 2-Year-Old Children with Congenital Heart Disease. CONGENIT HEART DIS 2015; 11:378-385. [PMID: 26680016 DOI: 10.1111/chd.12320] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this study was to describe social-emotional outcomes and the relationship with neurodevelopmental outcomes in a cohort of 2-year-old children who underwent surgery for congenital heart disease (CHD) in infancy, and explore the relationship between the outcomes and parental and surgical factors. DESIGN A two-center prospective cross-sectional cohort study. PATIENTS A cohort of 105 2-year-olds who underwent surgery in infancy for severe CHD MEASURES: Social-emotional and neurodevelopment was evaluated with the Infant and Toddler Social and Emotional Assessment tool (ITSEA), and the Bayley Scales of Infant Toddler Development, Third Edition. RESULTS Neurodevelopment was delayed in the CHD cohort with significantly worse results compared to published Australian-based norms in all domains (P < .001) and in the Cognitive (P < .001) and Language (P < .001) domains with respect to the reported American norms. Social-emotional outcome was similar to Australian norms in all domains but better than the American based norms in the Internalizing domain (P < .05). Higher maternal education was associated to better neurodevelopmental outcome in all domains and better scores in the internalizing and externalizing domains of the ITSEA. There was a moderate correlation (r = 0.43, P < .001) between Language and social-emotional competence. Motor development was influenced by the need for a significant cardiac reoperation. CONCLUSIONS The influences of social factors may be underestimated in the outcome of children with CHD. Language development in those with CHD may be improved with intervention targeting social-emotional competence; further research is needed in this area.
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Affiliation(s)
- Michelle Goldsworthy
- The University of Melbourne, Melbourne, Australia.,Baylor College of Medicine, Houston, Tex, USA
| | - Candice Franich-Ray
- The Royal Children's Hospital, Melbourne, Australia, New Zealand.,Murdoch Childrens Research Institute, Melbourne, Australia
| | - Sharon Kinney
- The University of Melbourne, Melbourne, Australia.,The Royal Children's Hospital, Melbourne, Australia, New Zealand
| | | | - John Beca
- Starship Children's Health, Auckland, New Zealand
| | - Julia Gunn
- The University of Melbourne, Melbourne, Australia. .,The Royal Children's Hospital, Melbourne, Australia, New Zealand. .,Murdoch Childrens Research Institute, Melbourne, Australia.
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The science of assessing the outcomes and improving the quality of the congenital and paediatric cardiac care. Curr Opin Cardiol 2015; 30:100-11. [PMID: 25469591 DOI: 10.1097/hco.0000000000000133] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Although significant progress has been made in the care of patients with paediatric and congenital cardiac disease, optimization of outcomes remains a constant goal. This review article will discuss the latest advances in the science of assessing the outcomes and improving the quality of the congenital and paediatric cardiac care, and will also review some of the latest associated research. RECENT FINDINGS Important advances continue to be made in each of the following domains: standardized nomenclature; established uniform core dataset; evaluation of case complexity; verification of the completeness and accuracy of the data; collaboration between subspecialties; strategies for longitudinal follow-up; and incorporating quality improvement. In January 2015, the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) will begin voluntary public reporting of programmatic congenital cardiac surgical outcomes using a new risk model that includes both procedural risk (as defined by the procedure itself and STAT Categories) and a number of patient-specific characteristics including age, weight, prior cardiothoracic operation, prematurity, chromosomal abnormalities, syndromes, noncardiac congenital anatomic abnormalities and preoperative factors. Clinical databases have been linked with administrative database to answer questions neither dataset can answer independently, providing new information about long-term mortality, rates of rehospitalization, long-term morbidity, comparative effectiveness of various treatments, and the cost of healthcare. Multiple research initiatives have recently been published using STS-CHSD. SUMMARY The science of assessing the outcomes and improving the quality of congenital and paediatric cardiac care continues to evolve. Recent advances will facilitate the continued evolution of a meaningful method of multiinstitutional outcomes analysis for congenital and paediatric cardiac surgery.
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Abstract
PURPOSE This review aims to outline a systematic approach for the assessment of quality of life in children and adolescents with CHD and to cite its main determinants. METHODS A systematic critical literature search in PubMed, Scopus, and Cinahl databases resulted in 954 papers published after 2000. After the quality assessment, 32 original articles met the inclusion criteria. RESULTS Methodological quality of the included studies varied greatly, showing a moderate quality. Impaired quality of life was associated with more severe cardiac lesions. Children with CHD, after cardiac surgery, reported diminished quality of life concerning physical, psycho-social, emotional, and school functioning. The majority of clinical studies showed significant differences among children and their parents' responses regarding their quality of life, with a tendency of children to report greater quality of life scores than their parents. According to our analysis, concerning children with CHD, the most cited determinants of their quality of life were as follows: (a) parental support; (b) lower socio-economic status; (c) limitations due to physical impairment; (d) sense of coherence; as well as (e) the level of child's everyday anxiety and depression. These findings suggest that differences in quality of life issues may exist across lesion severities. CONCLUSION Quality of life in children with CHD should be assessed according to age; severity; therapeutic approach; acceptance of the disease; and personality features. Effective management and early recognition of significant impairments in quality of life could impact clinical outcomes in children with CHD.
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Danford DA, Martin AB, Danford CJ, Kaul S, Marshall AM, Kutty S. Clinical Implications of a Multivariate Stratification Model for the Estimation of Prognosis in Ventricular Septal Defect. J Pediatr 2015; 167:103-7.e1-2. [PMID: 25935817 DOI: 10.1016/j.jpeds.2015.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 03/02/2015] [Accepted: 04/02/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To derive and validate a multivariate stratification model for prediction of survival free from intervention (SFFI) in ventricular septal defect (VSD). A secondary aim is for this model to serve as proof of concept for derivation of a more general congenital heart disease prognostic model, of which the VSD model will be the first component. STUDY DESIGN For 12 years, 2334 subjects with congenital heart disease were prospectively and consecutively enrolled. Of these, 675 had VSD and form the derivation cohort. One hundred seven other subjects with VSD followed in another practice formed the validation cohort. The derivation cohort was serially stratified based on clinical and demographic features correlating with SFFI. RESULTS Six strata were defined, the most favorable predicting nearly 100% SFFI at 10 years, and the least favorable, a high likelihood of event within weeks. Strata with best SFFI had many subjects with nearly normal physiology, muscular VSD location, or prior intervention. In the validation cohort, the relation between predicted and actual SFFI at 6 months, 1 year, 2 years, and 5 years follow-up had areas under the receiver operating characteristic curves 0.800 or greater. CONCLUSIONS A prediction model for SFFI in VSD has been derived and validated. It has potential for clinical application to the benefit of patients and families, medical trainees, and practicing physicians.
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Affiliation(s)
- David A Danford
- University of Nebraska Medical Center College of Medicine, Children's Hospital and Medical Center, Omaha, NE
| | - Ameeta B Martin
- Department of Cardiology, St. Elizabeth Hospital, Lincoln, NE
| | | | - Sheetal Kaul
- University of Nebraska Medical Center College of Medicine, Children's Hospital and Medical Center, Omaha, NE
| | - Amanda M Marshall
- University of Nebraska Medical Center College of Medicine, Children's Hospital and Medical Center, Omaha, NE
| | - Shelby Kutty
- University of Nebraska Medical Center College of Medicine, Children's Hospital and Medical Center, Omaha, NE.
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Cavalcanti PEF, Sá MPBDO, dos Santos CA, Esmeraldo IM, Chaves ML, Lins RFDA, Lima RDC. Stratification of complexity in congenital heart surgery: comparative study of the Risk Adjustment for Congenital Heart Surgery (RACHS-1) method, Aristotle basic score and Society of Thoracic Surgeons-European Association for Cardio- Thoracic Surgery (STS-EACTS) mortality score. Braz J Cardiovasc Surg 2015; 30:148-58. [PMID: 26107445 PMCID: PMC4462959 DOI: 10.5935/1678-9741.20150001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 01/13/2015] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To determine whether stratification of complexity models in congenital heart surgery (RACHS-1, Aristotle basic score and STS-EACTS mortality score) fit to our center and determine the best method of discriminating hospital mortality. METHODS Surgical procedures in congenital heart diseases in patients under 18 years of age were allocated to the categories proposed by the stratification of complexity methods currently available. The outcome hospital mortality was calculated for each category from the three models. Statistical analysis was performed to verify whether the categories presented different mortalities. The discriminatory ability of the models was determined by calculating the area under the ROC curve and a comparison between the curves of the three models was performed. RESULTS 360 patients were allocated according to the three methods. There was a statistically significant difference between the mortality categories: RACHS-1 (1) - 1.3%, (2) - 11.4%, (3)-27.3%, (4) - 50 %, (P<0.001); Aristotle basic score (1) - 1.1%, (2) - 12.2%, (3) - 34%, (4) - 64.7%, (P<0.001); and STS-EACTS mortality score (1) - 5.5 %, (2) - 13.6%, (3) - 18.7%, (4) - 35.8%, (P<0.001). The three models had similar accuracy by calculating the area under the ROC curve: RACHS-1- 0.738; STS-EACTS-0.739; Aristotle- 0.766. CONCLUSION The three models of stratification of complexity currently available in the literature are useful with different mortalities between the proposed categories with similar discriminatory capacity for hospital mortality.
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Affiliation(s)
- Paulo Ernando Ferraz Cavalcanti
- Division of Cardiovascular Surgery of Pronto Socorro
Cardiológico de Pernambuco (PROCAPE) and Universidade de Pernambuco (UPE),
Recife, PE, Brazil
| | - Michel Pompeu Barros de Oliveira Sá
- Division of Cardiovascular Surgery of Pronto Socorro
Cardiológico de Pernambuco (PROCAPE) and Universidade de Pernambuco (UPE),
Recife, PE, Brazil
| | - Cecília Andrade dos Santos
- Division of Cardiovascular Surgery of Pronto Socorro
Cardiológico de Pernambuco (PROCAPE) and Universidade de Pernambuco (UPE),
Recife, PE, Brazil
| | - Isaac Melo Esmeraldo
- Division of Cardiovascular Surgery of Pronto Socorro
Cardiológico de Pernambuco (PROCAPE) and Universidade de Pernambuco (UPE),
Recife, PE, Brazil
| | - Mariana Leal Chaves
- Division of Cardiovascular Surgery of Pronto Socorro
Cardiológico de Pernambuco (PROCAPE) and Universidade de Pernambuco (UPE),
Recife, PE, Brazil
| | - Ricardo Felipe de Albuquerque Lins
- Division of Cardiovascular Surgery of Pronto Socorro
Cardiológico de Pernambuco (PROCAPE) and Universidade de Pernambuco (UPE),
Recife, PE, Brazil
| | - Ricardo de Carvalho Lima
- Division of Cardiovascular Surgery of Pronto Socorro
Cardiológico de Pernambuco (PROCAPE), Universidade de Pernambuco (UPE),
Recife, PE, Brazil and Escola Paulista de Medicina da Universidade Federal de
São Paulo (EPM/Unifesp), São Paulo, SP, Brazil
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Brown KL, Crowe S, Franklin R, McLean A, Cunningham D, Barron D, Tsang V, Pagel C, Utley M. Trends in 30-day mortality rate and case mix for paediatric cardiac surgery in the UK between 2000 and 2010. Open Heart 2015; 2:e000157. [PMID: 25893099 PMCID: PMC4395835 DOI: 10.1136/openhrt-2014-000157] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 11/28/2014] [Accepted: 01/20/2015] [Indexed: 11/07/2022] Open
Abstract
Objectives To explore changes over time in the 30-day mortality rate for paediatric cardiac surgery and to understand the role of attendant changes in the case mix. Methods, setting and participants Included were: all mandatory submissions to the National Institute of Cardiovascular Outcomes Research (NICOR) relating to UK cardiac surgery in patients aged <16 years. The χ2 test for trend was used to retrospectively analyse the proportion of surgical episodes ending in 30-day mortality and with various case mix indicators, in 10 consecutive time periods, from 2000 to 2010. Comparisons were made between two 5-year eras of: 30-day mortality, period prevalence and mean age for 30 groups of specific operations. Main outcome measure 30-day mortality for an episode of surgical management. Results Our analysis includes 36 641 surgical episodes with an increase from 2283 episodes in 2000 to 3939 in 2009 (p<0.01). The raw national 30-day mortality rate fell over the period of review from 4.3% (95% CI 3.5% to 5.1%) in 2000 to 2.6% (95% CI 2.2% to 3.0%) in 2009/2010 (p<0.01). The case mix became more complex in terms of the percentage of patients <2.5 kg (p=0.05), with functionally univentricular hearts (p<0.01) and higher risk diagnoses (p<0.01). In the later time era, there was significant improvement in 30-day mortality for arterial switch with ventricular septal defect (VSD) repair, patent ductus arteriosus ligation, Fontan-type operation, tetralogy of Fallot and VSD repair, and the mean age of patients fell for a range of operations performed in infancy. Conclusions The raw 30-day mortality rate for paediatric cardiac surgery fell over a decade despite a rise in the national case mix complexity, and compares well with international benchmarks. Definitive repair is now more likely at a younger age for selected infants with congenital heart defects.
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Affiliation(s)
- Katherine L Brown
- Cardiac Unit , Great Ormond Street Hospital for Children , London , UK ; Institute for Cardiovascular Science, University College London, London , UK
| | - Sonya Crowe
- Clinical Operational Research Unit , University College London , London , UK
| | - Rodney Franklin
- Department of Paediatric Cardiology , Royal Brompton and Harefield NHS Foundation Trust , London , UK
| | - Andrew McLean
- Cardiac Surgery Department , The Royal Hospital for Sick Children , Glasgow , UK
| | - David Cunningham
- National Institute for Cardiac Outcomes Research (NICOR), University College London , London , UK
| | - David Barron
- Cardiac Surgery Department , Birmingham Children's Hospital , Birmingham , UK
| | - Victor Tsang
- Cardiac Unit , Great Ormond Street Hospital for Children , London , UK ; Institute for Cardiovascular Science, University College London, London , UK
| | - Christina Pagel
- Clinical Operational Research Unit , University College London , London , UK
| | - Martin Utley
- Clinical Operational Research Unit , University College London , London , UK
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Pasquali SK, He X, Jacobs JP, Jacobs ML, Gaies MG, Shah SS, Hall M, Gaynor JW, Peterson ED, Mayer JE, Hirsch-Romano JC. Measuring hospital performance in congenital heart surgery: administrative versus clinical registry data. Ann Thorac Surg 2015; 99:932-8. [PMID: 25624057 DOI: 10.1016/j.athoracsur.2014.10.069] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 10/23/2014] [Accepted: 10/31/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND In congenital heart surgery, hospital performance has historically been assessed using widely available administrative data sets. Recent studies have demonstrated inaccuracies in case ascertainment (coding and inclusion of eligible cases) in administrative versus clinical registry data; however, it is unclear whether this impacts assessment of performance on a hospital level. METHODS Merged data from The Society of Thoracic Surgeons (STS) database (clinical registry) and the Pediatric Health Information Systems (PHIS) database (administrative data set) for 46,056 children undergoing cardiac operations (2006-2010) were used to evaluate in-hospital mortality for 33 hospitals based on their administrative versus registry data. Standard methods to identify/classify cases were used: Risk Adjustment in Congenital Heart Surgery, version 1 (RACHS-1) in the administrative data and STS-European Association for Cardiothoracic Surgery (STAT) methodology in the registry. RESULTS Median hospital surgical volume based on the registry data was 269 cases per year; mortality was 2.9%. Hospital volumes and mortality rates based on the administrative data were on average 10.7% and 4.7% lower, respectively, although this varied widely across hospitals. Hospital rankings for mortality based on the administrative versus registry data differed by 5 or more rank positions for 24% of hospitals, with a change in mortality tertile classification (high, middle, or low mortality) for 18% and a change in statistical outlier classification for 12%. Higher volume/complexity hospitals were most impacted. Agency for Healthcare Quality and Research (AHRQ) methods in the administrative data yielded similar results. CONCLUSIONS Inaccuracies in case ascertainment in administrative versus clinical registry data can lead to important differences in assessment of hospital mortality rates for congenital heart surgery.
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Affiliation(s)
- Sara K Pasquali
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Xia He
- Duke Clinical Research Institute, Durham, North Carolina
| | - Jeffrey P Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael G Gaies
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
| | - Samir S Shah
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Matthew Hall
- Children's Hospital Association, Overland Park, Kansas
| | - J William Gaynor
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - John E Mayer
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Massachusetts
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Predicting economic and medical outcomes based on risk adjustment for congenital heart surgery classification of pediatric cardiovascular surgical admissions. Am J Cardiol 2014; 114:1740-4. [PMID: 25304977 DOI: 10.1016/j.amjcard.2014.09.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 09/02/2014] [Accepted: 09/02/2014] [Indexed: 11/22/2022]
Abstract
The Risk Adjustment for Congenital Heart Surgery (RACHS-1) classification is an established method for predicting mortality for congenital heart disease surgery. It is unknown if this extends to the cost of hospitalization or if differences in economic and medical outcomes exist in certain subpopulations. Using data obtained from the University HealthSystem Consortium, we examined inpatient resource use by patients with International Classification of Diseases, Ninth Revision, procedure codes representative of RACHS-1 classifications 1 through 5 and 6 from 2006 to 2012. A total of 15,453 pediatric congenital heart disease surgical admissions were analyzed, with overall mortality of 4.5% (n = 689). As RACHS-1 classification increased, the total cost of hospitalization, hospital charges, total length of stay, length of intensive care unit stay, and mortality increased. Even when controlled for RACHS-1 classification, black patients (n = 2034) had higher total costs ($96,884 ± $3,392, p = 0.003), higher charges ($318,313 ± $12,018, p <0.001), and longer length of stay (20.4 ± 0.7 days, p <0.001) compared with white patients ($85,396 ± $1,382, $285,622 ± $5,090, and 18.0 ± 0.3 days, respectively). Hispanic patients had similarly disparate outcomes ($104,292 ± $2,759, $351,371 ± $10,627, and 23.0 ± 0.6 days, respectively) and also spent longer in the intensive care unit (14.9 ± 0.5 days, p <0.001). In conclusion, medical and economic measures increased predictably with increased procedure risk, and admissions for black and Hispanic patients were longer and more expensive than those of their white counterparts but without increased mortality.
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Murakami A, Hirata Y, Motomura N, Miyata H, Iwanaka T, Takamoto S. The national clinical database as an initiative for quality improvement in Japan. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2014; 47:437-43. [PMID: 25346898 PMCID: PMC4207111 DOI: 10.5090/kjtcs.2014.47.5.437] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 08/21/2014] [Accepted: 08/22/2014] [Indexed: 12/03/2022]
Abstract
The JCVSD (Japan Cardiovascular Surgery Database) was organized in 2000 to improve the quality of cardiovascular surgery in Japan. Web-based data harvesting on adult cardiac surgery was started (Japan Adult Cardiovascular Surgery Database, JACVSD) in 2001, and on congenital heart surgery (Japan Congenital Cardiovascular Surgery Database, JCCVSD) in 2008. Both databases grew to become national databases by the end of 2013. This was influenced by the success of the Society for Thoracic Surgeons' National Database, which contains comparable input items. In 2011, the Japanese Board of Cardiovascular Surgery announced that the JACVSD and JCCVSD data are to be used for board certification, which improved the quality of the first paperless and web-based board certification review undertaken in 2013. These changes led to a further step. In 2011, the National Clinical Database (NCD) was organized to investigate the feasibility of clinical databases in other medical fields, especially surgery. In the NCD, the board certification system of the Japan Surgical Society, the basic association of surgery was set as the first level in the hierarchy of specialties, and nine associations and six board certification systems were set at the second level as subspecialties. The NCD grew rapidly, and now covers 95% of total surgical procedures. The participating associations will release or have released risk models, and studies that use 'big data' from these databases have been published. The national databases have contributed to evidence-based medicine, to the accountability of medical professionals, and to quality assessment and quality improvement of surgery in Japan.
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Affiliation(s)
- Arata Murakami
- Department of Cardiovascular Surgery, Gunma Children’s Medical Center
| | - Yasutaka Hirata
- Department of Cardiac Surgery, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo
| | - Noboru Motomura
- Department of Cardiac Surgery, Sakura Hospital, Toho University
| | - Hiroaki Miyata
- Department of Health Quality Assessment, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo
| | - Tadashi Iwanaka
- Department of Pediatric Surgery, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo
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Jacobs JP, O'Brien SM, Pasquali SK, Kim S, Gaynor JW, Tchervenkov CI, Karamlou T, Welke KF, Lacour-Gayet F, Mavroudis C, Mayer JE, Jonas RA, Edwards FH, Grover FL, Shahian DM, Jacobs ML. The importance of patient-specific preoperative factors: an analysis of the society of thoracic surgeons congenital heart surgery database. Ann Thorac Surg 2014; 98:1653-8; discussion 1658-9. [PMID: 25262395 DOI: 10.1016/j.athoracsur.2014.07.029] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 07/04/2014] [Accepted: 07/09/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND The most common forms of risk adjustment for pediatric and congenital heart surgery used today are based mainly on the estimated risk of mortality of the primary procedure of the operation. The goals of this analysis were to assess the association of patient-specific preoperative factors with mortality and to determine which of these preoperative factors to include in future pediatric and congenital cardiac surgical risk models. METHODS All index cardiac operations in The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) during 2010 through 2012 were eligible for inclusion. Patients weighing less than 2.5 kg undergoing patent ductus arteriosus closure were excluded. Centers with more than 10% missing data and patients with missing data for discharge mortality or other key variables were excluded. Rates of discharge mortality for patients with or without specific preoperative factors were assessed across age groups and were compared using Fisher's exact test. RESULTS In all, 25,476 operations were included (overall discharge mortality 3.7%, n=943). The prevalence of common preoperative factors and their associations with discharge mortality were determined. Associations of the following preoperative factors with discharge mortality were all highly significant (p<0.0001) for neonates, infants, and children: mechanical circulatory support, renal dysfunction, shock, and mechanical ventilation. CONCLUSIONS Current STS-CHSD risk adjustment is based on estimated risk of mortality of the primary procedure of the operation as well as age, weight, and prematurity. The inclusion of additional patient-specific preoperative factors in risk models for pediatric and congenital cardiac surgery could lead to increased precision in predicting risk of operative mortality and comparison of observed to expected outcomes.
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Affiliation(s)
- Jeffrey Phillip Jacobs
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, Florida; Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Sean M O'Brien
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sara K Pasquali
- Department of Pediatrics and Communicable Diseases, C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Sunghee Kim
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - Christo Ivanov Tchervenkov
- Division of Pediatric Cardiac Surgery, Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | - Tara Karamlou
- Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Karl F Welke
- Children's Hospital of Illinois, Peoria, Illinois
| | | | - Constantine Mavroudis
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John E Mayer
- Children's Hospital Boston, Harvard University Medical School, Boston, Massachusetts
| | - Richard A Jonas
- Children's National Heart Institute, Children's National Medical Center, Washington, DC
| | - Fred H Edwards
- Shands Jacksonville, University of Florida, College of Medicine-Jacksonville, Jacksonville, Florida
| | | | - David M Shahian
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marshall Lewis Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Evans JM, Dharmar M, Meierhenry E, Marcin JP, Raff GW. Association Between Down Syndrome and In-Hospital Death Among Children Undergoing Surgery for Congenital Heart Disease. Circ Cardiovasc Qual Outcomes 2014; 7:445-52. [DOI: 10.1161/circoutcomes.113.000764] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jacqueline M. Evans
- From the Department of Pediatrics (J.M.E., M.D., J.P.M.), School of Medicine (E.M.), and Department of Surgery (G.W.R.), University of California Davis Children’s Hospital, Sacramento
| | - Madan Dharmar
- From the Department of Pediatrics (J.M.E., M.D., J.P.M.), School of Medicine (E.M.), and Department of Surgery (G.W.R.), University of California Davis Children’s Hospital, Sacramento
| | - Erin Meierhenry
- From the Department of Pediatrics (J.M.E., M.D., J.P.M.), School of Medicine (E.M.), and Department of Surgery (G.W.R.), University of California Davis Children’s Hospital, Sacramento
| | - James P. Marcin
- From the Department of Pediatrics (J.M.E., M.D., J.P.M.), School of Medicine (E.M.), and Department of Surgery (G.W.R.), University of California Davis Children’s Hospital, Sacramento
| | - Gary W. Raff
- From the Department of Pediatrics (J.M.E., M.D., J.P.M.), School of Medicine (E.M.), and Department of Surgery (G.W.R.), University of California Davis Children’s Hospital, Sacramento
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