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Levine JC, Colan S, Trachtenberg F, Marcus E, Ferguson M, Parthiban A, Taylor C, Dragulescu A, Goot B, Lacro RV, McFarland C, Narasimhan S, O'Connor M, Schamberger M, Srivistava S, Taylor M, Nathan M. Echocardiographic image collection and evaluation in infants with CHD: lessons learned from the imaging core lab for the Residual Lesion Score study. Cardiol Young 2024; 34:570-575. [PMID: 37605979 DOI: 10.1017/s1047951123003037] [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] [Indexed: 08/23/2023]
Abstract
Many factors affect patient outcome after congenital heart surgery, including the complexity of the heart disease, pre-operative status, patient specific factors (prematurity, nutritional status and/or presence of comorbid conditions or genetic syndromes), and post-operative residual lesions. The Residual Lesion Score is a novel tool for assessing whether specific residual cardiac lesions after surgery have a measurable impact on outcome. The goal is to understand which residual lesions can be tolerated and which should be addressed prior to leaving the operating room. The Residual Lesion Score study is a large multicentre prospective study designed to evaluate the association of Residual Lesion Score to outcomes in infants undergoing surgery for CHD. This Pediatric Heart Network and National Heart, Lung, and Blood Institute-funded study prospectively enrolled 1,149 infants undergoing 5 different congenital cardiac surgical repairs at 17 surgical centres. Given the contribution of echocardiographic measurements in assigning the Residual Lesion Score, the Residual Lesion Score study made use of a centralised core lab in addition to site review of all data. The data collection plan was designed with the added goal of collecting image quality information in a way that would permit us to improve our understanding of the reproducibility, variability, and feasibility of the echocardiographic measurements being made. There were significant challenges along the way, including the coordination, de-identification, storage, and interpretation of very large quantities of imaging data. This necessitated the development of new infrastructure and technology, as well as use of novel statistical methods. The study was successfully completed, but the size and complexity of the population being studied and the data being extracted required more technologic and human resources than expected which impacted the length and cost of conducting the study. This paper outlines the process of designing and executing this complex protocol, some of the barriers to implementation and lessons to be considered in the design of future studies.
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Affiliation(s)
- Jami C Levine
- Department Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven Colan
- Department Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Edward Marcus
- Department Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew Ferguson
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Anitha Parthiban
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Carolyn Taylor
- Department of Pediatrics, Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - Andreea Dragulescu
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Benjamin Goot
- Department of Pediatrics, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ronald V Lacro
- Department Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Carol McFarland
- Department of Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Shanthi Narasimhan
- Department of Pediatric Cardiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, MN, USA
| | - Matthew O'Connor
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Marcus Schamberger
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Shubhika Srivistava
- Department of Pediatrics, Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - Michael Taylor
- Department of Pediatrics, Cincinnati Children's Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Meena Nathan
- Department Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Sengupta A, Gauvreau K, Kaza A, Baird CW, Schidlow DN, Del Nido PJ, Nathan M. A Risk Prediction Model for Reintervention After Total Anomalous Pulmonary Venous Connection Repair. Ann Thorac Surg 2023; 116:796-802. [PMID: 35779604 DOI: 10.1016/j.athoracsur.2022.05.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/10/2022] [Accepted: 05/25/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Outcomes after total anomalous pulmonary venous connection (TAPVC) repair remain suboptimal due to recurrent pulmonary vein (PV) obstruction requiring reinterventions. We sought to develop a clinical prediction rule for PV reintervention after TAPVC repair. METHODS Data from consecutive patients who underwent TAPVC repair at a single institution from January 1980 to January 2020 were retrospectively reviewed after Institutional Review Board approval. The primary outcome was postdischarge (late) unplanned PV surgical or transcatheter reintervention. Echocardiographic criteria were used to assess PV residual lesion severity at discharge (class 1: no residua; class 2: minor residua; class 3: major residua). Competing risk models were used to develop a weighted risk score for late reintervention. RESULTS Of 437 patients who met entry criteria, there were 81 (18.5%) reinterventions at a median follow-up of 15.6 (interquartile range, 5.5-22.2) years. On univariable analysis, minor and major PV residua, age, single-ventricle physiology, infracardiac and mixed TAPVC, and preoperative obstruction were associated with late reintervention (all P < .05). The final risk prediction model included PV residua (class 2: subdistribution hazard ratio [SHR], 4.8; 95% CI, 2.8-8.1; P < .001; class 3: SHR, 6.4; 95% CI, 3.5-11.7; P < .001), age <1 year (SHR, 3.3; 95% CI, 1.3-8.5; P = .014), and preoperative obstruction (SHR, 1.8; 95% CI, 1.1-2.8; P = .015). A risk score comprising PV residua (class 2 or 3: 3 points), age (neonate or infant: 2 points), and obstruction (1 point) was formulated. Higher risk scores were significantly associated with worse freedom from reintervention (P < .001). CONCLUSIONS A risk prediction model of late reintervention may guide prognostication of high-risk patients after TAPVC repair.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts.
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | - Aditya Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Christopher W Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - David N Schidlow
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
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Sengupta A, Gauvreau K, Kaza A, Hoganson D, Del Nido PJ, Nathan M. Timing of reintervention influences survival and resource utilization following first-stage palliation of single ventricle heart disease. J Thorac Cardiovasc Surg 2023; 165:436-446. [PMID: 35961880 DOI: 10.1016/j.jtcvs.2022.04.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/11/2022] [Accepted: 04/27/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Outcomes after first-stage palliation of single-ventricle heart disease are influenced by many factors, including the presence of residual lesions requiring reintervention. However, there is a dearth of information regarding the optimal timing of reintervention. We assessed if earlier reintervention would be favorably associated with in-hospital outcomes among patients requiring unplanned reinterventions after the Norwood operation. METHODS This was a single-center, retrospective review of all patients who underwent the Norwood procedure from January 1997 to November 2017 and required a predischarge unplanned surgical or transcatheter reintervention on 1 or more subcomponent areas repaired at the index operation. Outcomes of interest included in-hospital mortality or transplant, postoperative hospital length of stay, and inpatient cost. Associations between timing of reintervention and outcomes were assessed using logistic regression (mortality or transplant) or generalized linear models (postoperative hospital length of stay and cost), adjusting for baseline patient-related and procedural factors. RESULTS Of 500 patients who underwent the Norwood operation, 92 (18.4%) required an unplanned reintervention. Median time to reintervention was 12 days (interquartile range, 5-35 days). There were 31 (33.7%) deaths or transplants, median postoperative hospital length of stay was 49 days (interquartile range, 32-87 days), and median cost was $328,000 (interquartile range, $204,000-$464,000). On multivariable analysis, each 5-day increase in time to reintervention increased the odds of mortality or transplant by 20% (odds ratio, 1.2; 95% confidence interval, 1.1-1.3; P = .004). Longer time to reintervention was also significantly associated with greater postoperative hospital length of stay (P < .001) and higher cost (P < .001). CONCLUSIONS For patients requiring predischarge unplanned reinterventions after the Norwood operation, earlier reintervention is associated with improved in-hospital transplant-free survival and resource use.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Biostatistics, Harvard School of Public Health, Boston, Mass
| | - Aditya Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - David Hoganson
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass.
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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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Sainathan S, Mullinari L. Vasoactive-inotropic score: A dilatory predictor of adverse short-term postoperative outcomes in pediatric patients undergoing cardiac surgical procedures with cardiopulmonary bypass. J Card Surg 2022; 37:3662-3663. [PMID: 36069155 DOI: 10.1111/jocs.16917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Sandeep Sainathan
- Division of Cardiothoracic Surgery, University of Miami, Miami, Florida, USA
| | - Leonardo Mullinari
- Division of Cardiothoracic Surgery, University of Miami, Miami, Florida, USA
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Salna M, Anderson BR, Bacha E, Kurlansky P. Nothing changes if nothing changes. Interact Cardiovasc Thorac Surg 2022; 35:6671255. [PMID: 35980295 PMCID: PMC9403298 DOI: 10.1093/icvts/ivac217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Michael Salna
- Division of Cardiac Surgery, Columbia University Irving Medical Center , New York, NY, USA
| | - Brett R Anderson
- Department of Pediatrics, Columbia University Irving Medical Center , New York, NY, USA
| | - Emile Bacha
- Division of Cardiac Surgery, Columbia University Irving Medical Center , New York, NY, USA
| | - Paul Kurlansky
- Division of Cardiac Surgery, Columbia University Irving Medical Center , New York, NY, USA
- Center for Innovation and Outcomes Research, Columbia University Irving Medical Center , New York, NY, USA
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Capecci L, Mainwaring RD, Collins RT, Sidell D, Martin E, Lamberti JJ, Hanley FL. The number of postoperative surgical or diagnostic procedures following congenital heart surgery correlates with both mortality and hospital length of stay. J Card Surg 2022; 37:3028-3035. [PMID: 35917407 DOI: 10.1111/jocs.16817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/23/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Outcomes for congenital heart disease have dramatically improved over the past several decades. However, there are patients who encounter intraoperative or postoperative complications and ultimately do not survive. It was our hypothesis that the number of postoperative procedures (including surgical and unplanned diagnostic procedures) would correlate with hospital length of stay and operative mortality. METHODS This was a retrospective review of 938 consecutive patients undergoing congenital heart surgery at a single institution over a 2-year timeframe. The number of postoperative surgical and unplanned diagnostic procedures were counted and the impact on hospital length of stay and mortality was assessed. RESULTS 581 of the 938 (62%) patients had zero postoperative diagnostic or surgical procedures. These patients had a median length of stay of 6 days with a single operative mortality (0.2%). 357 of the 938 (38%) patients had one or more postoperative diagnostic or surgical procedures. These patients had a total of 1586 postoperative procedures. There was a significant correlation between the number of postoperative procedures and both hospital length of stay and mortality (p < .001). Patients who required 10 or more postoperative procedures had a median hospital length of stay of 89 days and had a 50% mortality. There were no survivors in patients who had 15 or more postoperative procedures. CONCLUSIONS The data demonstrate that the number of postoperative procedures was highly correlated with both hospital length of stay and mortality.
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Affiliation(s)
- Lou Capecci
- Divisions of Pediatric Cardiac Surgery, Pediatric Cardiology, and Pediatric Otorhinolaryngology, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Stanford, California, USA
| | - Richard D Mainwaring
- Divisions of Pediatric Cardiac Surgery, Pediatric Cardiology, and Pediatric Otorhinolaryngology, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Stanford, California, USA
| | - R Thomas Collins
- Division of Pediatric Cardiology, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Stanford, California, USA
| | - Doug Sidell
- Division of Pediatric Otorhinolaryngology, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Stanford, California, USA
| | - Elisabeth Martin
- Divisions of Pediatric Cardiac Surgery, Pediatric Cardiology, and Pediatric Otorhinolaryngology, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Stanford, California, USA
| | - John J Lamberti
- Divisions of Pediatric Cardiac Surgery, Pediatric Cardiology, and Pediatric Otorhinolaryngology, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Stanford, California, USA
| | - Frank L Hanley
- Divisions of Pediatric Cardiac Surgery, Pediatric Cardiology, and Pediatric Otorhinolaryngology, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Stanford, California, USA
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Sengupta A, Gauvreau K, Kohlsaat K, Colan SD, Newburger JW, Del Nido PJ, Nathan M. Long-Term Outcomes of Patients Requiring Unplanned Repeated Interventions After Surgery for Congenital Heart Disease. J Am Coll Cardiol 2022; 79:2489-2499. [PMID: 35738709 DOI: 10.1016/j.jacc.2022.04.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/25/2022] [Accepted: 04/04/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Unplanned catheter-based or surgical reinterventions after congenital heart operations are independently associated with operative mortality and increased postoperative length of stay. OBJECTIVES This study assessed the long-term outcomes of transplant-free survivors of hospital discharge requiring predischarge reinterventions after congenital cardiac surgery. METHODS Data from patients who required predischarge reinterventions in the anatomic area of repair after congenital cardiac surgery and survived to hospital discharge at a quaternary referral center from January 2011 to December 2019 were retrospectively reviewed. Previously published echocardiographic criteria were used to assess the severity of persistent residual lesions at discharge (Grade 1, no residua; Grade 2, minor residua; and Grade 3, major residua). Outcomes included postdischarge (late) mortality or transplant and unplanned reintervention. Associations between predischarge residual lesion severity and outcomes were assessed by using Cox or competing risk models, adjusting for baseline patient characteristics, case complexity, and preoperative risk factors. RESULTS Among the 408 patients who met entry criteria, there were 58 (14.2%) postdischarge deaths or transplants and 208 (51.0%) late reinterventions at a median follow-up of 3.0 years (IQR: 1.1-6.8 years). Greater predischarge residual lesion severity was associated with worse transplant-free survival and freedom from reintervention (both, P < 0.05). On multivariable analyses, Grade 3 patients had an increased risk of postdischarge mortality or transplant (HR: 4.8; 95% CI: 2.0-11; P < 0.001) and late reintervention (subdistribution HR: 2.1; 95% CI: 1.4-3.1; P < 0.001) vs Grade 1 patients. CONCLUSIONS Among transplant-free survivors requiring predischarge reinterventions after congenital cardiac surgery, those with persistent major residua have significantly worse long-term outcomes. These high-risk patients warrant closer surveillance.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Katherine Kohlsaat
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
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Reaching for the Stars With the Least Number of Interventions Possible. J Am Coll Cardiol 2022; 79:2500-2501. [PMID: 35738710 DOI: 10.1016/j.jacc.2022.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/13/2022] [Indexed: 11/20/2022]
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Miana LA, Nathan M, Tenório DF, Manuel V, Guerreiro G, Fernandes N, Campos CVD, Gaiolla PV, Cassar RS, Turquetto A, Amato L, Canêo LF, Daroda LL, Jatene MB, Jatene FB. Translation and Validation of the Boston Technical Performance Score in a Developing Country. Braz J Cardiovasc Surg 2021; 36:589-598. [PMID: 34787990 PMCID: PMC8597612 DOI: 10.21470/1678-9741-2021-0485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction The Technical Performance Score (TPS) was developed and subsequently refined at the Boston Children's Hospital. Our objective was to translate and validate its application in a developing country. Methods The score was translated into the Portuguese language and approved by the TPS authors. Subsequently, we studied 1,030 surgeries from June 2018 to October 2020. TPS could not be assigned in 58 surgeries, and these were excluded. Surgical risk score was evaluated using Risk Adjustment in Congenital Heart Surgery (or RACHS-1). The impact of TPS on outcomes was studied using multivariable linear and logistic regression adjusting for important perioperative covariates. Results Median age and weight were 2.2 (interquartile range [IQR] = 0.5-13) years and 10.8 (IQR = 5.6-40) kilograms, respectively. In-hospital mortality was 6.58% (n=64), and postoperative complications occurred in 19.7% (n=192) of the cases. TPS was categorized as 1 in 359 cases (37%), 2 in 464 (47.7%), and 3 in 149 (15.3%). Multivariable analysis identified TPS class 3 as a predictor of longer hospital stay (coefficient: 6.6; standard error: 2.2; P=0.003), higher number of complications (odds ratio [OR]: 1.84; 95% confidence interval [CI]: 1.1-3; P=0.01), and higher mortality (OR: 3.2; 95% CI: 1.4-7; P=0.004). Conclusion TPS translated into the Portuguese language was validated and showed to be able to predict higher mortality, complication rate, and prolonged postoperative hospital stay in a high-volume Latin-American congenital heart surgery program. TPS is generalizable and can be used as an outcome assessment tool in resource diverse settings.
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Affiliation(s)
- Leonardo A Miana
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Davi Freitas Tenório
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Valdano Manuel
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil.,Cardiovascular Surgery Division, Clínica Girassol, Luanda, Angola
| | - Gustavo Guerreiro
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Natália Fernandes
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Carolina Vieira de Campos
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Paula V Gaiolla
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Renata Sá Cassar
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Aida Turquetto
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Luciana Amato
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Luiz Fernando Canêo
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | | | - Marcelo Biscegli Jatene
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Fabio B Jatene
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
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Michalowski AK, Gauvreau K, Kaza A, Quinonez L, Hoganson D, Del Nido P, Nathan M. Technical Performance Score: A Predictor of Outcomes After the Norwood Procedure. Ann Thorac Surg 2020; 112:1290-1297. [PMID: 32987019 DOI: 10.1016/j.athoracsur.2020.07.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 07/12/2020] [Accepted: 07/22/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Technical Performance Score (TPS) can predict outcomes after congenital cardiac surgery. We sought to validate TPS as a predictor of both short- and long-term outcomes of the Norwood procedure. METHODS We conducted a retrospective review of patients who underwent the Norwood procedure from 1997 to 2017. We assigned TPS (class 1, no residua; class 2, minor residua; class 3, major residua or reintervention for major residua before discharge) based on subcomponent scores from discharge echocardiograms or unplanned reinterventions, or both. Multivariable Cox or competing risk analysis, adjusted for preoperative patient- and procedure-related covariates, examined the association of TPS with postoperative hospital length of stay, transplant-free survival, and postdischarge reinterventions. RESULTS Among 500 patients, 319 (64%) were male, 54 (11%) were premature, 56 (11%) had noncardiac anomalies/syndromes, 146 (29%) had preoperative risk factors, and 480 (96%) were assigned TPS. On multivariable analysis, class 3 had greater hazard for reinterventions in transplant-free survivors (class 3: subdistribution hazard ratio [HR], 2.06; 95% confidence interval [CI] 1.34-3.16; P = .001) and was associated with increased hospital length of stay vs class 1 (HR, 0.25; 95% CI, 0.18-0.34; P < .001). Transplant-free survival after Norwood surgery was shorter for both class 2 (HR, 2.48; 95% CI, 1.68-3.66; P < .001) and class 3 (HR, 3.29; 95% CI, 2.18-4.95; P < .001). CONCLUSIONS TPS predicts early and late outcomes after Norwood. Absence of residual lesions results in improved long-term prognosis for single-ventricle patients. TPS may improve outcomes after Norwood by identifying patients warranting closer follow-up and potentially earlier reintervention.
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Affiliation(s)
- Anna K Michalowski
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Aditya Kaza
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Luis Quinonez
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - David Hoganson
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Pedro Del Nido
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Meena Nathan
- Department of Surgery, Harvard Medical School, Boston, Massachusetts.
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12
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Muter A, Evans HM, Gauvreau K, Colan S, Newburger J, Del Nido PJ, Nathan M. Technical Performance Score's Association With Arterial Switch Operation Outcomes. Ann Thorac Surg 2020; 111:1367-1373. [PMID: 32603709 DOI: 10.1016/j.athoracsur.2020.05.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 05/01/2020] [Accepted: 05/07/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Outcomes after the arterial switch operation (ASO) for dextro-transposition of the great arteries have improved significantly since its inception in the 1980s. This study reviews contemporaneous outcomes and predictors for late reinterventions after ASO. METHODS We retrospectively reviewed patients who underwent ASO for dextro-transposition of the great arteries from 1997 to 2017. Technical performance score (TPS) class (class 1, trivial or no residua; class 2, minor residua; class 3, major residua or reintervention) was assigned at discharge based on echocardiographic evaluation of components of the ASO. Multivariable Cox regression identified patient- and procedure-specific factors associated with postdischarge reinterventions. RESULTS Among 598 patients, 410 (69%) underwent ASO and 188 (31%) underwent ASO with ventricular septal defect repair. Median age at surgery was 5 days (interquartile range, 3 to 7); median follow-up time was 8.2 years; 408 (68%) were male; 50 (8.3%) were premature; and 10 (1.7%) had noncardiac anomalies or syndromes. Survival to hospital discharge was 98% (n = 591). Among 349 patients with follow-up, freedom from unplanned reintervent2ion at 5 years was 99% for TPS class 1, compared with 84% for class 2 and 30% for class 3. On multivariable Cox regression, classes 2 and 3 had significantly higher hazard for reintervention (class 2 hazard ratio 10.6; 95% confidence interval, 2.5 to 44.2; P = .001; class 3 hazard ratio 58.2, 95% confidence interval, 13.1 to 259; P < .001). CONCLUSIONS At our center, ASO was associated with relatively low mortality. Class 2 and class 3 TPS were the most important independent predictors of reinterventions after discharge. Therefore, TPS can serve as a tool for identifying high-risk patients who warrant closer follow-up.
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Affiliation(s)
- Angelika Muter
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Haley M Evans
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Steven Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Jane Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts.
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13
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Shimada M, Hoashi T, Iida J, Ichikawa H. The Impact of Post-Graduate Year of Primary Surgeon on Technical Performance Score in Tetralogy of Fallot Repair. Circ J 2020; 84:495-500. [PMID: 32023573 DOI: 10.1253/circj.cj-19-0800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of this study was to assess the impact of surgeon years of experience on clinical outcomes of tetralogy of Fallot (TOF) repair using technical performance score (TPS), and to investigate the possibility of safe operations by surgical trainees.Methods and Results:We assessed the cases of 159 consecutive patients who underwent TOF repair between 2001 and 2015. Thirteen different primary surgeons performed operations with 41 different first assistants. The primary surgeon and first assistant mean postgraduate years were 19.1±5.1 years (range, 5.7-31.6 years) and 11.2±6.3 years (range, 3.2-36.3 years), respectively. TPS was assigned using pre-discharge echocardiography based on original criteria. Logistic regression analysis was used to examine the factors associated with TPS. TPS could be scored for all patients, 16 of whom were graded as having optimal (10%), 119 as adequate (75%), and 24 as having inadequate (15%) TPS. None of the preoperative and perioperative variables affected TPS. Although neither the primary surgeon nor the first assistant postgraduate years was associated with TPS independently, total primary surgeon and first assistant postgraduate years correlated with TPS (OR, 1.07; 95% CI: 1.01-1.13, P=0.031). CONCLUSIONS Primary surgeon postgraduate years was not associated with TPS for TOF repair. TOF repair can be performed adequately and safely by surgical trainees under the support of highly experienced supervisors.
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Affiliation(s)
- Masatoshi Shimada
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Takaya Hoashi
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Jun Iida
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
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14
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Lushaj EB, Bartlett HL, Lamers LJ, Arndt S, Hermsen J, Ralphe JC, Anagnostopoulos PV. Technical Performance Score Predicts Perioperative Outcomes in Complex Congenital Heart Surgery Performed in a Small-to-Medium-Volume Program. Pediatr Cardiol 2020; 41:88-93. [PMID: 31676956 DOI: 10.1007/s00246-019-02226-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/15/2019] [Indexed: 11/29/2022]
Abstract
As the quality of surgical outcomes depend on many factors, the development of validated tools to assess the different aspects of complex multidisciplinary teams' performance is crucial. The Technical Performance Score (TPS) has only been validated to correlate with outcomes in large-volume surgical programs. Here we assess the utility of TPS in correlation to perioperative outcomes for complex congenital heart surgeries (CHS) performed in a small-to-medium-volume program. 673 patients underwent CHS from 4/2012 to 12/2017 at our institution. Of those, 122 were STAT 4 and STAT 5. TPS was determined for each STAT 4 and STAT 5 operation using discharge echocardiogram: 1 = optimal, 2 = adequate, 3 = inadequate. Patient outcomes were compared including mortality, length of stay, ventilation times, and adverse events. 69 patients (57%) were neonates, 32 (26%) were infants, 17 (14%) were children, 4 (3%) were adults. TPS class 1 was assigned to 85 (70%) operations, TPS class 2 was assigned to 25 (20%) operations, and TPS class 3 was assigned to 12 (10%) operations. TPS was associated with re-intubation, ICU length of stay, postoperative length of stay, and mortality. TPS did not correlate with unplanned 30-day readmissions, need for reoperation, and inotropic score. Technical performance score was associated with perioperative outcomes and is a useful tool to assess the adequacy of repair for high complexity CHS in a small-to-medium-volume surgical program. TPS should be a part of program review in congenital heart programs of all sizes to identify strategies that may reduce postoperative morbidity and potentially improve long-term outcomes.
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Affiliation(s)
- Entela B Lushaj
- Department of Surgery-Cardiothoracic, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Heather L Bartlett
- Department of Pediatrics-Cardiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Luke J Lamers
- Department of Pediatrics-Cardiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Shannon Arndt
- University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Joshua Hermsen
- Department of Surgery-Cardiothoracic, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - J Carter Ralphe
- Department of Pediatrics-Cardiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Petros V Anagnostopoulos
- Department of Pediatrics-Cardiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA. .,Division of Cardiothoracic Surgery, School of Medicine and Public Health, University of Wisconsin, 600 Highland Avenue, Madison, WI, 53792, USA.
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15
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Nathan M, Trachtenberg FL, Van Rompay MI, Gaynor W, Kanter K, Ohye R, Bacha EA, Tweddell J, Schwartz SM, Minich LL, Mery CM, Colan SD, Levine J, Lambert LM, Newburger JW. The Pediatric Heart Network Residual Lesion Score Study: Design and objectives. J Thorac Cardiovasc Surg 2019; 160:218-223.e1. [PMID: 31870553 DOI: 10.1016/j.jtcvs.2019.10.146] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 10/28/2019] [Accepted: 10/30/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The Residual Lesion Score (RLS) was developed as a novel tool for assessing residual lesions after congenital heart operations based on widely available clinical and echocardiographic characteristics. The RLS ranks postoperative findings as follows: Class 1 (no/trivial residua), Class 2 (minor residua), or Class 3 (major residua or reintervention before discharge for residua). The multicenter prospective RLS study aims to analyze the influence of residual lesions on outcomes in common congenital cardiac operations. We hypothesize that RLS will predict postoperative adverse events, resource utilization, mortality, and reinterventions by 1 year postoperatively. METHODS The study cohort consisted of infants aged ≤12 months undergoing definitive surgery for complete atrioventricular septal defect, tetralogy of Fallot, dextro-transposition of the great arteries with or without intact ventricular septum, single ventricle (Norwood procedure), and coarctation or interrupted/hypoplastic arch with ventricular septal defect. Children with major congenital or acquired extracardiac anomalies that could independently affect the primary end point, which was number of days alive and out of the hospital within 30 days of surgery (60 days for Norwood procedure), were excluded. Secondary outcomes included ≥1 early major postoperative adverse event; days of intensive care unit and hospital stay, and initial and total ventilator time; mortality/transplant after discharge; unplanned reinterventions after discharge; and cost. All analyses will be performed separately by surgical operation. CONCLUSIONS This is the first multicenter prospective validation of a tool for surgical outcome assessment and quality improvement specific to congenital heart surgery.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass.
| | | | | | - William Gaynor
- Division of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Kirk Kanter
- Division of Pediatric Cardiac Surgery, Children's Health Care of Atlanta, Atlanta, Ga
| | - Richard Ohye
- Division of Pediatric Cardiac Surgery, C. S. Mott Children's Hospital, Ann Arbor, Mich
| | - Emile A Bacha
- Division of Cardiothoracic Surgery, New York Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - James Tweddell
- Division of Pediatric Cardiac Surgery, Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
| | - Steven M Schwartz
- Division of Cardiac Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - L LuAnn Minich
- Division of Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School/ Dell Children's Medical Center, Austin, Tex
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Jami Levine
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Linda M Lambert
- Division of Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
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16
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Bellsham-Revell HR, Deri A, Caroli S, Durward A, Miller OI, Mathur S, Saundankar J, Anderson DR, Austin BC, Salih C, Pushparajah K, Simpson JM. Application of the Boston Technical Performance Score to intraoperative echocardiography. Echo Res Pract 2019; 6:63-70. [PMID: 31413860 PMCID: PMC6689121 DOI: 10.1530/erp-19-0032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 07/09/2019] [Indexed: 11/11/2022] Open
Abstract
Background The Technical Performance Score (TPS) developed by Boston Children’s Hospital showed surgical outcomes correlate with adequacy of technical repair when implemented on pre-discharge echocardiograms. We applied this scoring system to intraoperative imaging in a tertiary UK congenital heart surgical centre. Methods After a period of training, intraoperative TPS (epicardial and/or transesophageal echocardiography) was instituted. TPS was used to inform intraoperative discussions and recorded on a custom-made database using the previously published scoring system. After a year, we reviewed the feasibility, results and relationship between the TPS and mortality, extubation time and length of stay. Results From 01 September 2015 to 04 July 2016, there were 272 TPS procedures in 251 operations with 208 TPS recorded. Seven patients had surgery with no documented TPS, three had operations with no current TPS score template available. Patients left the operating theatre with TPS optimal in 156 (75%), adequate 34 (16%) and inadequate 18 (9%). Of those with an optimal score on leaving theatre, ten had more than one period of cardiopulmonary bypass. All four deaths <30 days after surgery (1.9%) had optimal TPS. There was a statistically significant difference in extubation times in the RACHS category 4 patients (3 days vs 5 days, P < 0.05) and in PICU and total length of stay in the RACHS category three patients (2 and 8 days vs 12.5 and 21.5 days respectively) if leaving theatre with an inadequate result. Conclusions Application of intraoperative TPS is feasible and provides a way of objectively recording intraoperative imaging assessment of surgery. An ‘inadequate’ TPS did not predict mortality but correlated with a longer ventilation time and longer length of stay compared to those with optimal or adequate scores.
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Affiliation(s)
| | - Antigoni Deri
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - Silvia Caroli
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - Andrew Durward
- Paediatric Airway Service, Evelina London Children's Hospital, London, UK
| | - Owen I Miller
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - Sujeev Mathur
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - Jelena Saundankar
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - David R Anderson
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - B Conal Austin
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - Caner Salih
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - Kuberan Pushparajah
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK.,Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - John M Simpson
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK.,Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
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17
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Technical Performance Score Predicts Resource Utilization in Congenital Cardiac Procedures. J Am Coll Cardiol 2018; 67:2696-8. [PMID: 27256837 DOI: 10.1016/j.jacc.2016.03.545] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 02/16/2016] [Accepted: 03/22/2016] [Indexed: 01/30/2023]
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18
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Tishler B, Gauvreau K, Colan SD, Del Nido P, Nathan M. Technical Performance Score Predicts Partial/Transitional Atrioventricular Septal Defect Outcomes. Ann Thorac Surg 2017; 105:1461-1468. [PMID: 29269131 DOI: 10.1016/j.athoracsur.2017.11.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 11/08/2017] [Accepted: 11/10/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Repair of partial or transitional atrioventricular septal defects (P/TAVSDs) has excellent outcomes; however, late reinterventions remain a concern. Technical performance score (TPS) measures residua after repair and has been associated with early/mid-term outcomes after congenital cardiac operation. Our study investigates TPS as a predictor of outcomes after P/TAVSD repair. METHODS This was a single-center retrospective review of P/TAVSD repair from July 2000 to November 2015. Intraoperative and discharge TPS were assigned based on echocardiographic criteria: class 1, no residua; class 2, minor residua; and class 3, major residua or reintervention for major residua. Intensive care unit (ICU) hospital length of stay and reintervention after discharge were analyzed with Cox regression. RESULTS In our cohort, 124 partial (68%) and 59 transitional (32%) AVSDs underwent repair. Median age was 1.5 years (interquartile range [IQR]: 0.6 to 3.8 years), median weight was 9.7 kg (IQR: 6.6 to 14.1 kg), and 96 (52%) were female. Twenty patients (11%) required reintervention after discharge. On multivariable modeling, patients with TPS class 3 spent more days in the ICU (hazard ratio [HR] 0.33, 95% confidence interval [CI]: 0.19 to 0.58, p < 0.001) and hospital (HR 0.33, 95% CI: 0.19 to 0.57, p < 0.001) and had shorter time to reintervention after discharge (HR 8.76, 95% CI: 1.03 to 74.7, p = 0.047). CONCLUSIONS Major residua, that is TPS class 3, were a predictor of in-hospital outcomes and unplanned reinterventions after discharge, with left atrioventricular valve regurgitation being the strongest predictor. Use of TPS as a tool for residual lesions may identify patients predisposed to prolonged ICU hospital stay and reinterventions after discharge, providing feedback on areas in need of improvement in technique and identification of patients who warrant closer follow-up.
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Affiliation(s)
- Brielle Tishler
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Pedro Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts.
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19
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IJsselhof R, Gauvreau K, Del Nido P, Nathan M. Technical Performance Score: Predictor of Outcomes in Complete Atrioventricular Septal Defect Repair. Ann Thorac Surg 2017. [PMID: 28648535 DOI: 10.1016/j.athoracsur.2017.03.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Technical performance score (TPS) has been associated with both early and late outcomes across a wide range of congenital cardiac procedures. We sought to validate TPS as predictor of outcomes for complete atrioventricular septal defect (CAVSD) repair. METHODS This was a single-center retrospective review of patients after balanced CAVSD repair between January 1, 2000, and March 1, 2016. We assigned TPS (class 1, no residua; class 2, minor residua; class 3, major residua or reintervention before discharge for residua) based on summation of subcomponent scores from discharge echocardiograms. Outcomes of interest were in-hospital complications, postoperative days on ventilator, and postdischarge reintervention. RESULTS Among 350 patients, median age was 3.2 months (interquartile range [IQR], 2.4 to 4.2 months). Fifty-four patients (16%) had class 1 TPS, 218 (62%) class 2, 63 (18%) class 3, and 15 (4%) were unscorable. There were 36 complications (10%), and median postoperative days on ventilator were 2 (IQR, 1 to 3) days. There were 34 postdischarge reinterventions (10%). Median follow-up was 2.6 years (IQR, 0.09 to 7.9) years. On multivariable modeling, class 3 TPS was associated with complications (odds ratio 5.45, 95% confidence interval [CI]: 1.06 to 28.1, p = 0.04), prolonged postoperative ventilator days (hazard ratio [HR] 0.54, 95% CI: 0.37 to 0.80, p = 0.002), and postdischarge reintervention (HR 5.61, 95% CI: 1.28 to 24.5, p = 0.02) after adjusting for covariates such as age, weight, genetic abnormality, concomitant procedure, prematurity, and second bypass run. CONCLUSIONS At our center, CAVSD repair was associated with low morbidity. TPS may identify patients with complications, prolonged days on ventilator, and who require postdischarge reinterventions; thus, it provides feedback on areas of improvement and allows identification of patients who warrant closer follow-up.
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Affiliation(s)
| | - Kim Gauvreau
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pedro Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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21
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Cunningham MEA, Donofrio MT, Peer SM, Zurakowski D, Jonas RA, Sinha P. Optimal Timing for Elective Early Primary Repair of Tetralogy of Fallot: Analysis of Intermediate Term Outcomes. Ann Thorac Surg 2016; 103:845-852. [PMID: 27692918 DOI: 10.1016/j.athoracsur.2016.07.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 06/14/2016] [Accepted: 07/05/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND We have previously demonstrated that early primary repair of tetralogy of Fallot with pulmonary stenosis (TOF) can be safely performed without increase in hospital resource utilization or compromise to surgical technical performance scores (TPS). We sought to identify the optimal timing for elective early primary repair of TOF with respect to intermediate-term reintervention. METHODS Retrospective review of all patients with TOF undergoing elective primary repair between September 2004 and December 2013 was performed. Patients were stratified into reintervention group or no reintervention group. Multivariable Cox regression analysis identified independent predictors of reintervention. Youden's J-index in receiver operating characteristic analysis identified optimal age cutoff predictive of reintervention. Kaplan-Meier analysis with the log-rank test compared reintervention rates stratified by age and TPS. RESULTS A total of 129 patients with median (interquartile range) age and weight of 78 days (56 to 111) and 5 kg (4.1 to 5.7), respectively, underwent primary repair. After a median (interquartile range) follow-up of 2.3 years (0.1 to 4.6), 18 patients (14%) required a total of 22 reinterventions. Youden's J-index revealed significantly lower risk of intermediate-term reintervention when repaired after 55 days of age (8% for >55 days old versus 31% for ≤55 days of age). Multivariable Cox regression identified age 55 days and younger (hazard ratio [HR] 4.5, 95% confidence interval [CI] 1.6 to 12.8, p = 0.004), valve sparing repair (HR 15.3, 95% CI 1.8 to 128.5, p < 0.001), residual right ventricular outflow tract (RVOT) gradient (HR 1.11, 95% CI 1.1 to 1.2, p < 0.001), and inadequate TPS (HR 21.5, 95% CI 7.4 to 63, p < 0.001) as independent predictors of overall intermediate-term reintervention. CONCLUSIONS Elective repair in patients greater than 55 days of age, irrespective of size of the patient, can be safely performed without any increase in reintervention rates. Both residual peak RVOT gradient and TPS are effective in identifying patients at increased risk of reintervention.
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Affiliation(s)
- Michael E A Cunningham
- Department of Cardiology, Children's National Health System, Washington, District of Columbia
| | - Mary T Donofrio
- Department of Cardiology, Children's National Health System, Washington, District of Columbia
| | - Syed Murfad Peer
- Department of Cardiovascular Surgery, Children's National Health System, Washington, District of Columbia
| | - David Zurakowski
- Departments of Anesthesia and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Richard A Jonas
- Department of Cardiovascular Surgery, Children's National Health System, Washington, District of Columbia
| | - Pranava Sinha
- Department of Cardiovascular Surgery, Children's National Health System, Washington, District of Columbia.
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22
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Overman DM. Neonatal outcomes and length of stay: A firm grasp of the obvious? J Thorac Cardiovasc Surg 2016; 152:727-8. [PMID: 27378735 DOI: 10.1016/j.jtcvs.2016.05.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 05/31/2016] [Indexed: 10/21/2022]
Affiliation(s)
- David M Overman
- Division of Cardiac Surgery, The Children's Heart Clinic and Division of Cardiovascular Surgery, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minn.
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23
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Parthiban A, Levine JC, Nathan M, Marshall JA, Shirali GS, Simon SD, Colan SD, Newburger JW, Raghuveer G. Impact of Variability in Echocardiographic Interpretation on Assessment of Adequacy of Repair Following Congenital Heart Surgery: A Pilot Study. Pediatr Cardiol 2016; 37:144-50. [PMID: 26358473 DOI: 10.1007/s00246-015-1256-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 08/24/2015] [Indexed: 10/23/2022]
Abstract
Technical Performance Score (TPS) is based largely on the presence and magnitude of residual lesions on postoperative echocardiograms; this score correlates with outcomes following repair of congenital heart defects. We evaluated reader variability for echocardiographic components of TPS for complete repair of tetralogy of Fallot (TOF) and arterial switch operation (ASO) in two centers and measured its effect on TPS. Postoperative echocardiograms were evaluated in 67 children (39 TOF and 28 ASO). Two readers (one per center) interpreted each echocardiogram. Reader variability in image quality assessments and measurements was compared using weighted kappa (κ), percent agreement, and intra-class correlation. TPS class (1 optimal-no residua, 2 adequate-minor residua, 3 inadequate-major residua) was assigned for each echocardiographic review by an independent investigator. The effect of reader interpretation variability on TPS classification was measured. There was strong agreement for TPS between the two readers (κ = 0.88). The readers were concordant for TPS classes for 57 children (85%) and discordant for classes 2 (minor residua) versus 3 (major residua) in six (9%). Coronary arteries and branch pulmonary arteries were frequently suboptimally visualized. Although inter-reader agreement for TPS was strong, inter-reader variation in echocardiographic interpretations had a small, but important effect on TPS for TOF and ASO, particularly for the distinction between minor and major residua. Further studies of generalizability and reproducibility of TPS and refinement of scoring modules may be needed before it can be used as a tool to assess pediatric cardiac surgical performance and outcomes.
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Affiliation(s)
- Anitha Parthiban
- Heart Center, Children's Mercy Hospital, University of Missouri Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO, 64108, USA.
| | - Jami C Levine
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA.,Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Meena Nathan
- Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA.,Department of Cardiac Surgery, Boston Children's Hospital, Bader 665, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Jennifer A Marshall
- Heart Center, Children's Mercy Hospital, University of Missouri Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Girish S Shirali
- Heart Center, Children's Mercy Hospital, University of Missouri Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Stephen D Simon
- Department of Biostatistics, University of Missouri Kansas City School of Medicine, 2411 Holmes street, Kansas City, MO, 64108, USA
| | - Steve D Colan
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA.,Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA.,Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Geetha Raghuveer
- Heart Center, Children's Mercy Hospital, University of Missouri Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO, 64108, USA
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Nathan M, Marshall AC, Kerstein J, Liu H, Fynn-Thompson F, Baird CW, Mayer JE, Pigula FA, del Nido PJ, Emani S. Technical performance score as predictor for post-discharge reintervention in valve-sparing tetralogy of Fallot repair. Semin Thorac Cardiovasc Surg 2014; 26:297-303. [PMID: 25837542 DOI: 10.1053/j.semtcvs.2014.12.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2014] [Indexed: 11/11/2022]
Abstract
Recognition of late problems following repair of tetralogy of Fallot (TOF) with a transannular patch has stimulated modifications to preserve pulmonary valve (PV) function. This study assesses the ability of technical performance score (TPS) to determine the need for post-discharge reinterventions (RIs) in valve-sparing TOF repair. We retrospectively reviewed 157 patients following valve-sparing repair of TOF from 2007-2012. We assigned TPS as Class 1 (optimal), Class 2 (adequate), or Class 3 (inadequate) based on discharge echo and clinical criteria. Preoperative, discharge, and follow-up PV Z scores and post-discharge RIs were documented. Reasons for Class 2 or 3 designation were right ventricular outflow tract (RVOT) gradient in 52, pulmonary regurgitation in 13, residual ventricular septal defects in 7, both RVOT gradient and ventricular septal defects in 13, and both RVOT gradient and pulmonary regurgitation in 37 patients. Median follow-up was 19.6 (range: 0.1-86.1) months. Class 3 patients had a significantly longer median intensive care unit and hospital stay compared with Class 1 (3 vs 2 days [P = 0.015] and 7 vs 5 days [P < 0.001], respectively). Post-discharge RIs were significantly lower in Class 1 vs Class 2 and Class 3 (P = 0.003). Class 1 patients had significantly larger PV Z scores compared with Class 2 or Class 3 patients (P < 0.001). TPS is associated with post-discharge RI rate after valve-sparing TOF repair. Preoperative PV Z score is highly correlated with Class I TPS. Patient selection based on preoperative PV Z scores may help determine if valve-sparing approach is appropriate, thus minimizing the need for RIs.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Audrey C Marshall
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jason Kerstein
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hua Liu
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Francis Fynn-Thompson
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher W Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Frank A Pigula
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pedro J del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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25
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Nathan M, Sleeper LA, Ohye RG, Frommelt PC, Caldarone CA, Tweddell JS, Lu M, Pearson GD, Gaynor JW, Pizarro C, Williams IA, Colan SD, Dunbar-Masterson C, Gruber PJ, Hill K, Hirsch-Romano J, Jacobs JP, Kaltman JR, Kumar SR, Morales D, Bradley SM, Kanter K, Newburger JW. Technical performance score is associated with outcomes after the Norwood procedure. J Thorac Cardiovasc Surg 2014; 148:2208-13, 2214.e1-6. [PMID: 25037617 PMCID: PMC4253672 DOI: 10.1016/j.jtcvs.2014.05.076] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 04/30/2014] [Accepted: 05/29/2014] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The technical performance score (TPS) has been reported in a single center study to predict the outcomes after congenital cardiac surgery. We sought to determine the association of the TPS with outcomes in patients undergoing the Norwood procedure in the Single Ventricle Reconstruction trial. METHODS We calculated the TPS (class 1, optimal; class 2, adequate; class 3, inadequate) according to the predischarge echocardiograms analyzed in a core laboratory and unplanned reinterventions that occurred before discharge from the Norwood hospitalization. Multivariable regression examined the association of the TPS with interval to first extubation, Norwood length of stay, death or transplantation, unplanned postdischarge reinterventions, and neurodevelopment at 14 months old. RESULTS Of 549 patients undergoing a Norwood procedure, 356 (65%) had an echocardiogram adequate to assess atrial septal restriction or arch obstruction or an unplanned reintervention, enabling calculation of the TPS. On multivariable regression, adjusting for preoperative variables, a better TPS was an independent predictor of a shorter interval to first extubation (P=.019), better transplant-free survival before Norwood discharge (P<.001; odds ratio, 9.1 for inadequate vs optimal), shorter hospital length of stay (P<.001), fewer unplanned reinterventions between Norwood discharge and stage II (P=.004), and a higher Bayley II psychomotor development index at 14 months (P=.031). The TPS was not associated with transplant-free survival after Norwood discharge, unplanned reinterventions after stage II, or the Bayley II mental development index at 14 months. CONCLUSIONS TPS is an independent predictor of important outcomes after Norwood and could serve as a tool for quality improvement.
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Affiliation(s)
- Meena Nathan
- Children's Hospital Boston and Harvard Medical School, Boston, Mass.
| | | | | | - Peter C Frommelt
- Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wis
| | | | - James S Tweddell
- Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wis
| | - Minmin Lu
- New England Research Institutes, Watertown, Mass
| | - Gail D Pearson
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | - J William Gaynor
- Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia, Pa
| | | | - Ismee A Williams
- Morgan Stanley Children's Hospital of NewYork-Presbyterian, New York, NY
| | - Steven D Colan
- Children's Hospital Boston and Harvard Medical School, Boston, Mass; New England Research Institutes, Watertown, Mass
| | | | - Peter J Gruber
- University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | | | - Jeffrey P Jacobs
- Johns Hopkins All Children's Heart Institute, St Petersburg, Fla
| | - Jonathan R Kaltman
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | - S Ram Kumar
- Children's Hospital Los Angeles, Los Angeles, Calif
| | - David Morales
- Cincinnati Children's Medical Center, Cincinnati, Ohio
| | | | | | - Jane W Newburger
- Children's Hospital Boston and Harvard Medical School, Boston, Mass
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26
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Nathan M, Gauvreau K, Liu H, Pigula FA, Mayer JE, Colan SD, Del Nido PJ. Outcomes differ in patients who undergo immediate intraoperative revision versus patients with delayed postoperative revision of residual lesions in congenital heart operations. J Thorac Cardiovasc Surg 2014; 148:2540-6.e1-5. [PMID: 25173124 DOI: 10.1016/j.jtcvs.2014.07.073] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 07/07/2014] [Accepted: 07/20/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVES In a previous study of infants less than 6 month old, we found that delayed revision of residual lesions resulted in worse patient outcomes compared with intraoperative revision. We explored a larger cohort to determine if this finding persisted. METHODS A prospective cohort followed from index surgery to discharge from January 2011 to September 2013 were divided into 4 groups: (1) intraoperative revisions (IO) of residual lesions, (2) delayed postoperative revision (PO) of residual lesions during the same hospital stay, (3) both intraoperative and delayed (BOTH) revision of residual lesions, (4) no intraoperative or postoperative revision (NO). Linear and logistic regression analyses were used to compare outcomes of postoperative hospital length of stay, postoperative adverse events (AE), hospital costs, and mortality, after adjusting for age, prematurity, presence of extracardiac anomalies, and RACHS-1 (Risk Adjustment for Congenital Heart Surgery-1) risk category known to affect outcomes. RESULTS Of the 2427 patients discharged after a congenital cardiac operation, 1886 were eligible for this study after exclusion of adults, procedures performed off cardiopulmonary bypass, and transplants and assist devices. On multivariable modeling adjusting for other significant patient factors, the NO group fared better than the other 3 groups. The IO group had significantly lower postoperative length of stay, AE rate, and hospital costs compared with the PO and BOTH groups, but showed no significant differences in mortality. CONCLUSIONS Intraoperative correction of residual lesions results in shorter length of stay, and lower postoperative AE and costs compared with delayed postoperative revision of residual lesions.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Mass.
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Mass
| | - Hua Liu
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Mass
| | - Frank A Pigula
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Mass
| | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Mass
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Mass
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Mass
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27
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Chen JM. Editorial Commentary: Technical Performance Anxiety: Utility of the Technical Performance Scale in Predicting Later Intervention After Repair of Tetralogy of Fallot. Semin Thorac Cardiovasc Surg 2014; 26:304-5. [DOI: 10.1053/j.semtcvs.2015.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2015] [Indexed: 11/11/2022]
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28
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Association between Technical Performance Scores and neurodevelopmental outcomes after congenital cardiac surgery. J Thorac Cardiovasc Surg 2013; 148:232-237.e3. [PMID: 24084277 DOI: 10.1016/j.jtcvs.2013.08.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 07/29/2013] [Accepted: 08/11/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Technical Performance Score (TPS) has been shown to have a strong association with early and late outcomes after congenital cardiac surgery, with greater morbidity and reintervention in children with major residual lesions (TPS class 3). We sought to explore the effect of TPS on the neurodevelopmental outcomes. METHODS All infants undergoing cardiac surgery, excluding those with trisomy 21, were offered neurodevelopmental testing at 1 year of age using the Bayley Scales of Infant Development, 3rd edition. TPSs from the discharge echocardiograms were graded as class 1 (optimal), class 2 (minor residual), or class 3 (major residual). Multivariate regression analysis was performed using patient characteristics and preoperative variables. RESULTS Neurodevelopmental testing was performed in 140 patients at a median age of 16 months. Of these, 28 (20%) had single ventricle palliation; 39 (28%) were in Risk Adjustment for Congenital Heart Surgery category 4 to 6. Significant differences between the groups were found in the cognitive (P = .01) and motor (P = .05) domains, with subjects in TPS class 3 having significantly lower cognitive and motor composite scores. The scores did not vary significantly according to single ventricle versus biventricular repair or Risk Adjustment for Congenital Heart Surgery categorization. In multivariate modeling, class 3 TPS remained significantly associated with a lower Bayley cognitive score (P = .02), with a trend toward a lower Bayley motor score (P = .08). CONCLUSIONS We found that TPS is an independent predictor of neurodevelopmental outcomes after infant heart surgery. Future research should explore whether a structured program of intraoperative recognition and intervention on residual lesions can improve the TPS and neurodevelopmental outcomes.
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29
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Nathan M, Karamichalis J, Liu H, Gauvreau K, Colan S, Saia M, Pigula F, Fynn-Thompson F, Emani S, Baird C, Mayer JE, del Nido PJ. Technical Performance Scores are strongly associated with early mortality, postoperative adverse events, and intensive care unit length of stay-analysis of consecutive discharges for 2 years. J Thorac Cardiovasc Surg 2013; 147:389-94, 396.e1-396.e3. [PMID: 24035318 DOI: 10.1016/j.jtcvs.2013.07.044] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Revised: 06/20/2013] [Accepted: 07/16/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Previous work in our institution has indicated that the Technical Performance Score (TPS) is highly associated with early outcomes in select subsets of procedures and age groups. We hypothesized that the TPS could predict early outcomes in a wide range of diagnoses and age groups. METHODS Consecutive patients discharged from January 2011 to March 2013 were prospectively evaluated. The TPS was assigned according to the discharge echocardiographic findings and the need for reinterventions in the anatomic area of interest. Case complexity was determined using Risk Adjustment for Congenital Heart Surgery (RACHS-1) categories. Early mortality and postoperative adverse events were recorded. Relationships between the TPS and outcomes were assessed after adjusting for the baseline patient characteristics. RESULTS The median age of the 1926 patients was 1.8 years (range, 0 days to 68 years). Bypass was used in 1740 (90%); 322 (17%) were neonates, 520 (27%) infants, 873 (45%) children, 211 (11%) adults. TPS was class 1 (optimal) in 956 (50%), class 2 (adequate) in 584 (30%), and class 3 (inadequate) in 226 (12%); 160 patients (8%) could not be scored. A total of 51 early deaths (2.6%) and 111 adverse events (5.7%) occurred. On univariate analysis, age, RACHS-1 category, and TPS were significantly associated with mortality and the occurrence of adverse events. On multivariate modeling, class 3 (inadequate) TPS was strongly associated with mortality (odds ratio, 16.9; 95% confidence interval, 6.7-42.9; P < .001), adverse events (odds ratio, 6.9; 95% confidence interval, 4.1-11.6; P < .001), and postoperative intensive care unit length of stay (coefficient, 2.3; 95% confidence interval, 2.0-2.6; P < .001) after adjusting for other covariates. CONCLUSIONS The TPS is strongly associated with early outcomes across a wide range of ages and disease complexity and can serve as important tool for self-assessment and quality improvement.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass.
| | - John Karamichalis
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Hua Liu
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Kimberley Gauvreau
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Steven Colan
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Matthew Saia
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Frank Pigula
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Francis Fynn-Thompson
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Christopher Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Pedro J del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
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