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St Louis JD, Bhat A, Carey JC, Lin AE, Mann PC, Smith LM, Wilfond BS, Kosiv KA, Sorabella RA, Alsoufi B. The American Association for Thoracic Surgery (AATS) 2023 Expert Consensus Document: Recommendation for the care of children with trisomy 13 or trisomy 18 and a congenital heart defect. J Thorac Cardiovasc Surg 2024; 167:1519-1532. [PMID: 38284966 DOI: 10.1016/j.jtcvs.2023.11.054] [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: 09/09/2023] [Revised: 11/27/2023] [Accepted: 11/30/2023] [Indexed: 01/30/2024]
Abstract
OBJECTIVES Recommendations for surgical repair of a congenital heart defect in children with trisomy 13 or trisomy 18 remain controversial, are subject to biases, and are largely unsupported with limited empirical data. This has created significant distrust and uncertainty among parents and could potentially lead to suboptimal care for patients. A working group, representing several clinical specialties involved with the care of these children, developed recommendations to assist in the decision-making process for congenital heart defect care in this population. The goal of these recommendations is to provide families and their health care teams with a framework for clinical decision making based on the literature and expert opinions. METHODS This project was performed under the auspices of the AATS Congenital Heart Surgery Evidence-Based Medicine Taskforce. A Patient/Population, Intervention, Comparison/Control, Outcome process was used to generate preliminary statements and recommendations to address various aspects related to cardiac surgery in children with trisomy 13 or trisomy 18. Delphi methodology was then used iteratively to generate consensus among the group using a structured communication process. RESULTS Nine recommendations were developed from a set of initial statements that arose from the Patient/Population, Intervention, Comparison/Control, Outcome process methodology following the groups' review of more than 500 articles. These recommendations were adjudicated by this group of experts using a modified Delphi process in a reproducible fashion and make up the current publication. The Class (strength) of recommendations was usually Class IIa (moderate benefit), and the overall level (quality) of evidence was level C-limited data. CONCLUSIONS This is the first set of recommendations collated by an expert multidisciplinary group to address specific issues around indications for surgical intervention in children with trisomy 13 or trisomy 18 with congenital heart defect. Based on our analysis of recent data, we recommend that decisions should not be based solely on the presence of trisomy but, instead, should be made on a case-by-case basis, considering both the severity of the baby's heart disease as well as the presence of other anomalies. These recommendations offer a framework to assist parents and clinicians in surgical decision making for children who have trisomy 13 or trisomy 18 with congenital heart defect.
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Affiliation(s)
- James D St Louis
- Department of Surgery, Children's Hospital of Georgia, Augusta University, Augusta, Ga.
| | - Aarti Bhat
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Wash
| | - John C Carey
- Department of Pediatrics, University of Utah Health and Primary Children's Hospital, Salt Lake City, Utah
| | - Angela E Lin
- Department of Pediatrics, Mass General Hospital for Children, Boston, Mass
| | - Paul C Mann
- Department of Surgery, Children's Hospital of Georgia, Augusta University, Augusta, Ga
| | - Laura Miller Smith
- Department of Pediatrics, Oregon Health and Science University, Portland, Ore
| | - Benjamin S Wilfond
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Wash
| | - Katherine A Kosiv
- Department of Pediatrics, Yale University School of Medicine, New Haven, Conn
| | - Robert A Sorabella
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | - Bahaaldin Alsoufi
- Department of Surgery, University of Louisville and Norton Children's Hospital, Louisville, Ky
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Adair AB, Gong W, Lindsell CJ, Clay MA. Association between weight-for-length percentile and ICU length of stay in patients with a single ventricle undergoing bidirectional Glenn repair: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2024; 48:469-478. [PMID: 38417181 DOI: 10.1002/jpen.2616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 12/31/2023] [Accepted: 01/28/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Poor weight gain has been identified as an independent risk factor for increased surgical morbidity and mortality for patients with single-ventricle physiology undergoing staged surgical palliation. Conversely, excessive weight gain has also emerged as an independent risk factor predicting increased morbidity and mortality in a single-center study. Given this novel single-center concept, we investigated the impact of excessive weight on patients with single-ventricle physiology undergoing bidirectional Glenn palliation in a multicenter study model. METHODS Patients from the Pediatric Heart Network Single Ventricle Reconstruction Trial (n = 387) were analyzed in a retrospective cohort study examining the independent effect of weight percentile on intensive care unit (ICU) length of stay (LOS) and ventilator days. Locally estimated scatterplot smoothing (LOESS) regression was used to plot weight-for-length (WFL) percentiles by ICU LOS and ventilator days. Unadjusted and adjusted ordinal regression was used to model ICU LOS and ventilator days. RESULTS Scatterplots and LOESS regression curves demonstrated increasing ICU LOS and ventilator days for increasing WFL percentiles. Unadjusted ordinal regression analysis of ICU LOS demonstrated a trend of increasing ICU LOS for increasing WFL percentiles that was not statistically significant (P = 0.11). A similar trend was demonstrated in adjusted ordinal regression that was not statistically significant (P = 0.48). Unadjusted and adjusted ordinal regression analysis of ventilator days did not reach statistical significance (P = 0.07). CONCLUSION Excessive weight gain has a clinically relevant but not statistically significant association with increased ICU LOS and ventilator days for those patients in the >90th WFL percentile for age.
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Affiliation(s)
- Austin B Adair
- Department of Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pediatric Cardiac Critical Care, Dell Children's Medical Center, Austin, Texas, USA
| | - Wu Gong
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Christopher J Lindsell
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Mark A Clay
- Department of Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pediatric Cardiac Critical Care, Medical City Dallas Hospital, Dallas, Texas, USA
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Medina CK, Prabhu NK, Alderete IS, Parker LE, Lim HK, Moya-Mendez ME, Kang L, Campbell MJ, Overbey DM, Turek JW, Andersen ND. Days alive and out of hospital for children born with single-ventricle heart disease. Cardiol Young 2024:1-6. [PMID: 38410043 DOI: 10.1017/s1047951124000118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND This study describes the illness burden in the first year of life for children with single-ventricle heart disease, using the metric of days alive and out of hospital to characterize morbidity and mortality. METHODS This is a retrospective single-centre study of single-ventricle patients born between 2005 and 2021 who had their initial operation performed at our institution. Patient demographics, anatomical details, and hospitalizations were extracted from our institutional single-ventricle database. Days alive and out of hospital were calculated by subtracting the number of days hospitalized from number of days alive during the first year of life. A multivariable linear regression with stepwise variable selection was used to determine independent risk factors associated with fewer days alive and out of hospital. RESULTS In total, 437 patients were included. Overall median number of days alive and out of hospital in the first year of life for single-ventricle patients was 278 days (interquartile range 157-319 days). In a multivariable analysis, low birth weight (<2.5kg) (b = -37.55, p = 0.01), presence of a dominant right ventricle (b = -31.05, p = 0.01), moderate-severe dominant atrioventricular valve regurgitation at birth (b = -37.65, p < 0.05), index hybrid Norwood operation (b = -138.73, p < 0.01), or index heart transplant (b = -158.41, p < 0.01) were all independently associated with fewer days alive and out of hospital. CONCLUSIONS Children with single-ventricle heart defects have significant illness burden in the first year of life. Identifying risk factors associated with fewer days alive and out of hospital may aid in counselling families regarding expectations and patient prognosis.
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Affiliation(s)
- Cathlyn K Medina
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC, USA
| | - Neel K Prabhu
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC, USA
| | - Isaac S Alderete
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC, USA
| | - Lauren E Parker
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC, USA
| | - Hoe King Lim
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC, USA
| | - Mary E Moya-Mendez
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC, USA
| | - Lillian Kang
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC, USA
| | - M Jay Campbell
- Duke Children's Pediatric and Congenital Heart Center, Durham, NC, USA
| | - Douglas M Overbey
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC, USA
- Duke Children's Pediatric and Congenital Heart Center, Durham, NC, USA
| | - Joseph W Turek
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, NC, USA
- Duke Children's Pediatric and Congenital Heart Center, Durham, NC, USA
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Langanecha BD, Kesavan S, Schwartz SM, Honjo O, Seed M, Fan CPS, Dragulescu A, Taylor KL, Floh AA. Reintervention Before Bidirectional Cavopulmonary Shunt and Intermediate Outcomes in Children with Single Ventricle Who Underwent Main Pulmonary Artery Banding. Pediatr Cardiol 2023; 44:1839-1846. [PMID: 37522934 DOI: 10.1007/s00246-023-03242-6] [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: 03/26/2023] [Accepted: 07/14/2023] [Indexed: 08/01/2023]
Abstract
Unplanned reinterventions following pulmonary artery banding (PAB) in single ventricle patients are common before stage 2 palliation (S2P) but associated risk factors are unknown. We hypothesized that reintervention is more common when PAB is placed at younger age and with a looser band, reflected by lower PAB pressure gradient. Retrospective single center study of single ventricle patients undergoing PAB between Jan 2000 and Dec 2020. The association with reintervention and successful S2P was modeled using exploratory cause-specific hazard regression. A multivariable model was developed adjusting for clinical and statistically relevant predictors. The cumulative proportion of patients undergoing reintervention were summarized using a competing risk model. 77 patients underwent PAB at median (IQR) 47 (24-66) days and 3.73 (3.2-4.5) kg. Within18 months of PAB, 60 (78%) reached S2P, 9 (12%) died, 1 (1%) transplanted and 7 (9%) were alive without S2P. Within 18 months of PAB 10 (13%) patients underwent reintervention related to pulmonary blood flow modification: PAB adjustment (n = 6) and conversion to Damus-Kaye-Stansel/Blalock-Taussig-Thomas shunt (n = 4). 6/10 (60%) reached S2P following reintervention. A trend toward higher intervention in patients with a genetic syndrome (p-0.06) and weight < 3 kg (p-0.057) at time of PAB was noted. Only genetic syndrome was a risk factor associated with poor outcome (p-0.025). PAB has a reasonable outcome in SV patients with unobstructed systemic and pulmonary blood flow, but with a high reintervention rate. Only a quarter of patients with genetic syndromes reach S2P and further study is required to explore the benefits from an alternative palliative strategy.
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Affiliation(s)
- Bhavikkumar D Langanecha
- Labatt Family Heart Centre, Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - Sajith Kesavan
- Department of Paediatric Pulmonary and Critical Care, Amrita Institute of Medical Sciences, Kochi, India
| | - Steven M Schwartz
- Labatt Family Heart Centre, Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Department of Critical Care Medicine, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Osami Honjo
- Labatt Family Heart Centre, Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Mike Seed
- Labatt Family Heart Centre, Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Chun-Po S Fan
- Ted Rogers Computational Program, The University Health Network, University of Toronto, Toronto, ON, Canada
| | - Andreea Dragulescu
- Labatt Family Heart Centre, Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Katherine L Taylor
- Division of Cardiac Anaesthesia, Department of Anaesthesia, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Alejandro A Floh
- Labatt Family Heart Centre, Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Department of Critical Care Medicine, University of Toronto, The Hospital for Sick Children, Toronto, Canada
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Averin K, Ryerson L, Hajihosseini M, Dinu IA, Freed DH, Bond G, Joffe AR, Jonker DV, Hendson L, Robertson CM, Atallah J. Infants less than or equal to 2.5 kg have increased mortality and worse motor neurodevelopmental outcomes at 2 years of age after Norwood-Sano palliation. JTCVS OPEN 2023; 14:417-425. [PMID: 37425435 PMCID: PMC10328833 DOI: 10.1016/j.xjon.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/11/2023] [Accepted: 03/07/2023] [Indexed: 07/11/2023]
Abstract
Objectives In infants with single-ventricle congenital heart disease, prematurity and low weight at the time of the Norwood operation are risk factors for mortality. Reports assessing outcomes (including neurodevelopment) post Norwood palliation in infants ≤2.5 kg are limited. Methods All infants who underwent a Norwood-Sano procedure between 2004 and 2019 were identified. Infants ≤2.5 kg at the time of the operation (cases) were matched 3:1 with infants >3.0 kg (comparisons) for year of surgery and cardiac diagnosis. Demographic and perioperative characteristics, survival, and functional and neurodevelopmental outcomes were compared. Results Twenty-seven cases (mean ± standard deviation: weight 2.2 ± 0.3 kg and age 15.6 ± 14.1 days at surgery) and 81 comparisons (3.5 ± 0.4 kg and age 10.9 ± 7.9 days at surgery) were identified. Post-Norwood, cases had a longer time to lactate ≤2 mmol/L (33.1 ± 27.5 vs 17.9 ± 12.2 hours, P < .001), longer duration of ventilation (30.5 ± 24.5 vs 18.6 ± 17.5 days, P = .005), greater need for dialysis (48.1% vs 19.8%, P = .007), and greater need for extracorporeal membrane oxygenation support (29.6% vs 12.3%, P = .004). Cases had significantly greater postoperative (in-hospital) (25.9% vs 1.2%, P < .001) and 2-year (59.2% vs 11.1%, P < .001) mortality. Neurodevelopmental assessment showed the following for cases versus comparisons, respectively: cognitive delay (18.2% vs 7.9%, P = .272), language delay (18.2% vs 11.1%, P = .505), and motor delay (27.3% vs 14.3%, P = .013). Conclusions Infants ≤2.5 kg at Norwood-Sano palliation have significantly increased postoperative morbidity and mortality up to 2-year follow-up. Neurodevelopmental motor outcomes were worse in these infants. Additional studies are warranted to assess the outcome of alternative medical and interventional treatment plans in this patient population.
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Affiliation(s)
- Konstantin Averin
- Division of Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Lindsay Ryerson
- Division of Critical Care, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Irina A. Dinu
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Darren H. Freed
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Gwen Bond
- Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada
| | - Ari R. Joffe
- Division of Critical Care, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Leonora Hendson
- Section of Neonatology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Charlene M.T. Robertson
- Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Joseph Atallah
- Division of Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Backes ER, Afonso NS, Guffey D, Tweddell JS, Tabbutt S, Rudd NA, O'Harrow G, Molossi S, Hoffman GM, Hill G, Heinle JS, Bhat P, Anderson JB, Ghanayem NS. Cumulative comorbid conditions influence mortality risk after staged palliation for hypoplastic left heart syndrome and variants. J Thorac Cardiovasc Surg 2023; 165:287-298.e4. [PMID: 35599210 DOI: 10.1016/j.jtcvs.2022.01.056] [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: 05/10/2021] [Revised: 12/29/2021] [Accepted: 01/27/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Prematurity, low birth weight, genetic syndromes, extracardiac conditions, and secondary cardiac lesions are considered high-risk conditions associated with mortality after stage 1 palliation. We report the impact of these conditions on outcomes from a prospective multicenter improvement collaborative. METHODS The National Pediatric Cardiology Quality Improvement Collaborative Phase II registry was queried. Comorbid conditions were categorized and quantified to determine the cumulative burden of high-risk diagnoses on survival to the first birthday. Logistic regression was applied to evaluate factors associated with mortality. RESULTS Of the 1421 participants, 40% (575) had at least 1 high-risk condition. The aggregate high-risk group had lower survival to the first birthday compared with standard risk (76.2% vs 88.1%, P < .001). Presence of a single high-risk diagnosis was not associated with reduced survival to the first birthday (odds ratio, 0.71; confidence interval, 0.49-1.02, P = .066). Incremental increases in high-risk diagnoses were associated with reduced survival to first birthday (odds ratio, 0.23; confidence interval, 0.15-0.36, P < .001) for 2 and 0.17 (confidence interval, 0.10-0.30, P < .001) for 3 to 5 high-risk diagnoses. Additional analysis that included prestage 1 palliation characteristics and stage 1 palliation perioperative variables identified multiple high-risk diagnoses, poststage 1 palliation extracorporeal membrane oxygenation support (odds ratio, 0.14; confidence interval, 0.10-0.22, P < .001), and cardiac reoperation (odds ratio, 0.66; confidence interval, 0.45-0.98, P = .037) to be associated with reduced survival odds to the first birthday. CONCLUSIONS The presence of 1 high-risk diagnostic category was not associated with decreased survival at 1 year. Cumulative diagnoses across multiple high-risk diagnostic categories were associated with decreased odds of survival. Further patient accrual is needed to evaluate the impact of specific comorbid conditions within the broader high-risk categories.
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Affiliation(s)
- Emily R Backes
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex.
| | - Natasha S Afonso
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - Danielle Guffey
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - James S Tweddell
- Division of Cardiology, Department of Surgery, Department of Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sarah Tabbutt
- Divisions of Critical Care and Cardiology, Department of Pediatrics, University of California San Francisco and Benioff Children's Hospital, San Francisco, Calif
| | - Nancy A Rudd
- Division of Cardiology, Department of Pediatrics, Department of Anesthesia, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Ginny O'Harrow
- Division of Critical Care, Department of Pediatrics, University of Chicago Medicine and Comer Children's Hospital, Chicago, Ill
| | - Silvana Molossi
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - George M Hoffman
- Division of Cardiology, Department of Pediatrics, Department of Anesthesia, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Garick Hill
- Division of Cardiology, Department of Surgery, Department of Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey S Heinle
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - Priya Bhat
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - Jeffrey B Anderson
- Division of Cardiology, Department of Surgery, Department of Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nancy S Ghanayem
- Division of Critical Care, Department of Pediatrics, University of Chicago Medicine and Comer Children's Hospital, Chicago, Ill; Advocate Children's Hospital, Oak Lawn, Ill
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Survival After Intervention for Single-Ventricle Heart Disease Over 15 Years at a Single Institution. Ann Thorac Surg 2022; 114:2303-2312. [PMID: 35430225 DOI: 10.1016/j.athoracsur.2022.03.060] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 02/23/2022] [Accepted: 03/22/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Children with single-ventricle (SV) heart disease possess a spectrum of heart malformations, yet progress through similar hemodynamic states, suggesting differences in outcomes are related to fundamental morphologic differences, patient characteristics, or procedural pathways. We sought to provide a holistic overview of survival after intervention for SV heart disease at our institution. METHODS SV heart disease was defined as patients born with a hypoplastic or dysfunctional ventricle with uncertain or unacceptable candidacy for a 2-ventricle circulation. Patients were stratified into 8 diagnostic groups and 11 procedural categories based on the initial interventional procedure. RESULTS Between 2005 and 2020, 381 patients born with SV heart disease underwent intervention at our institution. Ten-year survival was highest for patients with double inlet left ventricle (89% ± 7%) and lowest for patients with hypoplastic left heart syndrome (55% ± 5%). Initial palliation with less invasive procedures, such as ductal stent (4-year: 100%) or pulmonary artery banding (10-year: 95% ± 5%), demonstrated superior survival compared with more invasive procedures such as the Norwood procedure (10-year: 59% ± 4%). Survival of patients who achieved a biventricular circulation was superior to patients who remained with SV physiology (10-year: 87% ± 5% vs 63% ± 3%, P = .04). In a multivariable analysis, chromosomal/syndromic abnormality, lower weight, hybrid Norwood procedure, nonleft ventricular dominance, and earlier year of operation were risk factors for death. CONCLUSIONS Survival differences in patients with SV heart disease were related primarily to underlying cardiac anatomy, patient characteristics, and procedural complexity. Left ventricular dominance, more recent intervention, and attainment of a 2-ventricle circulation were associated with improved survival.
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Dehghan B, Ahmadi A, Sarfarazi Moghadam S, Sabri MR, Ghaderian M, Mahdavi C, Sedighi M, Bigdelian H. Biventricular strain and strain rate impairment shortly after surgical repair of tetralogy of Fallot in children: A case-control study. Health Sci Rep 2022; 5:e613. [PMID: 35517373 PMCID: PMC9063058 DOI: 10.1002/hsr2.613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 01/23/2022] [Accepted: 02/07/2022] [Indexed: 12/01/2022] Open
Abstract
Background Early biventricular dysfunction in repaired tetralogy of Fallot (TOF) children may lead to poor clinical outcomes. We aimed to assess biventricular function in TOF children before and after surgery by speckle tracking echocardiography (STE) and compare them with the controls. Methods Twenty repaired TOF children and 20 normal children as controls were assessed by STE. Tricuspid annular plane systolic excursion (TAPSE), left ventricular ejection fraction (LVEF), biventricular strain, and strain rate were compared before and after surgery and between TOF children and controls. Results Postoperative LVEF (p = 0.001), strain (p = 0.001), and strain rate (p = 0.001) for left ventricle improved significantly compared to preoperative phase. However, postoperative left ventricular strain (p = 0.05) and strain rate (p = 0.01) in TOF children were significantly impaired compared to controls. Postoperative LVEF was correlated inversely with postoperative strain rate (r = −0.40, p = 0.04). Postoperative TAPSE (p = 0.001), strain (p = 0.001), and strain rate (p = 0.001) for right ventricle significantly worsened when compared with the preoperative phase. Moreover, postoperative TAPSE (p = 0.001), strain (p = 0.001), and strain rate (p = 0.01) were significantly impaired compared to controls. Postoperative right ventricular strain rate was correlated significantly with the weight of children (r = 0.48, p = 0.02), and postoperative left ventricular strain showed significant correlations with aortic clamp time (r = 0.44, p = 0.04) and with ICU stay (r = −0.46, p = 0.04). Conclusion Despite normal LVEF, TOF children exhibit impaired left ventricular strain and strain rate after surgery. TAPSE, strain, and strain rate for the right ventricle worsen after surgical repair. STE‐driven strain can be used to detect early ventricular dysfunction and the associated prognostic implications.
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Affiliation(s)
- Bahar Dehghan
- Pediatric Cardiovascular Research Center, Cardiovascular Research Institute Isfahan University of Medical Sciences Isfahan Iran
| | - Alireza Ahmadi
- Pediatric Cardiovascular Research Center, Cardiovascular Research Institute Isfahan University of Medical Sciences Isfahan Iran
| | - Shima Sarfarazi Moghadam
- Pediatric Cardiovascular Research Center, Cardiovascular Research Institute Isfahan University of Medical Sciences Isfahan Iran
| | - Mohammad Reza Sabri
- Pediatric Cardiovascular Research Center, Cardiovascular Research Institute Isfahan University of Medical Sciences Isfahan Iran
| | - Mehdi Ghaderian
- Pediatric Cardiovascular Research Center, Cardiovascular Research Institute Isfahan University of Medical Sciences Isfahan Iran
| | - Chehreh Mahdavi
- Pediatric Cardiovascular Research Center, Cardiovascular Research Institute Isfahan University of Medical Sciences Isfahan Iran
| | - Mohsen Sedighi
- Trauma and Injury Research Center Iran University of Medical Sciences Tehran Iran
| | - Hamid Bigdelian
- Pediatric Cardiovascular Research Center, Cardiovascular Research Institute Isfahan University of Medical Sciences Isfahan Iran
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Freud LR, Seed M. Prenatal Diagnosis and Management of Single Ventricle Heart Disease. Can J Cardiol 2022; 38:897-908. [DOI: 10.1016/j.cjca.2022.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 03/27/2022] [Accepted: 04/04/2022] [Indexed: 12/18/2022] Open
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Sinha R, Altin HF, McCracken C, Well A, Rosenblum J, Kanter K, Kogon B, Alsoufi B. Effect of Atrioventricular Valve Repair on Multistage Palliation Results of Single-Ventricle Defects. Ann Thorac Surg 2021; 111:662-670. [DOI: 10.1016/j.athoracsur.2020.03.126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 03/17/2020] [Accepted: 03/30/2020] [Indexed: 11/30/2022]
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Abstract
Tricuspid atresia (TA) is a complex congenital heart disease that presents with cyanosis in the neonatal period. It is invariably fatal if left untreated and requires multiple stages of palliation. Early recognition and timely surgical intervention are therefore pivotal in the management of these infants. This literature review considers the pathophysiology, presentation, investigations, and classification of TA. Moreover, it discusses the evidence upon which the latest medical and surgical treatments are based, as well as numerous recent case reports. Further work is needed to elucidate the etiology of TA, clarify the role of pharmacotherapy, and optimize the surgical management that these patients receive.
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Affiliation(s)
- Anoop S Sumal
- School of Clinical Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Harry Kyriacou
- School of Clinical Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Ahmed M H A M Mostafa
- School of Clinical Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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Alsoufi B, McCracken C, Kanter K, Shashidharan S, Border W, Kogon B. Outcomes of Multistage Palliation of Infants With Single Ventricle and Atrioventricular Septal Defect. World J Pediatr Congenit Heart Surg 2019; 11:39-48. [DOI: 10.1177/2150135119885890] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background: Published palliation outcomes of infants with functional single ventricle (SV) and common atrioventricular septal defect (AVSD) are poor due to associated cardiac and extracardiac anomalies and development of atrioventricular valve (AVV) regurgitation. We report current palliation results. Methods: From 2002 to 2012, 80 infants with functional SV with AVSD underwent multistage palliation. Competing-risks analyses modeled events after first-stage surgery and Glenn (death/transplantation vs next palliation surgery) and examined factors associated with survival and AVV intervention. Results: Sixty-eight (80%) patients received neonatal palliation: modified Blalock-Taussig shunt (n = 33, 41%), Norwood (n = 20, 25%), and pulmonary artery band (n = 15, 19%), whereas 12 (15%) received primary Glenn. On competing-risks analysis, one-year following first-stage surgery, 29% of patients had died or received transplantation and 62% had undergone Glenn. Five years following Glenn, 9% of patients had died or received transplantation and 68% had undergone Fontan. Overall eight-year survival was 64% and was lower in patients with genetic syndromes (53% vs 82%), patients requiring concomitant total anomalous pulmonary venous connection repair (53% vs 69%), and those requiring neonatal palliation (48% vs 100%). Factors associated with mortality were unplanned reoperation (hazard ratio [HR]: 3.7 [1.7-8.0], P = .001) and extracorporeal membrane oxygenation use (HR: 7.1 [3.0-16.6], P < .001). Initial AVV regurgitation ≥ moderate was associated with AVV intervention (HR: 6.2 [2.4-16.1], P = .002) with eight-year freedom from death or AVV intervention of 25% in those patients. Conclusions: Patients with SV with AVSD are a distinct group and commonly have associated cardiac and extracardiac malformations that complicate care and affect survival. The development of AVV regurgitation requiring intervention is common but does not affect survival.
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Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children’s Hospital, Louisville, KY, USA
| | - Courtney McCracken
- Division of Pediatric Cardiology, Emory University and Children’s Healthcare of Atlanta, Druid Hills, GA, USA
| | - Kirk Kanter
- Division of Cardiothoracic Surgery, Emory University and Children’s Healthcare of Atlanta, Druid Hills, GA, USA
| | - Subhadra Shashidharan
- Division of Cardiothoracic Surgery, Emory University and Children’s Healthcare of Atlanta, Druid Hills, GA, USA
| | - William Border
- Division of Pediatric Cardiology, Emory University and Children’s Healthcare of Atlanta, Druid Hills, GA, USA
| | - Brian Kogon
- Division of Cardiothoracic Surgery, University of Mississippi Medical Center, Jackson, MS, USA
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De Jesus-Brugman N, Hobson MJ, Herrmann JL, Friedman ML, Cordes T, Mastropietro CW. Improved outcomes in neonates who require venoarterial extracorporeal membrane oxygenation after the Norwood procedure. Int J Artif Organs 2019; 43:180-188. [PMID: 31623516 DOI: 10.1177/0391398819882020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation after the Norwood procedure has historically been associated with poor outcomes, with reported hospital survival rates of 13%-48%. We hypothesized that contemporary outcomes in this population have improved. We aimed to compare clinical outcomes of contemporary cohorts of patients with functional single ventricle physiology who did and did not receive extracorporeal membrane oxygenation after the Norwood procedure. METHODS Single-center retrospective cohort study of patients with single ventricle anatomy who underwent the Norwood procedure between 2009 and 2017 was performed. Kaplan-Meier survival curves were constructed, and Cox proportional hazard regression analyses were performed to compare transplant-free survival in patients who did and did not receive venoarterial extracorporeal membrane oxygenation. RESULTS In total, 85 patients met inclusion criteria. Venoarterial extracorporeal membrane oxygenation was utilized in 25 patients (29%). A total of 18 patients (72%) who received venoarterial extracorporeal membrane oxygenation survived to hospital discharge, compared to 54 patients (92%) who did not receive venoarterial extracorporeal membrane oxygenation (p = 0.013). Post-discharge transplant-free survival was not significantly different between patients who did and did not receive venoarterial extracorporeal membrane oxygenation (log-rank p value = 0.28). Cox proportional hazard regression analysis revealed that the occurrence of cardiac arrest requiring cardiopulmonary resuscitation (hazard ratio = 4.5; 95% confidence interval = 2.0-10.1) during the perioperative period was independently associated with death or transplantation, whereas venoarterial extracorporeal membrane oxygenation was not an independent risk factor for death or transplantation (hazard ratio = 2.0; 95% confidence interval = 0.8-4.9). CONCLUSION In our cohort of children who received venoarterial extracorporeal membrane oxygenation after the Norwood procedure, hospital survival was improved compared to historical data. In addition, venoarterial extracorporeal membrane oxygenation utilization was not independently associated with worse outcomes.
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Affiliation(s)
- Nicole De Jesus-Brugman
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Michael Joe Hobson
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Jeremy L Herrmann
- Department of Surgery, Division of Vascular and Cardiothoracic Surgery, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Matthew L Friedman
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Timothy Cordes
- Department of Pediatrics, Division of Cardiology, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Christopher W Mastropietro
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
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Tanem J, Rudd N, Rauscher J, Scott A, Frommelt MA, Hill GD. Survival After Norwood Procedure in High-Risk Patients. Ann Thorac Surg 2019; 109:828-833. [PMID: 31520639 DOI: 10.1016/j.athoracsur.2019.07.070] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 07/08/2019] [Accepted: 07/23/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Multiple single-ventricle populations are noted to be at increased risk for mortality after the Norwood procedure. Preoperative risk factors include low birth weight, restrictive/intact atrial septum, obstructed pulmonary veins, ventricular dysfunction, and atrioventricular valve regurgitation. We report outcomes of the Norwood procedure in standard- and high-risk patients in the recent era. METHODS All patients born with hypoplastic left heart syndrome between 2006 and 2016 who underwent a Norwood procedure at our institution were included. Patient data were retrospectively reviewed, and Kaplan-Meier analysis was used to evaluate survival between groups. RESULTS The cohort included 177 patients. Fifty patients were determined high-risk preoperatively: low birth weight (n = 18), ventricular dysfunction/atrioventricular valve regurgitation (n = 13), intact or restrictive atrial septum/obstructed anomalous pulmonary venous return (n = 14), and multiple factors (n = 5). There were 2 (1.6%) deaths before Glenn in the standard-risk group, with a total of 10 (20%) from the high-risk groups (P < .0001). Survival at 1 year differed greatly between groups, with highest being standard risk at 89% and lowest in the intact septum/obstructed veins group at 54%. The difference between groups in long-term survival was significant (P < .001). CONCLUSIONS Outcomes after the Norwood procedure have improved for standard-risk patients. Those with preoperative risk factors account for most of the early deaths after the Norwood procedure. This high-risk status does not resolve after Glenn, because longer-term survival continues to diverge from the standard-risk group.
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Affiliation(s)
- Jena Tanem
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and the Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin.
| | - Nancy Rudd
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and the Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Jennifer Rauscher
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and the Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Ann Scott
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and the Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Michele A Frommelt
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and the Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Garick D Hill
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and the Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
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Hill GD, Tanem J, Ghanayem N, Rudd N, Ollberding NJ, Lavoie J, Frommelt M. Selective Use of Inpatient Interstage Management After Norwood Procedure. Ann Thorac Surg 2019; 109:139-147. [PMID: 31518582 DOI: 10.1016/j.athoracsur.2019.07.062] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 07/08/2019] [Accepted: 07/22/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND We report our intermediate-term results after Norwood procedure, including use of an interstage inpatient management strategy for high-risk patients, and seek to create a predictive model for probability of discharge. METHODS A single-site retrospective review was conducted for all patients undergoing Norwood procedure from 2006 to 2016 (N = 177). We compared those discharged home with those who either remained hospitalized until Glenn procedure or died before Norwood procedure discharge. Multivariable logistic regression was used to develop a predictive model for discharge. RESULTS During the study period, 120 (68%) patients were discharged home, 45 (25%) remained hospitalized, and 12 (7%) died before Glenn procedure (median age: 71 days). Interstage survival for those discharged after Norwood procedure was 100%. Longitudinal survival for the cohort was 86%, 81%, and 77% at 1, 5, and 10 years, resepectively. Ten-year survival was significantly greater for the discharged group compared with the interstage inpatients (86% vs 56%, P < .001). A reduced predictive model of discharge included lower gestational age (odds ratio [OR]: 0.95), lower median income for ZIP code (OR: 0.4), lower birth-weight-for-age z-score (OR: 0.56), longer cardiopulmonary bypass time (OR: 0.45), and Blalock-Taussig shunt (OR: 0.32). CONCLUSIONS Survival up to 10 years after Norwood procedure is good using a strategy of inpatient care for a subset of high-risk patients to mitigate home interstage mortality. A probabilistic model used after Norwood procedure was able to predict interstage discharge with good accuracy, but will require external validation to ensure generalizability. Further work is also needed to determine optimal palliative pathways for the high-risk patients because of the notable attrition beyond successful bidirectional Glenn procedure.
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Affiliation(s)
- Garick D Hill
- Department of Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio.
| | - Jena Tanem
- Department of Pediatric Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Nancy Ghanayem
- Department of Pediatric Critical Care, Texas Children's Hospital, Houston, Texas
| | - Nancy Rudd
- Department of Pediatric Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Nicholas J Ollberding
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio; Department of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Julie Lavoie
- Department of Pediatric Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Michele Frommelt
- Department of Pediatric Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
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Lu C, Yu L, Wei J, Chen J, Zhuang J, Wang S. Predictors of postoperative outcomes in infants with low birth weight undergoing congenital heart surgery: a retrospective observational study. Ther Clin Risk Manag 2019; 15:851-860. [PMID: 31371972 PMCID: PMC6628950 DOI: 10.2147/tcrm.s206147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 05/27/2019] [Indexed: 11/23/2022] Open
Abstract
Background Despite improvements in neonatal cardiac surgery and postoperative care, hospitalized death for infants with low birth weight remains high. Objective This study sought to identify predictors of postoperative outcomes in low-birth-weight infants undergoing congenital heart surgery and establish nomograms to predict postoperative intensive-care unit (ICU) stay. Methods From June 2009 to June 2018, a retrospective review of 114 infants with low birth weight (≤2.5 kg) undergoing congenital heart surgery was conducted at Guangdong Provincial People’s Hospital. Purely surgical ligation of patent ductus arteriosus was excluded from this study. A total of 26 clinical variables were chosen for univariate, multivariate, and Cox regression analysis, and 14 variables were analyzed as predictors of postoperative outcomes. Nomograms were established to predict risk of postoperative cardiac ICU (CICU) stay, postoperative neonatal ICU (NICU) stay, and total ICU length of stay in infants with cardiac diseases. Results Two variables were independent predictors in multiple logistic regression analysis of hospitalized death: operation weight and Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery (STAT) risk categories. Six variables were independent predictors in the Cox model of postoperative ICU length of stay, including sex, prematurity, birth weight, preoperative stay time in NICU, diagnostic classification, and STAT risk categories. We calculated concordance-index values to estimate the discriminative ability of models of risk of postoperative CICU stay, postoperative NICU stay, and total ICU length of stay, with values of 0.758 (95% CI 0.696–0.820), 0.604 (95% CI 0.525–0.682), and 0.716 (95% CI 0.657–0.776), which indicated the possibility of true-positive results. Conclusion Our findings might help clinicians predict postoperative outcomes and optimize therapeutic strategies.
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Affiliation(s)
- Chao Lu
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Lina Yu
- Department of Anesthesiology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China
| | - Jinfeng Wei
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Jimei Chen
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Jian Zhuang
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Sheng Wang
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
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Zielonka B, Snarr BS, Liu MY, Zhang X, Mascio CE, Fuller S, Gaynor JW, Spray TL, Rychik J. Resource Utilization for Prenatally Diagnosed Single-Ventricle Cardiac Defects: A Philadelphia Fetus-to-Fontan Cohort Study. J Am Heart Assoc 2019; 8:e011284. [PMID: 31140350 PMCID: PMC6585367 DOI: 10.1161/jaha.118.011284] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Healthcare resource utilization is substantial for single‐ventricle cardiac defects (SVCD), with effort commencing at time of fetal diagnosis through staged surgical palliation. We sought to characterize and identify variables that influence resource utilization for SVCD from fetal diagnosis through death, completed staged palliation, or cardiac transplant. Methods and Results Patients with a prenatal diagnosis of SVCD at our institution from 2004 to 2011 were screened. Patients delivered with intent to treat who received cardiac care exclusively at our institution were included. Primary end points included the total days hospitalized and the numbers of echocardiograms and cardiac catheterizations. Subanalysis was performed on survivors of completed staged palliation on the basis of Norwood operation, dominant ventricular morphology, and additional risk factors. Of 202 patients born with intent to treat, 136 patients survived to 6 months after completed staged palliation. The median number of days hospitalized per patient‐year was 25.1 days, and the median numbers of echocardiograms and catheterizations per patient‐year were 7.2 and 0.7, respectively. Mortality is associated with increased resource utilization. Survivors had a cumulative length of stay of 57 days and underwent a median of 21 echocardiograms and 2 catheterizations through staged palliation. Right‐ventricle–dominant lesions requiring Norwood operation are associated with increased resource utilization among survivors of staged palliation. Conclusions For fetuses with SVCD, those with dominant right‐ventricular morphology requiring Norwood operation demand increased resource utilization regardless of mortality. Our findings provide insight into care for SVCD, facilitate precise prenatal counseling, and provide information about the resources utilized to successfully manage SVCD.
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Affiliation(s)
- Benjamin Zielonka
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Brian S Snarr
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Michael Y Liu
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Xuemei Zhang
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Christopher E Mascio
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Stephanie Fuller
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - J William Gaynor
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Thomas L Spray
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Jack Rychik
- 1 Divisions of Cardiology and Cardiothoracic Surgery The Children's Hospital of Philadelphia and the Departments of Pediatrics and Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
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Alsoufi B, McCracken C, Kochilas LK, Clabby M, Kanter K. Factors Associated With Interstage Mortality Following Neonatal Single Ventricle Palliation. World J Pediatr Congenit Heart Surg 2018; 9:616-623. [DOI: 10.1177/2150135118787723] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background: Several advances have led to improved hospital survival following neonatal palliation (NP) of single ventricle (SV) anomalies. Nonetheless, a number of patients continue to suffer from interstage mortality (ISM) prior to subsequent Glenn. We aim to study patients’ characteristics and anatomic, surgical, and clinical details associated with ISM. Methods: A total of 453 SV neonates survived to hospital discharge following NP. Competing risk analysis modeled events after NP (Glenn, transplantation, or death) and examined variables associated with ISM. Results: Competing risk analysis showed that one year following NP, 10% of patients had died, 87% had progressed to Glenn, 1% had received heart transplantation, and 2% were alive without subsequent surgery. On multivariable analysis, factors associated with ISM were as follows: weight ≤2.5 kg (hazard ratio, HR = 2.4 [1.2-4.6], P = .013), premature birth ≤36 weeks (HR = 2.0 [1.0-4.0], P = .05), genetic syndromes (HR = 3.2 [1.7-6.1], P < .001), unplanned cardiac reoperation (HR = 2.1 [1.0-4.4], P = .05), and prolonged intensive care unit (ICU) stay >30 days following NP (HR = 2.5 [1.4-4.5], P < .001). Palliative surgery type (shunt, Norwood, band) was not associated with ISM, although aortopulmonary shunt circulation after Norwood was (HR = 5.4 [1.5-19.2] P = .01). Of interest, underlying SV anatomy was not associated with ISM (HR = 1.1 [0.6-2.2], P = .749). Conclusions: In our series, ISM following NP occurred in 10% of hospital survivors. As opposed to hospital death, underlying SV anomaly was not associated with ISM. Conversely, several patient factors (prematurity, low weight, and genetic syndromes) and clinical factors (unplanned reoperation and prolonged ICU stay following NP) were associated with ISM. Vigilant outpatient management that is individualized to specific clinical and social needs, taking into account all associated factors, is warranted to improve survival in high-risk patients.
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Affiliation(s)
- Bahaaldin Alsoufi
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Courtney McCracken
- Sibley Heart Center, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Lazaros K. Kochilas
- Sibley Heart Center, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Martha Clabby
- Sibley Heart Center, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Kirk Kanter
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
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Alsoufi B, McCracken C, Oster M, Shashidharan S, Kanter K. Genetic and Extracardiac Anomalies Are Associated With Inferior Single Ventricle Palliation Outcomes. Ann Thorac Surg 2018; 106:1204-1212. [DOI: 10.1016/j.athoracsur.2018.04.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 04/10/2018] [Accepted: 04/18/2018] [Indexed: 12/20/2022]
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20
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DiLorenzo MP, Elci OU, Wang Y, Banerjee A, Sato T, Ky B, Goldmuntz E, Mercer-Rosa L. Longitudinal Changes in Right Ventricular Function in Tetralogy of Fallot in the Initial Years after Surgical Repair. J Am Soc Echocardiogr 2018; 31:816-821. [PMID: 29627138 PMCID: PMC6035101 DOI: 10.1016/j.echo.2018.02.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Right ventricular (RV) dysfunction is associated with adverse long-term outcomes in patients with tetralogy of Fallot. Little is known about RV function in the first years after surgical repair. The aim of this study was to investigate perioperative changes in myocardial deformation using global longitudinal strain. METHODS A retrospective analysis of patients with surgically repaired tetralogy of Fallot was performed. Global longitudinal peak systolic RV strain was measured on early postoperative echocardiograms, two subsequent postoperative echocardiograms through 2 years postoperatively, and preoperative echocardiograms, when available. Preoperative and late follow-up strain was compared with strain in 0- to 8-month-old and 1- to 4-year-old control subjects, respectively. RESULTS Forty-seven patients were included. Compared with postoperative strain (7 ± 7 days postoperatively), strain at follow-up 1 (8.3 ± 4 months postoperatively) was significantly improved (-12.3 ± 3.3% vs -18.8 ± 2.5%, P < .001), with no additional improvement 23.2 ± 6 months postoperatively (-18.8 ± 2.5% vs -19.8 ± 3.1%, P = .12). Postoperative strain was worse than preoperative strain (n = 25, -12.5 ± 3.6% vs -18.4 ± 2.9%, P < .001). Compared with control subjects, preoperative strain was similar (-19.3 ± 3.8% vs -18.4 ± 2.9%, P = .30), though late follow-up strain was significantly worse (-27.7 ± 2.8% vs -19.8 ± 3.1%, P < .001). CONCLUSIONS RV global longitudinal strain worsens in the early postoperative period following surgical repair of tetralogy of Fallot but recovers through 2 postoperative years. Despite recovery to preoperative values, the presence of RV dysfunction compared with control subjects suggests that long-term dysfunction may begin early. The trajectory of RV dysfunction through the later years needs further study.
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Affiliation(s)
- Michael P DiLorenzo
- Division of Pediatric Cardiology, Department of Pediatrics, New York-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York.
| | - Okan U Elci
- Biostatistics and Data Management Core, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yan Wang
- Division of Pediatric Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Anirban Banerjee
- Division of Pediatric Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Tomoyuki Sato
- Division of Pediatric Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Bonnie Ky
- Penn Cardiovascular Institute, Department of Medicine, Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Biostatistics and Epidemiology, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth Goldmuntz
- Division of Pediatric Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Laura Mercer-Rosa
- Division of Pediatric Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Alsoufi B, Sinha R, McCracken C, Figueroa J, Altin F, Kanter K. Outcomes and risk factors associated with tricuspid valve repair in children with hypoplastic left heart syndrome†. Eur J Cardiothorac Surg 2018; 54:993-1000. [DOI: 10.1093/ejcts/ezy198] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 04/19/2018] [Indexed: 11/15/2022] Open
Affiliation(s)
- Bahaaldin Alsoufi
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Raina Sinha
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Courtney McCracken
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Janet Figueroa
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Firat Altin
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Kirk Kanter
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
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22
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Alsoufi B, McCracken C, Kanter K, Shashidharan S, Kogon B. Current Results of Single Ventricle Palliation of Patients With Double Inlet Left Ventricle. Ann Thorac Surg 2017; 104:2064-2071. [DOI: 10.1016/j.athoracsur.2017.04.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 04/08/2017] [Accepted: 04/12/2017] [Indexed: 11/28/2022]
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Abstract
BACKGROUND Numerous advances in surgical techniques and understanding of single-ventricle physiology have resulted in improved survival. We sought to determine the influence of various demographic, perioperative, and patient-specific factors on the survival of single-ventricle patients following stage 1 palliation at our institution. METHODS We conducted a retrospective study of all single-ventricle patients who had undergone staged palliation at our institution over an 8-year period. Data were collected from the Society of Thoracic Surgeons Congenital Heart Surgery database and from patient charts. Information on age, weight at stage 1 palliation, prematurity, genetic abnormalities, non-cardiac anomalies, ventricular dominance, and type of palliation was collected. Information on mortality and unplanned reinterventions was also collected. RESULTS A total of 72 patients underwent stage 1 palliation over an 8-year period. There were 12 deaths before and one death after stage 2 palliation. There was no hospital mortality following Glenn or Fontan procedures. On univariate analysis, low weight at the time of stage 1 palliation and prematurity were found to be risk factors for mortality following stage 1 palliation. However, multivariable Cox regression analysis revealed weight at stage 1 palliation to be a strong predictor of mortality. The type of stage 1 palliation did not have any influence on the outcome. No difference in survival was noted following the Glenn procedure. CONCLUSION Low weight has a deleterious impact on survival following stage 1 palliation. This is mitigated by stage 2 palliation. The type of stage 1 palliation itself has no bearing on the outcome.
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Alsoufi B, McCracken C, Shashidharan S, Deshpande S, Kanter K, Kogon B. The Impact of 22q11.2 Deletion Syndrome on Surgical Repair Outcomes of Conotruncal Cardiac Anomalies. Ann Thorac Surg 2017; 104:1597-1604. [PMID: 28669502 DOI: 10.1016/j.athoracsur.2017.04.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 04/09/2017] [Accepted: 04/11/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND We aim to describe the impact of 22q11.2 deletion syndrome (22q11DS) on clinical characteristics, postoperative course, and early and late outcomes of neonates undergoing surgery for conotruncal anomalies. METHODS A retrospective review was performed (2002 to 2012) of 224 neonates who underwent surgery for interrupted aortic arch (n = 67), truncus arteriosus (n = 85), or ductal-dependent pulmonary atresia and ventricular septal defect (n = 72). Patients were divided into three groups: group 1, n = 119, no genetic syndrome; group 2, n = 64, 22q11DS; and group 3, n = 41, other genetic syndrome. Adjusted analysis to compare outcomes was performed. RESULTS In comparison with group 1, group 2 had longer mechanical ventilation duration (148 versus 102 hours, p = 0.008), intensive care unit stay (268 versus 159 hours, p < 0.001), and hospital stay (19.3 versus 11.5 days, p < 0.001). On adjusted analysis, there was an insignificant increase in unplanned reoperation (odds ratio [OR] 2.4, 95% confidence interval [CI]: 0.7 to 8.4, p = 0.167) but no increased extracorporeal membrane oxygenation use (OR 1.5, 95% CI: 0.3 to 6.1, p = 0.612), hospital mortality (OR 0.6, 95% CI: 0.1 to 3.3, p = 0.570), or decreased late survival (hazard ratio 0.9, 95% CI: 0.4 to 2.1, p = 0.822). In comparison with group 1, group 3 had longer mechanical ventilation duration (190 versus 102 hours, p < 0.001), intensive care unit stay (236 versus 159 hours, p = 0.007), and hospital stay (21.5 versus 11.5 days, p < 0.001); and increased unplanned reoperation (OR 3.7, 95% CI: 1.1 to 12.5, p = 0.032), extracorporeal membrane oxygenation use (OR 4.4, 95% CI: 1.1 to 17.6, p = 0.038), hospital mortality (OR 4.2, 95% CI: 1.2 to 14.5, p = 0.021), and diminished late survival (hazard ratio 4.0, 95% CI: 2.1 to 8.1, p < 0.001). CONCLUSIONS In neonates with conotruncal anomalies, 22q11DS is associated with prolonged recovery and increased resource utilization. However, despite a small increase in unplanned reoperation, there is no significant impact on early or late survival. In comparison, other genetic syndromes are associated with increased unplanned reoperation, extracorporeal membrane oxygenation use, hospital mortality, and diminished late survival. These findings are important for family counseling and risk stratification.
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Affiliation(s)
- Bahaaldin Alsoufi
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia.
| | - Courtney McCracken
- Sibley Heart Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Subhadra Shashidharan
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Shriprasad Deshpande
- Sibley Heart Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Kirk Kanter
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Brian Kogon
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
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Chittithavorn V, Duangpakdee P, Rergkliang C, Pruekprasert N. Risk factors for in-hospital shunt thrombosis and mortality in patients weighing less than 3 kg with functionally univentricular heart undergoing a modified Blalock–Taussig shunt†. Interact Cardiovasc Thorac Surg 2017; 25:407-413. [DOI: 10.1093/icvts/ivx147] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 04/14/2017] [Indexed: 12/13/2022] Open
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Evans CF, Sorkin JD, Abraham DS, Wehman B, Kaushal S, Rosenthal GL. Interstage Weight Gain Is Associated With Survival After First-Stage Single-Ventricle Palliation. Ann Thorac Surg 2017; 104:674-680. [PMID: 28347534 DOI: 10.1016/j.athoracsur.2016.12.031] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 12/11/2016] [Accepted: 12/19/2016] [Indexed: 10/19/2022]
Abstract
BACKGROUND Low birth and operative weight have been identified as risk factors for death after first-stage single-ventricle palliation. We hypothesize that weight gain after the first-stage operation is associated with transplant-free interstage survival to admission for the second-stage operation. METHODS We used historical data from the National Pediatric Cardiology Quality Improvement Collaborative database to conduct a longitudinal study to assess the association between weight gain and transplant-free interstage survival. The primary predictor was weight gain. The primary outcome was transplant-free survival. We constructed a repeated-measures logistic regression model using the general estimating equation method to examine the association between weight gain and transplant-free interstage survival. RESULTS The study population included 1,501 infants who were discharged alive from the first-stage single-ventricle palliation between June 2008 and January 2015. Patients who underwent a hybrid operation (n = 132) or were lost to follow-up (n = 11) were excluded. Transplant-free interstage survival was 90% (1,228 of 1,358). The mean weight gain was 2.5 (SD, 1.0) kg. Adjusted for age at the time of each measurement, the number of measurements, age at discharge from the first-stage operation, sex, diagnosis, postoperative arrhythmia, postoperative complications, and discharge antibiotic therapy, each 100-g increase in weight was associated with an odds ratio of transplant-free interstage survival of 1.03 (95% confidence limit, 1.01, 1.05). CONCLUSIONS After first-stage single-ventricle palliation, interstage weight gain is significantly associated with transplant-free interstage survival.
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Affiliation(s)
- Charles F Evans
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland.
| | - John D Sorkin
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Danielle S Abraham
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Brody Wehman
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sunjay Kaushal
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Geoffrey L Rosenthal
- Division of Pediatric Cardiology, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland
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Talbot LJ, Sinyard RD, Rialon KL, Englum BR, Tracy ET, Rice HE, Adibe OO. Influence of weight at enterostomy reversal on surgical outcomes in infants after emergent neonatal stoma creation. J Pediatr Surg 2017; 52:35-39. [PMID: 27916444 DOI: 10.1016/j.jpedsurg.2016.10.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 10/20/2016] [Indexed: 12/29/2022]
Abstract
PURPOSE Neonates after emergent enterostomy creation frequently require reversal at low weight because of complications including cholestasis, dehydration, dumping, failure to thrive, and failure to achieve enteral independence. We investigated whether stoma reversal at low weight (< 2.5kg) is associated with poor surgical outcomes. METHODS Patients who underwent enterostomy reversal from 2005 to 2013 at less than 6months old were identified in our institutional database. Only patients who underwent emergent enterostomy creation (i.e. for necrotizing enterocolitis or spontaneous perforation) were included. Demographics, disease process, comorbidities, stoma type, reversal indication, operative details, and complications were examined. Patients were categorized by weight at reversal of less than 2kg, 2.01-2.5kg, 2.51-3.5kg, and greater than 3.5kg. Data were analyzed using univariable and multivariable regression with significance level of p<0.05. The primary outcome examined was major morbidity, defined as the presence of anastomotic leak, obstruction, hernia, EC fistula, perforation, wound infection, sepsis, or death. RESULTS Eighty-nine patients met inclusion criteria. Demographics (sex, ethnicity, surgical disease process, reversal indication, and ASA score) were similar. The lowest weight group had lower gestational age (p<0.001) and birth weight (p=0.005), and contained a higher proportion of jejunostomies to ileostomies (p=0.013). On univariable analysis, only incisional hernia was significantly different as a complication between weight groups. On multivariable analysis controlling for gestational age and ASA, there was no significant difference in odds of major operative morbidity between groups. CONCLUSIONS Enterostomy reversal at lower weight may not be associated with increased risk of perioperative complications. Early stoma reversal may be acceptable when required for progression of neonatal care. LEVEL OF EVIDENCE Level III, Treatment Study (Retrospective comparative study).
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Affiliation(s)
| | - Robert D Sinyard
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Kristy L Rialon
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Brian R Englum
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Elizabeth T Tracy
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC, USA
| | - Henry E Rice
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC, USA
| | - Obinna O Adibe
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC, USA
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Palliation Outcomes of Neonates Born With Single-Ventricle Anomalies Associated With Aortic Arch Obstruction. Ann Thorac Surg 2016; 103:637-644. [PMID: 27592600 DOI: 10.1016/j.athoracsur.2016.06.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 06/07/2016] [Accepted: 06/13/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND The two most common surgical strategies for the treatment of neonates born with single-ventricle anomalies associated with aortic arch obstruction are the Norwood operation and pulmonary artery banding plus coarctation repair (PAB+COA). We reviewed characteristics and outcomes of neonates who underwent those two surgical strategies at our institution. METHODS Between 2002 and 2012, 94 neonates with a single ventricle and aortic arch obstruction (excluding hypoplastic left heart syndrome) underwent Norwood (n = 65) or PAB+COA (n = 29). Outcomes were parametrically modeled, and risk factors associated with early and late death were analyzed. RESULTS Competing-risks analysis showed that, at 2 years after the operation, 24% of patients had died or received transplantation and 75% had undergone a Glenn shunt. At 5 years after the Glenn shunt, 10% of patients had died or received transplantation, 62% had undergone Fontan, and 28% were alive awaiting Fontan. Overall 8-year survival was 70%. Outcomes after Norwood included extracorporeal membrane oxygenation use in 9 (14%), unplanned reoperation in 13 (20%), hospital death in 10 (15%), and interstage death in 8 (12%), with 8-year survival of 66%. Outcomes after PAB+COA included extracorporeal membrane oxygenation use in 1 (3%), unplanned reoperation in 9 (30%), hospital death in 1 (3%), and interstage death in 3 (10%), with 8-year survival of 76%. There was an association trend between underlying anatomy and survival (hazard ratio [HR], 2.1; 95% confidence interval [CI], 0.9 to 4.7; p = 0.087). On multivariable analysis, factors associated with death were extracorporeal membrane oxygenation use (HR, 5.5; 95% CI, 1.9 to 15.9; p = 0.002), genetic syndromes/extracardiac anomalies (HR, 3.5; 95% CI, 1.5 to 8.2; p = 0.003), and weight of 2.5 kg or less (HR, 3.0; 95% CI, 1.3 to 7.2; p = 0.012). CONCLUSIONS Anatomic and patient characteristics influence palliation outcomes in neonates born with single-ventricle anomalies associated with aortic arch obstruction. Although the Norwood operation is applicable in most of these patients, the PAB+COA strategy is a valid alternative in well-selected patients.
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Outcomes of neonates requiring prolonged stay in the intensive care unit after surgical repair of congenital heart disease. J Thorac Cardiovasc Surg 2016; 152:720-727.e1. [DOI: 10.1016/j.jtcvs.2016.04.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 04/08/2016] [Accepted: 04/13/2016] [Indexed: 12/31/2022]
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Alsoufi B, Gillespie S, Kim D, Shashidharan S, Kanter K, Maher K, Kogon B. The Impact of Dominant Ventricle Morphology on Palliation Outcomes of Single Ventricle Anomalies. Ann Thorac Surg 2016; 102:593-601. [DOI: 10.1016/j.athoracsur.2016.04.054] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 04/14/2016] [Accepted: 04/18/2016] [Indexed: 11/16/2022]
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Mah DY, Cheng H, Alexander ME, Sleeper L, Newburger JW, del Nido PJ, Thiagarajan RR, Rajagopal SK. Heart block following stage 1 palliation of hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2016; 152:189-94. [DOI: 10.1016/j.jtcvs.2016.03.074] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 03/25/2016] [Accepted: 03/31/2016] [Indexed: 11/28/2022]
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Alsoufi B, McCracken C, Schlosser B, Sachdeva R, Well A, Kogon B, Border W, Kanter K. Outcomes of multistage palliation of infants with functional single ventricle and heterotaxy syndrome. J Thorac Cardiovasc Surg 2016; 151:1369-77.e2. [DOI: 10.1016/j.jtcvs.2016.01.054] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 12/22/2015] [Accepted: 01/23/2016] [Indexed: 01/15/2023]
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Alsoufi B, Gillespie S, Mori M, Clabby M, Kanter K, Kogon B. Factors affecting death and progression towards next stage following modified Blalock-Taussig shunt in neonates. Eur J Cardiothorac Surg 2016; 50:169-77. [DOI: 10.1093/ejcts/ezw017] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 12/29/2015] [Indexed: 12/13/2022] Open
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Alsoufi B, Gillespie S, Mahle WT, Deshpande S, Kogon B, Maher K, Kanter K. The Effect of Noncardiac and Genetic Abnormalities on Outcomes Following Neonatal Congenital Heart Surgery. Semin Thorac Cardiovasc Surg 2015; 28:105-14. [PMID: 27568146 DOI: 10.1053/j.semtcvs.2015.10.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2015] [Indexed: 11/11/2022]
Abstract
Significant noncardiac and genetic abnormalities (NC and GA) are common in neonates with congenital heart defects. We sought to examine current-era effect of those abnormalities on early and late outcomes following cardiac surgery. The method from 2002-2012, 1538 neonates underwent repair (n = 860, 56%) or palliation (n = 678, 44%) of congenital heart defects. Regression models examined the effect of NC and GA on operative results, resource utilization, and late outcomes. Neonates with NC and GA (n = 312, 20%) had higher incidence of prematurity (21% vs 13%; P < 0.001) and weight ≤2.5kg (24% vs 12%; P < 0.001) than neonates without NC and GA (n = 1226, 80%). Although the incidence of single ventricle was comparable (34% vs 31%; P = 0.37), neonates with NC and GA underwent more palliation (52% vs 42%; P = 0.001) and subsequently had higher percentage of STAT mortality categories (Society of Thoracic Surgeons (STS) and the European Association for Cardio-thoracic Surgery (EACTS) Congenital Heart Surgery Mortality Categories) 4 and 5 procedures (78% vs 66%; P < 0.001). Adjusted logistic regression models that included disparate patient and operative variables showed that the presence of NC and GA was associated with increased unplanned reoperation (odds ratio = 1.7; 95% CI: 1.1-2.7; P = 0.03) and hospital mortality (odds ratio = 2.2; 95% CI: 1.3-3.6; P = 0.002). Adjusted linear regression models showed significant association between NC and GA and increased postoperative mechanical ventilation duration, intensive care unit, and hospital stays (P < 0.001 each). Adjusted hazard analysis showed that the presence of NC and GA was associated with diminished late survival (hazard ratio = 2.4; 95% CI: 1.9-3.1; P < 0.001) and that was evident in all subgroups of patients (P < 0.001 each). Conclusion is neonates with NC and GA commonly have associated risk factors for morbidity and mortality such as prematurity and low weight. After adjusting for those factors, the presence of NC and GA continues to have significant association with increased unplanned reoperation, hospital mortality, and resource utilization after palliative and corrective cardiac surgery. Importantly, the hazard of death in those patients continues beyond the perioperative period for at least 1 year. Our findings show that the presence of NC and GA should be emphasized during parent counseling and decision making; and underscore the need to explore strategies to improve outcomes for this high-risk population that must address perioperative care, outpatient surveillance, and management.
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Affiliation(s)
- Bahaaldin Alsoufi
- Division of Cardiothoracic Surgery, Children׳s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia.
| | - Scott Gillespie
- Sibley Heart Center, Children׳s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - William T Mahle
- Sibley Heart Center, Children׳s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Shriprasad Deshpande
- Sibley Heart Center, Children׳s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Brian Kogon
- Division of Cardiothoracic Surgery, Children׳s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Kevin Maher
- Sibley Heart Center, Children׳s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Kirk Kanter
- Division of Cardiothoracic Surgery, Children׳s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
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Results of Primary Repair Versus Shunt Palliation in Ductal Dependent Infants With Pulmonary Atresia and Ventricular Septal Defect. Ann Thorac Surg 2015; 100:639-46. [DOI: 10.1016/j.athoracsur.2015.05.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 05/03/2015] [Accepted: 05/05/2015] [Indexed: 12/17/2022]
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Impact of Patient Characteristics and Anatomy on Results of Norwood Operation for Hypoplastic Left Heart Syndrome. Ann Thorac Surg 2015; 100:591-8. [DOI: 10.1016/j.athoracsur.2015.03.106] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 03/23/2015] [Accepted: 03/25/2015] [Indexed: 11/19/2022]
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Alsoufi B, Schlosser B, Mori M, McCracken C, Slesnick T, Kogon B, Petit C, Sachdeva R, Kanter K. Influence of Morphology and Initial Surgical Strategy on Survival of Infants With Tricuspid Atresia. Ann Thorac Surg 2015; 100:1403-9; discussion 1409-10. [PMID: 26233275 DOI: 10.1016/j.athoracsur.2015.05.037] [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] [Received: 01/29/2015] [Revised: 05/06/2015] [Accepted: 05/08/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Tricuspid atresia (TA) is a heterogeneous single-ventricle anomaly in which initial presentation and, consequently, timing and mode of palliation vary based on morphology and degree of pulmonary or systemic outflow obstruction. We report current era palliation outcomes and examine whether morphologic and, subsequently, surgical factors influence survival. METHODS From 2002 to 2012, 105 infants with TA underwent surgical palliation. Competing risks analyses modeled events after first-stage surgery (Glenn versus death) and after Glenn (Fontan versus death) and examined risk factors affecting outcomes. RESULTS Seventy-eight patients (74%) required neonatal first-stage palliation, including modified Blalock-Taussig shunt (n = 46, 44%), Norwood (n = 18, 17%), and pulmonary artery band (n = 14, 13%), whereas 27 (26%) received primary Glenn as their initial surgery. Hospital mortality was 5 patients (4.8%). Competing risks models showed that by 1 year after first-stage surgery, 15% of patients had died and 83% had undergone Glenn. By 5 years after Glenn, 2% of patients had died and 80% had undergone Fontan. Overall 8-year survival was 84%. On multivariable analysis, risk factors for mortality were genetic/extracardiac anomalies (hazard ratio 7.0, 95% confidence interval: 2.4 to 20.6, p < 0.001) and pulmonary atresia (hazard ratio 4.4, 95% confidence interval: 1.6 to 12.2, p = 0.004). Survival was not affected by initial palliation type (p = 0.36), ventriculoarterial discordance (p = 0.25), systemic outflow obstruction (p = 0.84), or arch obstruction (p = 0.62). CONCLUSIONS Despite morphologic and physiologic variations necessitating different palliative sequences, multistage palliation outcomes of various TA subtypes are comparable and generally good, with the exception of patients with associated genetic/extracardiac anomalies. The bulk of mortality is interstage, indicating continued opportunity for improvement in monitoring and managing patients during this critical period.
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Affiliation(s)
- Bahaaldin Alsoufi
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia.
| | - Brian Schlosser
- Division of Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Makoto Mori
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Courtney McCracken
- Division of Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Timothy Slesnick
- Division of Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Brian Kogon
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Christopher Petit
- Division of Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Ritu Sachdeva
- Division of Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Kirk Kanter
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
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Results of Palliation With an Initial Modified Blalock-Taussig Shunt in Neonates With Single Ventricle Anomalies Associated With Restrictive Pulmonary Blood Flow. Ann Thorac Surg 2015; 99:1639-46; discussion 1646-7. [DOI: 10.1016/j.athoracsur.2014.12.082] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 12/20/2014] [Accepted: 12/30/2014] [Indexed: 12/20/2022]
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