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Sengupta A, Gauvreau K, Lee JM, Colan SD, Emani S, Baird CW, Del Nido PJ, Nathan M. Prognostic utility of a risk prediction model for predischarge major residual lesions or unplanned reinterventions following congenital mitral valve repair. J Thorac Cardiovasc Surg 2024; 168:1192-1202.e8. [PMID: 37995862 DOI: 10.1016/j.jtcvs.2023.11.024] [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: 06/28/2023] [Revised: 10/18/2023] [Accepted: 11/15/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE We sought to develop a risk prediction model for predischarge major mitral valve (MV) residual lesions or unplanned MV reinterventions following congenital MV repair. METHODS Patients who underwent congenital MV repair (excluding primary repair, but including secondary repair, of canal-type defects) at a single institution from January 2000 to December 2020 and survived to discharge were retrospectively reviewed. The primary outcome was major MV residua (mean gradient >6 mm Hg or moderate or greater regurgitation on the discharge echocardiogram) or predischarge unplanned MV reintervention. Risk factors of interest included age, single-ventricle physiology, preoperative and intraoperative postrepair MV stenosis and regurgitation severity, MV annular diameter z score, systemic ventricle ejection fraction, unfavorable anatomy, concomitant left-heart procedure, and various technique-related categories. Logistic regression was used to develop a weighted risk score for the primary outcome. Internal validation using bootstrap-resampling was performed. RESULTS Of 866 patients who underwent congenital MV repair at a median age of 2.7 years (interquartile range, 0.7-9.1 years), 202 (23.3%) patients developed the primary outcome. The final risk prediction model had a C-statistic of 0.82 (95% confidence interval, 0.78-0.85). A weighted risk score was formulated per the variables in this model. The median risk score was 8 (interquartile range, 6-11) points. Patients were categorized as low (score 0-5), medium (score 6-10), high (score 11-15), or very high (score ≥16) risk. The probability of the primary outcome was 5.0 ± 1.7%, 15.2 ± 6.7%, 45.9 ± 12.6%, and 76.7 ± 8.8% for low-, medium-, high-, and very-high-risk patients, respectively. CONCLUSIONS Our risk prediction model may guide prognostication of patients following congenital MV repair.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Mass
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Mass
| | - Ji M Lee
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Mass
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Sitaram Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Christopher W Baird
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Pedro J Del Nido
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Meena Nathan
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass.
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McGeoghegan PB, Lu M, Sleeper LA, Emani SM, Baird CW, Feins EN, Gellis LA, Friedman KG. Cleft closure and other predictors of contemporary outcomes after atrioventricular canal repair in patients with parachute left atrioventricular valve. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae048. [PMID: 38539038 PMCID: PMC11014788 DOI: 10.1093/icvts/ivae048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/17/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVES Parachute left atrioventricular valve (LAVV) complicates atrioventricular septal defect (AVSD) repair. We evaluate outcomes of AVSD patients with parachute LAVV and identify risk factors for adverse outcomes. METHODS We evaluated all patients undergoing repair of AVSD with parachute LAVV from 2012 to 2021. The primary outcome was a composite of time-to-death, LAVV reintervention and development of greater than or equal to moderate LAVV dysfunction (greater than or equal to moderate LAVV stenosis and/or LAVV regurgitation). Event-free survival for the composite outcome was estimated using Kaplan-Meier methodology and competing risks analysis. Cox proportional hazards regression was used to identify predictors of the primary outcome. RESULTS A total of 36 patients were included with a median age at repair of 4 months (interquartile range 2.3-5.5 months). Over a median follow-up of 2.6 years (interquartile range 1.0-5.6 years), 6 (17%) patients underwent LAVV reintervention. All 6 patients who underwent LAVV reintervention had right-dominant AVSD. Sixteen patients (44%) met the composite outcome, and all did so within 2 years of initial repair. Transitional AVSD (versus complete), prior single-ventricle palliation, leaving the cleft completely open and greater than or equal to moderate preoperative LAVV regurgitation were associated with a higher risk of LAVV reintervention in univariate analysis. In multivariate analysis, leaving the cleft completely open was associated with the composite outcome. CONCLUSIONS Repair of AVSD with parachute LAVV remains a challenge with a significant burden of LAVV reintervention and dysfunction in medium-term follow-up. Unbalanced, right-dominant AVSDs are at higher risk for LAVV reintervention. Leaving the cleft completely open might independently predict poor overall outcomes and should be avoided when possible. CLINICAL TRIAL REGISTRATION NUMBER IRB-P00041642.
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Affiliation(s)
| | - Minmin Lu
- Department of Cardiology, Children’s Hospital Boston, Boston, MA, USA
| | - Lynn A Sleeper
- Department of Cardiology, Children’s Hospital Boston, Boston, MA, USA
| | - Sitaram M Emani
- Department of Cardiothoracic Surgery, Children’s Hospital Boston, Boston, MA, USA
| | - Christopher W Baird
- Department of Cardiothoracic Surgery, Children’s Hospital Boston, Boston, MA, USA
| | - Eric N Feins
- Department of Cardiothoracic Surgery, Children’s Hospital Boston, Boston, MA, USA
| | - Laura A Gellis
- Department of Cardiology, Children’s Hospital Boston, Boston, MA, USA
| | - Kevin G Friedman
- Department of Cardiology, Children’s Hospital Boston, Boston, MA, USA
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Alifu A, Wang H, Chen R. Technical performance scores associate with early prognosis of tetralogy of Fallot repair. Front Pediatr 2024; 12:1274913. [PMID: 38357504 PMCID: PMC10864547 DOI: 10.3389/fped.2024.1274913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/11/2024] [Indexed: 02/16/2024] Open
Abstract
Objective This study aimed to investigate the relationship between technical performance scores (TPS) and the early prognosis of tetralogy of Fallot repair (TOF). Methods A retrospective study was conducted on TOF repair patients at our center from Oct 2017 to Oct 2022. Patients were classified into Class 1 (no residua), Class 2 (minor residua), or Class 3 (major residua) based on TPS derived from predischarge echocardiograms and need for reintervention. Statistical methods were used to assess the association between TPS and early prognosis. Results A total of 75 TOF repair patients (40% female, 60% male) were analyzed and categorized into TPS1 (24%), TPS2 (53.3%), and TPS3 (22.6%) based on pre-discharge echocardiographic findings. The median follow-up time was 7.0 months. The multivariable Cox regression analysis indicated that TPS3 scores are associated with a 12.68-fold increase in risk compared to TPS1 and TPS2 scores [95% CI = 12.68 (0.9∼179.28), P = 0.06]. The Spearman rank correlation analysis revealed a weak positive correlation between TPS classification and low cardiac output syndrome (r = 0.26, P = 0.03). However, there were no significant differences in ICU stay or duration of mechanical ventilation among the groups. Conclusion TPS3 after intracardiac TOF repair is associated with higher risk of early re-intervention, highlighting the importance of close follow-up and monitoring in this patient population. Patients who develop low cardiac output syndrome in the early postoperative period may have residual defects that require prompt identification.
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Affiliation(s)
| | | | - Renwei Chen
- Department of Cardiothoracic Surgery, Hainan Women and Children’s Medical Center, Haikou, Hainan, China
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Kalfa D, Karamichalis JM, Singh SK, Jiang P, Anderson BR, Vargas D, Choudhury T, Habib A, Bacha E. Operative mortality after Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1 to 3 procedures: Deficiencies and opportunities for quality improvement. J Thorac Cardiovasc Surg 2023; 166:325-333.e3. [PMID: 36621456 DOI: 10.1016/j.jtcvs.2022.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 11/08/2022] [Accepted: 11/12/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVES We examined cases of operative mortality at a single quaternary academic center for patients undergoing relatively lower-risk (Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1-3) procedures, as a means of identifying systemic weaknesses and opportunities for quality improvement. METHODS A retrospective review of all operative mortality events for patients who underwent a Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1, 2, or 3 index procedure (2009-2020) at our institution was performed. After a detailed chart review was performed by 2 independent faculty for each case, factors and system deficiencies that contributed to mortality were identified. RESULTS A total of 42 mortalities were identified. A total of 37 patients (88%) had at least 1 Society of Thoracic Surgeons-designated risk factor, including prior cardiac operations (48%), extracardiac malformations (43%), and preoperative ventilation (33%). Eight patients (19%) had non-Society of Thoracic Surgeons-designated preoperative patient-level variables considered as at potential risk, including severe ventricular dysfunction, pulmonary hypertension, lung hypoplasia, and undiagnosed severe coronary abnormalities. Four patients (10%) had no identified preoperative risk factors. After detailed chart review, 5 broad categories were identified: patient-related factors (n = 33; 78%), postoperative infection (n = 13; 31%), postoperative residual lesions (n = 7; 17%), Fontan physiology failure (n = 4; 10%), and unexplained left ventricular failure after tetralogy of Fallot repair (n = 3; 7%). A total of 74% of patients had at least 1 preoperative, intraoperative, or postoperative system deficiency. A total of 50% of surgeries were urgent or emergency. CONCLUSIONS Operative mortality after Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1 to 3 procedures is related to the presence of multifactorial risk patterns (Society of Thoracic Surgeons and non-Society of Thoracic Surgeons-designated patient-level risk factors and variables, broad risk categories, system deficiencies, emergency surgery). A multidisciplinary approach to care, with early recognition and treatment of modifiable additional burdens, could reduce this risk.
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Affiliation(s)
- David Kalfa
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY.
| | - John M Karamichalis
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Sameer K Singh
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Pengfei Jiang
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Brett R Anderson
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Diana Vargas
- Division of Pediatrics, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Tarif Choudhury
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Anthony Habib
- Division of Anesthesiology, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Emile Bacha
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
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Intraoperative Technical Performance Score Predicts Outcomes After Congenital Cardiac Surgery. Ann Thorac Surg 2023; 115:471-477. [PMID: 35595087 DOI: 10.1016/j.athoracsur.2022.04.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/24/2022] [Accepted: 04/13/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The utility of the intraoperative technical performance score (IO-TPS) in predicting outcomes after congenital cardiac surgery remains unknown. METHODS Data from patients undergoing surgery for congenital heart disease from January 2011 to December 2019 at a single institution were retrospectively reviewed. Intraoperative echocardiograms were used to assign IO-TPS for each index operation (class 1, no residua; class 2, minor residua; class 3, major residua). The primary outcome was a composite of in-hospital mortality, transplant, unplanned reintervention in the anatomic area of repair, and new permanent pacemaker implantation. Secondary outcomes included postdischarge (late) mortality or transplant and unplanned reintervention. Associations between IO-TPS and outcomes were assessed using logistic (primary) and Cox or competing risk (secondary) models, adjusting for preoperative patient- and procedure-related covariates. RESULTS The primary outcome was observed in 784 (11.5%) of 6793 patients who met entry criteria. On multivariable analysis, IO-TPS was a significant predictor of the primary outcome (class 2: odds ratio, 1.7 [95% CI, 1.4-2.0; P < .001]; class 3: odds ratio, 6.0 [95% CI, 4.0-8.9; P < .001]). Among 6661 transplant-free survivors of hospital discharge observed for up to 10.5 years, there were 185 (2.8%) deaths or transplants and 1171 (17.6%) reinterventions. Class 3 patients had a greater adjusted risk of late mortality or transplant (hazard ratio, 2.2; 95% CI, 1.2-4.2; P = .012) and late reintervention (subdistribution hazard ratio, 2.5; 95% CI, 1.8-3.3; P < .001) vs class 1 patients. CONCLUSIONS IO-TPS is significantly associated with adverse early and late outcomes after congenital heart surgery and may serve as an important adjunct for self-assessment and quality improvement.
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Nathan M, Newburger JW, Bell M, Tang A, Gongwer R, Dunbar-Masterson C, Atz AM, Bacha E, Colan S, Gaynor JW, Kanter K, Levine JC, Ohye R, Pizarro C, Schwartz S, Shirali G, Tani L, Tweddell J, Gurvitz M. Development of the Residual Lesion Score for congenital heart surgery: the RAND Delphi methodology. Cardiol Young 2022; 33:1-14. [PMID: 36562256 DOI: 10.1017/s1047951122003791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVE The Residual Lesion Score is a novel tool for assessing the achievement of surgical objectives in congenital heart surgery based on widely available clinical and echocardiographic characteristics. This article describes the methodology used to develop the Residual Lesion Score from the previously developed Technical Performance Score for five common congenital cardiac procedures using the RAND Delphi methodology. METHODS A panel of 11 experts from the field of paediatric and congenital cardiology and cardiac surgery, 2 co-chairs, and a consultant were assembled to review and comment on validity and feasibility of measuring the sub-components of intraoperative and discharge Residual Lesion Score for five congenital cardiac procedures. In the first email round, the panel reviewed and commented on the Residual Lesion Score and provided validity and feasibility scores for sub-components of each of the five procedures. In the second in-person round, email comments and scores were reviewed and the Residual Lesion Score revised. The modified Residual Lesion Score was scored independently by each panellist for validity and feasibility and used to develop the "final" Residual Lesion Score. RESULTS The Residual Lesion Score sub-components with a median validity score of ≥7 and median feasibility score of ≥4 that were scored without disagreement and with low absolute deviation from the median were included in the "final" Residual Lesion Score. CONCLUSION Using the RAND Delphi methodology, we were able to develop Residual Lesion Score modules for five important congenital cardiac procedures for the Pediatric Heart Network's Residual Lesion Score study.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
- Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Margaret Bell
- Department of Cardiac Psychiatry Research Program, Massachusetts General Hospital, Boston, MA, USA
| | - Alexander Tang
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Andrew M Atz
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Emile Bacha
- Division of Cardiothoracic Surgery, New York-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Steven Colan
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - J William Gaynor
- Division of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kirk Kanter
- Division of Pediatric Cardiac Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Jami C Levine
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Richard Ohye
- Division of Pediatric Cardiac Surgery, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Christian Pizarro
- Division of Cardiac Surgery, Nemours Cardiac Center, Alfred I duPont Hospital for Children, Wilmington, DE, USA
| | - Steven Schwartz
- Division of Cardiac Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Girish Shirali
- Heart Center, Children's Mercy Hospital, Kansas City, MO, USA
| | - Lloyd Tani
- Division of Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA
| | - James Tweddell
- Division of Pediatric Cardiac Thoracic Surgery, Cincinnati Children's Hospital and Medical Center (Posthumous), Cincinnati, OH, USA
| | - Michelle Gurvitz
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Comparison of Intraoperative and Discharge Residual Lesion Severity in Congenital Heart Surgery. Ann Thorac Surg 2022; 114:1731-1737. [PMID: 35398038 DOI: 10.1016/j.athoracsur.2022.02.081] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/10/2022] [Accepted: 02/22/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND While the predischarge technical performance score (DC-TPS) is significantly associated with outcomes after congenital cardiac surgery, the utility of the intraoperative TPS (IO-TPS) remains unknown. METHODS This was a single-center retrospective review of consecutive patients who underwent congenital cardiac surgery from January 2011 to December 2019. Intraoperative and predischarge echocardiograms were used to assign IO-TPS and DC-TPS, respectively, for each index operation (class 1, no residua; class 2, minor residua; class 3, major residua). Anatomic modules identifying the principal residual lesion were assigned to all class 2/3 patients. Overall and module-specific TPS comparisons were made. Multivariable regression models with IO-TPS and DC-TPS as separate predictors of postoperative outcomes were compared. RESULTS Of 6201 patients, overall agreement between IO-TPS and DC-TPS was observed in 4251 patients (68.6%); scores were likelier to be worse at discharge (P < .001). Paired comparative analyses revealed that among patients with at least class 2 atrioventricular and semilunar valve residua, IO-TPS was likelier to worsen than improve (both P < .001). Class 3 patients had a higher risk of in-hospital/early mortality (IO-TPS: odds ratio, 7.5; 95% CI, 2.4-23; DC-TPS: odds ratio, 6.6; 95% CI, 3.0-15), postdischarge/late mortality (IO-TPS: hazard ratio [HR], 3.1, 95% CI, 1.3-7.1; DC-TPS: HR, 2.3; 95% CI, 1.2-4.4), and late unplanned reintervention (IO-TPS: HR, 2.8; 95% CI, 1.9-4.0; DC-TPS: HR, 3.4; 95% CI, 2.8-4.2) vs class 1 (all P < .05). IO- and DC-TPS models were equivalent fits for predicting early and late mortality; the latter was a marginally better fit for late reintervention. CONCLUSIONS IO-TPS and DC-TPS are both important adjuncts for quality improvement in congenital cardiac surgery.
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Sengupta A, Nathan M. Commentary: Scoops and Goose Necks: Long Term Challenges Following Atrioventricular Septal Defect Repair. Semin Thorac Cardiovasc Surg 2022; 35:539-540. [PMID: 35843513 DOI: 10.1053/j.semtcvs.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Meena Nathan
- Department of Surgery, Harvard Medical School, Boston, Massachusetts.
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Sengupta A, Gauvreau K, Kohlsaat K, Colan SD, Newburger JW, Del Nido PJ, Nathan M. Long-Term Outcomes of Patients Requiring Unplanned Repeated Interventions After Surgery for Congenital Heart Disease. J Am Coll Cardiol 2022; 79:2489-2499. [PMID: 35738709 DOI: 10.1016/j.jacc.2022.04.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/25/2022] [Accepted: 04/04/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Unplanned catheter-based or surgical reinterventions after congenital heart operations are independently associated with operative mortality and increased postoperative length of stay. OBJECTIVES This study assessed the long-term outcomes of transplant-free survivors of hospital discharge requiring predischarge reinterventions after congenital cardiac surgery. METHODS Data from patients who required predischarge reinterventions in the anatomic area of repair after congenital cardiac surgery and survived to hospital discharge at a quaternary referral center from January 2011 to December 2019 were retrospectively reviewed. Previously published echocardiographic criteria were used to assess the severity of persistent residual lesions at discharge (Grade 1, no residua; Grade 2, minor residua; and Grade 3, major residua). Outcomes included postdischarge (late) mortality or transplant and unplanned reintervention. Associations between predischarge residual lesion severity and outcomes were assessed by using Cox or competing risk models, adjusting for baseline patient characteristics, case complexity, and preoperative risk factors. RESULTS Among the 408 patients who met entry criteria, there were 58 (14.2%) postdischarge deaths or transplants and 208 (51.0%) late reinterventions at a median follow-up of 3.0 years (IQR: 1.1-6.8 years). Greater predischarge residual lesion severity was associated with worse transplant-free survival and freedom from reintervention (both, P < 0.05). On multivariable analyses, Grade 3 patients had an increased risk of postdischarge mortality or transplant (HR: 4.8; 95% CI: 2.0-11; P < 0.001) and late reintervention (subdistribution HR: 2.1; 95% CI: 1.4-3.1; P < 0.001) vs Grade 1 patients. CONCLUSIONS Among transplant-free survivors requiring predischarge reinterventions after congenital cardiac surgery, those with persistent major residua have significantly worse long-term outcomes. These high-risk patients warrant closer surveillance.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Katherine Kohlsaat
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
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Ramgren JJ, Nozohoor S, Zindovic I, Gustafsson R, Hakacova N, Sjögren J. Reoperations After Repair for Atrioventricular Septal Defects: >25 Years Experience at a Single Center. Semin Thorac Cardiovasc Surg 2022; 35:530-538. [PMID: 35738495 DOI: 10.1053/j.semtcvs.2022.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 11/11/2022]
Abstract
Our aim was to evaluate the total burden of reoperations after previous repair for atrioventricular septal defects, including long-term survival and identify risk factors for reoperation. All patients with surgical correction for atrioventricular septal defect (AVSD) 1993- 2020 underwent a follow-up in October 2020. Clinical data were obtained by retrospective review and evaluated with Kaplan-Meier and competing risk analysis. Of 477 patients who underwent initial repair, 53 patients (11.1%) underwent a total of 82 reoperations. The perioperative mortality at reoperation was 3.8% (2/53). There were no late deaths (0/51) during follow-up. In patients requiring reoperation for left atrioventricular valve regurgitation, a re-repair was performed in 90% (26/29) at first attempt. Estimated overall survival was 96.2 ± 2.6% (95% CI 91.2-100) in the Any reoperation group and 96.7 ± 0.9% (95% CI 94.9-98.5) in the No reoperation group at 20 years (P = 0.80). The cumulative incidence function of Any reoperation (with death as competing risk) was 13.0% (95% CI 9.4-16.5) at 20 years. Independent risk factors for Any reoperation included severe mitral regurgitation after primary repair (HR 40.7; 95% CI 14.9-111; P < 0.001). The risk of perioperative mortality in AVSD patients undergoing reoperation was low in the present study. Long-term survival was very good and not significantly different when compared to patients who did not need reoperation. Re-repair for left atrioventricular valve regurgitation was possible in most cases and showed long-term durability. Our data suggest that reoperations after primary repair of AVSD have very good long-term outcomes when performed at a high-volume pediatric cardiac surgery center.
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Affiliation(s)
- Jens Johansson Ramgren
- Section for Pediatric Cardiac Surgery, Department of Pediatrics, Lund University and Childrens Hospital, Skane University Hospital, Lund, Sweden.
| | - Shahab Nozohoor
- Department of Cardiothoracic and Vascular Surgery, Lund University and Skane University Hospital, Lund, Sweden
| | - Igor Zindovic
- Department of Cardiothoracic and Vascular Surgery, Lund University and Skane University Hospital, Lund, Sweden
| | - Ronny Gustafsson
- Department of Cardiothoracic and Vascular Surgery, Lund University and Skane University Hospital, Lund, Sweden
| | - Nina Hakacova
- Department of Pediatric Cardiology, Lund University and Childrens Hospital, Skane University Hospital, Lund, Sweden
| | - Johan Sjögren
- Department of Cardiothoracic and Vascular Surgery, Lund University and Skane University Hospital, Lund, Sweden
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Callahan CP, Jegatheeswaran A, Barron DJ, Husain SA, Fuller S, Overman DM, McCrindle BW. Association of atrial septal fenestration with outcomes after atrioventricular septal defect repair. J Thorac Cardiovasc Surg 2021; 163:1142-1152.e6. [PMID: 34627603 DOI: 10.1016/j.jtcvs.2021.06.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 06/01/2021] [Accepted: 06/30/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE During repair of atrioventricular septal defect (AVSD), surgeons might leave an atrial level shunt when concerned about postoperative physiology, or as part of routine practice. However, the association of fenestration with outcomes is unclear. We sought to determine factors associated with mortality after biventricular repair of AVSD. METHODS We included 581 patients enrolled from 32 Congenital Heart Surgeons' Society institutions from January 1, 2012, to June 1, 2020 in the Congenital Heart Surgeons' Society AVSD cohort. Parametric multiphase hazard analysis was used to identify factors associated with mortality. A random effect model was used to account for possible intersite variability in mortality. RESULTS An atrial fenestration was placed during repair in 133/581 (23%) patients. Overall 5-year survival after repair was 91%. Patients who had fenestration had an 83% 5-year survival versus 93% for those not fenestrated (P < .001). Variables associated with mortality in multivariable hazard analysis included institutional diagnosis of ventricular unbalance (hazard ratio [HR], 2.7 [95% confidence interval (CI): 1.5-4.9]; P = .003), preoperative mechanical ventilation (HR, 4.1 [95% CI, 1.3-13.1]; P = .02), atrial fenestration (HR, 2.8 [95% CI, 1.5-4.9]; P < .001), and reoperation for ventricular septal defect (HR, 4.0 [95% CI, 1.3-13.1]; P = .002). There was no difference in measures of ventricular unbalance for comparisons of fenestrated with nonfenestrated patients. No significant interinstitution variability in mortality was observed on the basis of the random effect model (P = .7). CONCLUSIONS An atrial communication at biventricular repair of AVSD is associated with significantly reduced long-term survival after adjusting for other known associated factors, including unbalance. These findings might challenge the routine practice of fenestration.
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Affiliation(s)
- Connor P Callahan
- Division of Cardiovascular Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| | - Anusha Jegatheeswaran
- Division of Cardiovascular Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - David J Barron
- Division of Cardiovascular Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - S Adil Husain
- Division of Pediatric Cardiothoracic Surgery, University of Utah/Primary Children's Medical Center, Salt Lake City, Utah
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, Pa
| | - David M Overman
- Division of Cardiovascular Surgery, Children's Minnesota, Minneapolis, Minn; Mayo Clinic - Children's Minnesota Cardiovascular Collaborative, Rochester, Minn
| | - Brian W McCrindle
- Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Nathan M, Levine JC, Van Rompay MI, Lambert LM, Trachtenberg FL, Colan SD, Adachi I, Anderson BR, Bacha EA, Eckhauser A, Gaynor JW, Graham EM, Goot B, Jacobs JP, John R, Kaltman JR, Kanter KR, Mery CM, LuAnn Minich L, Ohye R, Overman D, Pizarro C, Raghuveer G, Schamberger MS, Schwartz SM, Narasimhan SL, Taylor MD, Wang K, Newburger JW. Impact of Major Residual Lesions on Outcomes After Surgery for Congenital Heart Disease. J Am Coll Cardiol 2021; 77:2382-2394. [PMID: 33985683 PMCID: PMC8245007 DOI: 10.1016/j.jacc.2021.03.304] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/04/2021] [Accepted: 03/22/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Many factors affect outcomes after congenital cardiac surgery. OBJECTIVES The RLS (Residual Lesion Score) study explored the impact of severity of residual lesions on post-operative outcomes across operations of varying complexity. METHODS In a prospective, multicenter, observational study, 17 sites enrolled 1,149 infants undergoing 5 common operations: tetralogy of Fallot repair (n = 250), complete atrioventricular septal defect repair (n = 249), arterial switch operation (n = 251), coarctation or interrupted arch with ventricular septal defect (VSD) repair (n = 150), and Norwood operation (n = 249). The RLS was assigned based on post-operative echocardiography and clinical events: RLS 1 (trivial or no residual lesions), RLS 2 (minor residual lesions), or RLS 3 (reintervention for or major residual lesions before discharge). The primary outcome was days alive and out of hospital within 30 post-operative days (60 for Norwood). Secondary outcomes assessed post-operative course, including major medical events and days in hospital. RESULTS RLS 3 (vs. RLS 1) was an independent risk factor for fewer days alive and out of hospital (p ≤ 0.008) and longer post-operative hospital stay (p ≤ 0.02) for all 5 operations, and for all secondary outcomes after coarctation or interrupted arch with VSD repair and Norwood (p ≤ 0.03). Outcomes for RLS 1 versus 2 did not differ consistently. RLS alone explained 5% (tetralogy of Fallot repair) to 20% (Norwood) of variation in the primary outcome. CONCLUSIONS Adjusting for pre-operative factors, residual lesions after congenital cardiac surgery impacted in-hospital outcomes across operative complexity with greatest impact following complex operations. Minor residual lesions had minimal impact. These findings may provide guidance for surgeons when considering short-term risks and benefits of returning to bypass to repair residual lesions.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.
| | - Jami C Levine
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria I Van Rompay
- HealthCore, New England Research Institutes, Watertown, Massachusetts, USA
| | - Linda M Lambert
- Division of Pediatric Cardiology, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | | | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Iki Adachi
- Division of Congenital Heart Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Brett R Anderson
- Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York, USA
| | - Emile A Bacha
- Division of Cardiothoracic Surgery, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York, USA
| | - Aaron Eckhauser
- Division of Pediatric Cardiothoracic Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - J William Gaynor
- Division of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Eric M Graham
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Benjamin Goot
- Division of Pediatric Cardiology, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jeffrey P Jacobs
- Division of Cardiac Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA; Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Rija John
- Division of Congenital Heart Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Jonathan R Kaltman
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Kirk R Kanter
- Division of Pediatric Cardiac Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, Dell Children's Medical Center, University of Texas Dell Medical School, Austin, Texas, USA
| | - L LuAnn Minich
- Division of Pediatric Cardiology, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Richard Ohye
- Division of Pediatric Cardiac Surgery, C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - David Overman
- Division of Cardiovascular Surgery, Children's Minnesota, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, Minnesota, USA
| | - Christian Pizarro
- Division of Cardiac Surgery, Nemours Cardiac Center, Alfred I duPont Hospital for Children, Wilmington, Delaware, USA
| | - Geetha Raghuveer
- Heart Center, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Marcus S Schamberger
- Division of Pediatric Cardiology, Riley Hospital for Children, Indiana University, Indianapolis, Indiana, USA
| | - Steven M Schwartz
- Division of Cardiac Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shanthi L Narasimhan
- Division of Pediatric Cardiology, Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Michael D Taylor
- Division of Pediatric Cardiology, Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio, USA
| | - Ke Wang
- HealthCore, New England Research Institutes, Watertown, Massachusetts, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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13
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Nathan M, Trachtenberg FL, Van Rompay MI, Gaynor W, Kanter K, Ohye R, Bacha EA, Tweddell J, Schwartz SM, Minich LL, Mery CM, Colan SD, Levine J, Lambert LM, Newburger JW. The Pediatric Heart Network Residual Lesion Score Study: Design and objectives. J Thorac Cardiovasc Surg 2020; 160:218-223.e1. [PMID: 31870553 PMCID: PMC7225045 DOI: 10.1016/j.jtcvs.2019.10.146] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 10/28/2019] [Accepted: 10/30/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The Residual Lesion Score (RLS) was developed as a novel tool for assessing residual lesions after congenital heart operations based on widely available clinical and echocardiographic characteristics. The RLS ranks postoperative findings as follows: Class 1 (no/trivial residua), Class 2 (minor residua), or Class 3 (major residua or reintervention before discharge for residua). The multicenter prospective RLS study aims to analyze the influence of residual lesions on outcomes in common congenital cardiac operations. We hypothesize that RLS will predict postoperative adverse events, resource utilization, mortality, and reinterventions by 1 year postoperatively. METHODS The study cohort consisted of infants aged ≤12 months undergoing definitive surgery for complete atrioventricular septal defect, tetralogy of Fallot, dextro-transposition of the great arteries with or without intact ventricular septum, single ventricle (Norwood procedure), and coarctation or interrupted/hypoplastic arch with ventricular septal defect. Children with major congenital or acquired extracardiac anomalies that could independently affect the primary end point, which was number of days alive and out of the hospital within 30 days of surgery (60 days for Norwood procedure), were excluded. Secondary outcomes included ≥1 early major postoperative adverse event; days of intensive care unit and hospital stay, and initial and total ventilator time; mortality/transplant after discharge; unplanned reinterventions after discharge; and cost. All analyses will be performed separately by surgical operation. CONCLUSIONS This is the first multicenter prospective validation of a tool for surgical outcome assessment and quality improvement specific to congenital heart surgery.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass.
| | | | | | - William Gaynor
- Division of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Kirk Kanter
- Division of Pediatric Cardiac Surgery, Children's Health Care of Atlanta, Atlanta, Ga
| | - Richard Ohye
- Division of Pediatric Cardiac Surgery, C. S. Mott Children's Hospital, Ann Arbor, Mich
| | - Emile A Bacha
- Division of Cardiothoracic Surgery, New York Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - James Tweddell
- Division of Pediatric Cardiac Surgery, Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
| | - Steven M Schwartz
- Division of Cardiac Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - L LuAnn Minich
- Division of Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School/ Dell Children's Medical Center, Austin, Tex
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Jami Levine
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Linda M Lambert
- Division of Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
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14
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Shimada M, Hoashi T, Iida J, Ichikawa H. The Impact of Post-Graduate Year of Primary Surgeon on Technical Performance Score in Tetralogy of Fallot Repair. Circ J 2020; 84:495-500. [PMID: 32023573 DOI: 10.1253/circj.cj-19-0800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of this study was to assess the impact of surgeon years of experience on clinical outcomes of tetralogy of Fallot (TOF) repair using technical performance score (TPS), and to investigate the possibility of safe operations by surgical trainees.Methods and Results:We assessed the cases of 159 consecutive patients who underwent TOF repair between 2001 and 2015. Thirteen different primary surgeons performed operations with 41 different first assistants. The primary surgeon and first assistant mean postgraduate years were 19.1±5.1 years (range, 5.7-31.6 years) and 11.2±6.3 years (range, 3.2-36.3 years), respectively. TPS was assigned using pre-discharge echocardiography based on original criteria. Logistic regression analysis was used to examine the factors associated with TPS. TPS could be scored for all patients, 16 of whom were graded as having optimal (10%), 119 as adequate (75%), and 24 as having inadequate (15%) TPS. None of the preoperative and perioperative variables affected TPS. Although neither the primary surgeon nor the first assistant postgraduate years was associated with TPS independently, total primary surgeon and first assistant postgraduate years correlated with TPS (OR, 1.07; 95% CI: 1.01-1.13, P=0.031). CONCLUSIONS Primary surgeon postgraduate years was not associated with TPS for TOF repair. TOF repair can be performed adequately and safely by surgical trainees under the support of highly experienced supervisors.
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Affiliation(s)
- Masatoshi Shimada
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Takaya Hoashi
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Jun Iida
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
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15
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Contemporary results after repair of partial and transitional atrioventricular septal defects. J Thorac Cardiovasc Surg 2019; 157:1117-1127.e4. [DOI: 10.1016/j.jtcvs.2018.10.154] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 09/28/2018] [Accepted: 10/12/2018] [Indexed: 11/24/2022]
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16
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Nathan M. The left atrioventricular valve: The Achilles' heel of incomplete endocardial cushion defects. J Thorac Cardiovasc Surg 2018; 157:1130-1131. [PMID: 30538029 DOI: 10.1016/j.jtcvs.2018.10.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 10/31/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass.
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