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El-Amin A, Koehlmoos T, Yue D, Chen J, Cho NY, Benharash P, Franzini L. The Association of High-Quality Hospital Use on Health Care Outcomes for Pediatric Congenital Heart Defects in a Universal Health Care System. Mil Med 2024; 189:e2163-e2169. [PMID: 38364865 DOI: 10.1093/milmed/usae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/18/2024] [Accepted: 01/29/2024] [Indexed: 02/18/2024] Open
Abstract
INTRODUCTION Congenital heart disease (CHD) has an incidence of 0.8% to 1.2% worldwide, making it the most common birth defect. Researchers have compared high-volume to low-volume hospitals and found significant hospital-level variation in major complications, health resource utilization, and mortality after CHD surgery. In addition, researchers found critical CHD patients at low-volume/non-teaching facilities to be associated with higher odds of inpatient mortality when compared to CHD patients at high-volume/teaching hospitals (odds ratio 1.76). We examined the effects of high-quality hospital (HQH) use on health care outcomes and health care costs in pediatric CHD care using an instrumental variable (IV) approach. MATERIALS AND METHODS Using nationwide representative claim data from the United States Military Health System from 2016 to 2020, TRICARE beneficiaries with a diagnosis of CHD were tabulated based on relevant ICD-10 (International Classification of Diseases, 10th revision) codes. We examined the relationships between annual readmissions, annual emergency room (ER) use, and mortality and HQH use. We applied both the naive linear probability model (LPM), controlling for the observed patient and hospital characteristics, and the two-stage least squares (2SLS) model, accounting for the unobserved confounding factors. The differential distance between the patient and the closest HQH at the index date and the patient and nearest non-HQH was used as the IV. This protocol was approved by the Institutional Review Board at the University of Maryland, College Park (Approval Number: 1576246-2). RESULTS The naive LPM indicated that HQH use was associated with a higher probability of annual readmissions (marginal effect, 18%; 95% CI, 0.12 to 0.23). The naive LPM indicated that HQH use was associated with a higher probability of mortality (marginal effect, 2.2%; 95% CI, 0.01 to 0.03). Using the differential distance of closest HQH and non-HQH, we identified a significant association between HQH use and annual ER use (marginal effect, -14%; 95% CI, -0.24 to -0.03). CONCLUSIONS After controlling for patient-level and facility-level covariates and adjusting for endogeneity, (1) HQH use did not increase the probability of more than one admission post 1-year CHD diagnosis, (2) HQH use lowered the probability of annual ER use post 1-year CHD diagnosis, and (3) HQH use did not increase the probability of mortality post 1-year CHD diagnosis. Patients who may have benefited from utilizing HQH for CHD care did not, alluding to potential barriers to access, such as health insurance restrictions or lack of patient awareness. Although we used hospital quality rating for congenital cardiac surgery as reported by the Society of Thoracic Surgeons, the contributing data span a 4-year period and may not reflect real-time changes in center performance. Since this study focused on inpatient care within the first-year post-initial CHD diagnosis, it may not reflect the full range of health system utilization. It is necessary for clinicians and patient advocacy groups to collaborate with policymakers to promote the development of an overarching HQH designation authority for CHD care. Such establishment will facilitate access to HQH for military beneficiary populations suffering from CHD.
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Affiliation(s)
- Amber El-Amin
- Center for Health Services Research, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
| | - Tracey Koehlmoos
- Center for Health Services Research, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
| | - Dahai Yue
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
| | - Jie Chen
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA 90024, USA
| | - Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA 90024, USA
- Department of Surgery, University of California, Los Angeles, CA 90024, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA 90024, USA
- Department of Surgery, University of California, Los Angeles, CA 90024, USA
| | - Luisa Franzini
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
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Hussain AM, Younes MA. Early outcomes of experience warm surgery in children undergoing complete repair of tetralogy of Fallot in developing countries. BMC Pediatr 2024; 24:499. [PMID: 39097678 PMCID: PMC11297559 DOI: 10.1186/s12887-024-04976-9] [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: 03/14/2024] [Accepted: 07/26/2024] [Indexed: 08/05/2024] Open
Abstract
OBJECTIVES While significant evidence supports the benefits of normothermic cardiopulmonary bypass (NCPB) over hypothermic techniques, many institutions in developing countries, including ours, continue to employ hypothermic methods. This study aimed to assess the early postoperative outcomes of normothermic cardiopulmonary bypass (NCPB) for complete surgical repair via the Tetralogy of Fallot (TOF) within our national context. METHODS We conducted this study in the Pediatric Cardiac Intensive Care Unit (PCICU) at the University Children's Hospital. One hundred patients who underwent complete TOF repair were enrolled and categorized into two groups: the normothermic group (n = 50, temperature 35-37 °C) and the moderate hypothermic group (n = 50, temperature 28-32 °C). We evaluated mortality, morbidity, and postoperative complications in the PCICU as outcome measures. RESULTS The demographic characteristics were similar between the two groups. However, the cardiopulmonary bypass (CPB) time and aortic cross-clamp (ACC) time were notably longer in the hypothermic group. The study recorded seven deaths, yielding an overall mortality rate of 7%. No significant differences were observed between the two groups concerning mortality, morbidity, or postoperative complications in the PCICU. CONCLUSIONS Our findings suggest that normothermic procedures, while not demonstrably effective, are safe for pediatric cardiac surgery. Further research is warranted to substantiate and endorse the adoption of this technique.
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Affiliation(s)
- Alaa Mohamad Hussain
- University Children's Hospital, Damascus University, Damascus, Syrian Arab Republic.
| | - Mohammad Ali Younes
- University Children's Hospital, Damascus University, Damascus, Syrian Arab Republic.
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El-Amin A, Koehlmoos T, Yue D, Chen J, Cho NY, Benharash P, Franzini L. High-Quality Hospital Status on Health Care Costs for Pediatric Congenital Heart Disease Care for U.S. Military Beneficiaries. Mil Med 2024:usae350. [PMID: 38970436 DOI: 10.1093/milmed/usae350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 06/05/2024] [Accepted: 06/25/2024] [Indexed: 07/08/2024] Open
Abstract
INTRODUCTION Congenital heart disease (CHD) is the most common and resource demanding birth defect managed in the United States, with approximately 40,000 children undergoing CHD surgery year. Researchers have compared high-volume to low-volume hospitals and found significant hospital-level variation in major complications, health resource utilization, and health care costs after CHD surgery. MATERIALS AND METHODS Using nationwide representative claim data from the United States Military Health System from 2016 to 2020, TRICARE beneficiaries diagnosed with CHD were tabulated based on ICD-10 codes (International Classification of Diseases, 10th revision). We examined the relationships between total costs and total hospitalizations costs post 1-year CHD diagnosis and presence or absence of High-Quality Hospital (HQH) designation. We applied both the naive generalized linear model (GLM) to control for the observed patient and hospital characteristics and the 2-stage least squares (2SLS) model to account for the unobserved confounding factors. This study was approved by University of Maryland, College Park Institutional Review Board (IRB) (Approval Number: 1576246-2). RESULTS A relationship between HQH designation and total CHD related costs was not seen across 2SLS model specifications (marginal effect; -$41,579; 95% CI, -$83,429 to $271). For patients diagnosed with a moderate-complex or single ventricle CHD, the association of HQH status was a statistically significant reduction in total costs (marginal effect; -$84,395; 95% CI, -$140,560 to -$28,229) and hospitalization costs (marginal effect; -$73,958; 95% CI, -$121,878 to -$26,039). CONCLUSIONS It is very imperative for clinicians and patient support advocates to urge policymakers to deliberate the establishment of a quality designation authority for CHD management. These efforts will not only help to identify and standardize quality care metrics but to improve long-term health, effectiveness, and equity in the management of CHD. Furthermore, these efforts can be used to navigate patients to proven HQH, thereby improving care and reducing associated treatment costs for CHD patients.
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Affiliation(s)
- Amber El-Amin
- Center for Health Services Research, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
| | - Tracey Koehlmoos
- Center for Health Services Research, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
| | - Dahai Yue
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
| | - Jie Chen
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA 90024, USA
| | - Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA 90024, USA
- Department of Surgery, University of California, Los Angeles, CA 90024, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA 90024, USA
- Department of Surgery, University of California, Los Angeles, CA 90024, USA
| | - Luisa Franzini
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
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Crook S, Dragan K, Woo JL, Neidell M, Nash KA, Jiang P, Zhang Y, Sanchez CM, Cook S, Hannan EL, Newburger JW, Jacobs ML, Petit CJ, Goldstone A, Vincent R, Walsh-Spoonhower K, Mosca R, Kumar TKS, Devejian N, Biddix B, Alfieris GM, Swartz MF, Meyer D, Paul EA, Billings J, Anderson BR. Impact of Social Determinants of Health on Predictive Models for Outcomes After Congenital Heart Surgery. J Am Coll Cardiol 2024; 83:2440-2454. [PMID: 38866447 DOI: 10.1016/j.jacc.2024.03.430] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/13/2024] [Accepted: 03/28/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Despite documented associations between social determinants of health and outcomes post-congenital heart surgery, clinical risk models typically exclude these factors. OBJECTIVES The study sought to characterize associations between social determinants and operative and longitudinal mortality as well as assess impacts on risk model performance. METHODS Demographic and clinical data were obtained for all congenital heart surgeries (2006-2021) from locally held Congenital Heart Surgery Collaborative for Longitudinal Outcomes and Utilization of Resources Society of Thoracic Surgeons Congenital Heart Surgery Database data. Neighborhood-level American Community Survey and composite sociodemographic measures were linked by zip code. Model prediction, discrimination, and impact on quality assessment were assessed before and after inclusion of social determinants in models based on the 2020 Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model. RESULTS Of 14,173 total index operations across New York State, 12,321 cases, representing 10,271 patients at 8 centers, had zip codes for linkage. A total of 327 (2.7%) patients died in the hospital or before 30 days, and 314 children died by December 31, 2021 (total n = 641; 6.2%). Multiple measures of social determinants of health explained as much or more variability in operative and longitudinal mortality than clinical comorbidities or prior cardiac surgery. Inclusion of social determinants minimally improved models' predictive performance (operative: 0.834-0.844; longitudinal 0.808-0.811), but significantly improved model discrimination; 10.0% more survivors and 4.8% more mortalities were appropriately risk classified with inclusion. Wide variation in reclassification was observed by site, resulting in changes in the center performance classification category for 2 of 8 centers. CONCLUSIONS Although indiscriminate inclusion of social determinants in clinical risk modeling can conceal inequities, thoughtful consideration can help centers understand their performance across populations and guide efforts to improve health equity.
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Affiliation(s)
- Sarah Crook
- Center for Child Health Services Research, Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Division of Pediatric Cardiology; Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Kacie Dragan
- New York University, Wagner Graduate School of Public Service, New York, New York, USA; Interfaculty Initiative in Health Policy, Harvard University, Cambridge, Massachusetts, USA
| | - Joyce L Woo
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew Neidell
- Department of Health Policy and Management; Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Katherine A Nash
- Division of Pediatric Critical Care and Hospital Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Pengfei Jiang
- Center for Child Health Services Research, Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Division of Pediatric Cardiology; Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA; Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Yun Zhang
- Division of Pediatric Cardiology; Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Chantal M Sanchez
- Center for Child Health Services Research, Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Division of Pediatric Cardiology; Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Stephen Cook
- Department of Pediatrics, Internal Medicine, and Center for Community Health, University of Rochester Medical Center, Rochester, New York, USA; New York State Department of Health; Offices of Health Insurance Programs, Albany, New York, USA
| | - Edward L Hannan
- University at Albany School of Public Health, Rensselaer, New York, USA
| | - Jane W Newburger
- Department of Pediatric Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Marshall L Jacobs
- Division of Cardiac Surgery; Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher J Petit
- Division of Pediatric Cardiology; Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Andrew Goldstone
- Department of Cardiothoracic Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center & Weill Cornell Medical Center, New York, New York, USA
| | - Robert Vincent
- Division of Pediatric Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | | | - Ralph Mosca
- Department of Cardiothoracic Surgery, New York University, New York, New York, USA
| | - T K Susheel Kumar
- Department of Cardiothoracic Surgery, New York University, New York, New York, USA
| | - Neil Devejian
- Division of Pediatric Cardiothoracic Surgery, Albany Medical College, Albany, New York, USA
| | - Ben Biddix
- Division of Pediatric Cardiology, Albany Medical College, Albany, New York, USA
| | - George M Alfieris
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York, USA; Department of Surgery, State University of New York Upstate Medical Center, Syracuse, New York, USA
| | - Michael F Swartz
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - David Meyer
- Departments of Cardiothoracic Surgery and Pediatrics, Hofstra-Northwell School of Medicine, Uniondale, New York, USA
| | - Erin A Paul
- Division of Pediatric Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Billings
- New York University, Wagner Graduate School of Public Service, New York, New York, USA
| | - Brett R Anderson
- Center for Child Health Services Research, Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Division of Pediatric Cardiology; Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA; Division of Pediatric Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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Schneider K, de Loizaga S, Beck AF, Morales DLS, Seo J, Divanovic A. Socioeconomic Influences on Outcomes Following Congenital Heart Disease Surgery. Pediatr Cardiol 2024; 45:1072-1078. [PMID: 38472658 PMCID: PMC11056327 DOI: 10.1007/s00246-024-03451-7] [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: 11/09/2023] [Accepted: 02/12/2024] [Indexed: 03/14/2024]
Abstract
Associations between social determinants of health (SDOH) and adverse outcomes for children with congenital heart disease (CHD) are starting to be recognized; however, such links remain understudied. We examined the relationship between community-level material deprivation on mortality, readmission, and length of stay (LOS) for children undergoing surgery for CHD. We performed a retrospective cohort study of patients who underwent cardiac surgery at our institution from 2015 to 2018. A community-level deprivation index (DI), a marker of community material deprivation, was generated to contextualize the lived experience of children with CHD. Generalized mixed-effects models were used to assess links between the DI and outcomes of mortality, readmission, and LOS following cardiac surgery. The DI and components were scaled to provide mean differences for a one standard deviation (SD) increase in deprivation. We identified 1,187 unique patients with surgical admissions. The median LOS was 11 days, with an overall mortality rate of 4.6% and readmission rate of 7.6%. The DI ranged from 0.08 to 0.85 with a mean of 0.37 (SD 0.12). The DI was associated with increased LOS for patients with more complex heart disease (STAT 3, 4, and 5), which persisted after adjusting for factors that could prolong LOS (all p < 0.05). The DI approached but did not meet a significant association with mortality (p = 0.0528); it was not associated with readmission (p = 0.36). Community-level deprivation is associated with increased LOS for patients undergoing cardiac surgery. Future work to identify the specific health-related social needs contributing to LOS and identify targets for intervention is needed.
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Affiliation(s)
- Kristin Schneider
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Sarah de Loizaga
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew F Beck
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Divisions of General & Community Pediatrics and Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David L S Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - JangDong Seo
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA
| | - Allison Divanovic
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Chauhan D, Mehaffey JH, Hayanga JWA, Udassi JP, Badhwar V, Mascio CE. Volume Alone Does Not Predict Quality Outcomes in Hospitals Performing Pediatric Cardiac Surgery. Ann Thorac Surg 2024; 117:1187-1193. [PMID: 38290594 DOI: 10.1016/j.athoracsur.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 01/04/2024] [Accepted: 01/15/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Lower institutional volume has been associated with inferior pediatric cardiac surgery outcomes. This study explored the variation in mortality rates among low-, mid-, and high-volume hospitals performing pediatric cardiac surgery in the United States. METHODS The Kids' Inpatient Database was explored for the years 2016 and 2019. Hospitals performing only off-bypass coarctation and ventricular septal defect repair were omitted. The hospitals were divided into 3 groups by their annual case volume. Multivariable logistic regression models were fit to obtain risk-adjusted in-hospital mortality rates. RESULTS A total of 25,749 operations performed by 235 hospitals were included in the study. The risk-adjusted mortality rate for the entire sample was 1.9%. There were 140 hospitals in the low-volume group, 64 hospitals in the mid-volume group, and 31 in the high-volume group. All groups had low-mortality (mortality <1.9%) and high-mortality (mortality >1.9%) hospitals. Among low-volume hospitals, 53% were low-mortality (n = 74) and 47% were high-mortality (n = 66) hospitals. Among mid-volume hospitals, 58% were low-mortality (n = 37) and 42% were high-mortality (n = 27) hospitals. Among high-volume hospitals, 68% were low-mortality (n = 21) and 32% were high-mortality (n = 10) hospitals. There was no statistically significant difference in risk-adjusted in-hospital mortality when comparing low-, mid-, and high-volume centers for 7 Society of Thoracic Surgeons benchmark procedures. CONCLUSIONS This national, real-world, risk-adjusted volume outcome analysis highlights that volume alone may not be the sole arbiter to predict quality of pediatric cardiac surgery outcomes. Using case volume alone as a surrogate for quality may unfairly asperse high-performing, low-volume programs.
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Affiliation(s)
- Dhaval Chauhan
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - J Hunter Mehaffey
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - J W Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Jai P Udassi
- Division of Pediatric Cardiology, Department of Pediatrics, West Virginia University, Morgantown, West Virginia
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Christopher E Mascio
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia.
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Johansson M, Hedström E, Steding-Ehrenborg K, Bhat M, Liuba P, Arheden H, Sjöberg P. Atrioventricular Area Difference Aids Diastolic Filling in Patients with Repaired Tetralogy of Fallot. Pediatr Cardiol 2024:10.1007/s00246-024-03508-7. [PMID: 38806793 DOI: 10.1007/s00246-024-03508-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 04/22/2024] [Indexed: 05/30/2024]
Abstract
A hydraulic force aids diastolic filling of the left ventricle (LV) and is proportional to the difference in short-axis area between the left ventricle and atrium; the atrioventricular area difference (AVAD). Patients with repaired Tetralogy of Fallot (rToF) and pulmonary regurgitation (PR) have reduced LV filling which could lead to a negative AVAD and a hydraulic force impeding diastolic filling. The aim was to assess AVAD and to determine whether the hydraulic force aids or impedes diastolic filling in patients with rToF and PR, compared to controls. Twelve children with rToF (11.5 [9-13] years), 12 pediatric controls (10.5 [9-13] years), 12 adults with rToF (21.5 [19-27] years) and 12 adult controls (24 [21-29] years) were retrospectively included. Cine short-axis images were acquired using cardiac magnetic resonance imaging. Atrioventricular area difference was calculated as the largest left ventricular short-axis area minus the largest left atrial short-axis area at beginning of diastole and end diastole and indexed to height (AVADi). Children and adults with rToF and PR had higher AVADi (0.3 cm2/m [- 1.3 to 0.8] and - 0.6 [- 1.5 to - 0.2]) at beginning of diastole compared to controls (- 2.7 cm2/m [- 4.9 to - 1.7], p = 0.015) and - 3.3 cm2/m [- 3.8 to - 2.8], p = 0.017). At end diastole AVADi did not differ between patients and controls. Children and adults with rToF and pulmonary regurgitation have an atrioventricular area difference that do not differ from controls and thus a net hydraulic force that contributes to left ventricular diastolic filling, despite a small underfilled left ventricle due to pulmonary regurgitation.
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Affiliation(s)
- Martin Johansson
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Clinical Physiology, Skåne University Hospital, 22185, Lund, Sweden
- Department of Pediatric Anesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden
- Diagnostic Radiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Erik Hedström
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Clinical Physiology, Skåne University Hospital, 22185, Lund, Sweden
- Diagnostic Radiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Radiology, Skåne University Hospital, Lund, Sweden
| | - Katarina Steding-Ehrenborg
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Clinical Physiology, Skåne University Hospital, 22185, Lund, Sweden
| | - Misha Bhat
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Pediatric Cardiology, Children's Heart Centre, Skåne University Hospital, Lund, Sweden
| | - Petru Liuba
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Pediatric Cardiology, Children's Heart Centre, Skåne University Hospital, Lund, Sweden
| | - Håkan Arheden
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Clinical Physiology, Skåne University Hospital, 22185, Lund, Sweden
| | - Pia Sjöberg
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
- Department of Clinical Physiology, Skåne University Hospital, 22185, Lund, Sweden.
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Pignatti M, Dolci G, Zamagni E, Pascale R, Piccin O, Ammar A, Zeneli F, Miralles MEL, Mancuso K, Cipriani R, Viale P, Pacini D, Martin-Suàrez S. Multidisciplinary Management of Sternal Osteomyelitis Due to Klebsiella aerogenes after Open Heart Surgery in a Patient with Multiple Myeloma: A Case Report and Discussion of the Literature. Microorganisms 2023; 11:2699. [PMID: 38004712 PMCID: PMC10673517 DOI: 10.3390/microorganisms11112699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/29/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023] Open
Abstract
Sternal wound complications following cardiac surgery, including sternal dehiscence, mediastinitis, and osteomyelitis, pose significant challenges in terms of management and patient outcomes. We present a case report highlighting the complex management of a patient who underwent open heart surgery for severe aortic valve stenosis, followed by sternal wound dehiscence and sternum osteomyelitis due to extended spectrum beta lactamase (ESBL) producing Klebsiella aerogenes. A multiple myeloma diagnosis was also suspected at the positron emission tomography (PET) scan and confirmed with bone marrow biopsy. Multidisciplinary evaluation of the case led to a comprehensive treatment plan. To control the sternal osteomyelitis, total sternectomy was performed followed by immediate reconstruction with a bone (tibia) graft from the tissue bank and fixation with the minimal hardware possible. A microsurgical latissimus dorsi free flap was required to reconstruct the soft tissue defect. After 6 weeks of antibiotic treatment with ertapenem and fosfomycin based on a culture of intraoperative material, no clinical, imaging, or laboratory signs of infection were seen. Multiple myeloma treatment was then started. At 1 year of follow up, no recurrence of infection occurred, and the reconstruction was stable and closed. Multiple myeloma is under chronic treatment with novel agent combination, with an excellent haematological response.
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Affiliation(s)
- Marco Pignatti
- Plastic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.A.); (F.Z.); (M.E.L.M.); (R.C.)
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (E.Z.); (R.P.); (K.M.); (P.V.); (D.P.)
| | - Giampiero Dolci
- Thoracic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Elena Zamagni
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (E.Z.); (R.P.); (K.M.); (P.V.); (D.P.)
- Haematology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Renato Pascale
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (E.Z.); (R.P.); (K.M.); (P.V.); (D.P.)
- Infectious Disease Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Ottavio Piccin
- Otorinolaryngology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Alessandro Ammar
- Plastic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.A.); (F.Z.); (M.E.L.M.); (R.C.)
- Plastic Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Flavia Zeneli
- Plastic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.A.); (F.Z.); (M.E.L.M.); (R.C.)
- Plastic Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Maria Elisa Lozano Miralles
- Plastic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.A.); (F.Z.); (M.E.L.M.); (R.C.)
- Plastic Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Katia Mancuso
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (E.Z.); (R.P.); (K.M.); (P.V.); (D.P.)
- Haematology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Riccardo Cipriani
- Plastic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.A.); (F.Z.); (M.E.L.M.); (R.C.)
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (E.Z.); (R.P.); (K.M.); (P.V.); (D.P.)
- Plastic Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Davide Pacini
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (E.Z.); (R.P.); (K.M.); (P.V.); (D.P.)
- Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Sofia Martin-Suàrez
- Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
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El-Amin A, Koehlmoos T, Yue D, Chen J, Benharash P, Franzini L. Does universal insurance influence disparities in high-quality hospital use for inpatient pediatric congenital heart defect care within the first year of diagnosis? BMC Health Serv Res 2023; 23:702. [PMID: 37381049 DOI: 10.1186/s12913-023-09668-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 06/07/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Healthcare disparities are an issue in the management of Congenital Heart Defects (CHD) in children. Although universal insurance may mitigate racial or socioeconomic status (SES) disparities in CHD care, prior studies have not examined these effects in the use of High-Quality Hospitals (HQH) for inpatient pediatric CHD care in the Military Healthcare System (MHS). To assess for racial and SES disparities in inpatient pediatric CHD care that may persist despite universal insurance coverage, we performed a cross-sectional study of the HQH use for children treated for CHD in the TRICARE system, a universal healthcare system for the U.S. Department of Defense. In the present work we evaluated for the presence of disparities, like those seen in the civilian U.S. healthcare system, among military ranks (SES surrogate) and races and ethnicities in HQH use for pediatric inpatient admissions for CHD care within a universal healthcare system (MHS). METHODS We conducted a cross-sectional study using claims data from the U.S. MHS Data Repository from 2016 to 2020. We identified 11,748 beneficiaries aged 0 to 17 years who had an inpatient admission for CHD care from 2016 to 2020. The outcome variable was a dichotomous indicator for HQH utilization. In the sample, 42 hospitals were designated as HQH. Of the population, 82.9% did not use an HQH at any point for CHD care and 17.1% used an HQH at some point for CHD care. The primary predictor variables were race and sponsor rank. Military rank has been used as an indicator of SES status. Patient demographic information at the time of index admission post initial CHD diagnosis (age, gender, sponsor marital status, insurance type, sponsor service branch, proximity to HQH based on patient zip code centroid, and provider region) and clinical information (complexity of CHD, common comorbid conditions, genetic syndromes, and prematurity) were used as covariates in multivariable logistic regression analysis. RESULTS After controlling for demographic and clinical factors including age, gender, sponsor marital status, insurance type, sponsor service branch, proximity to HQH based on patient zip code centroid, provider region, complexity of CHD, common comorbid conditions, genetic syndromes, and prematurity, we did not find disparities in HQH use for inpatient pediatric CHD care based upon military rank. After controlling for demographic and clinical factors, lower SES (Other rank) was less likely to use an HQH for inpatient pediatric CHD care; OR of 0.47 (95% CI of 0.31 to 0.73). CONCLUSIONS We found that for inpatient pediatric CHD care in the universally insured TRICARE system, historically reported racial disparities in care were mitigated, suggesting that this population benefitted from expanded access to care. Despite universal coverage, SES disparities persisted in the civilian care setting, suggesting that universal insurance alone cannot sufficiently address differences in SES disparities in CHD care. Future studies are needed to address the pervasiveness of SES disparities and potential interventions to mitigate these disparities such as a more comprehensive patient travel program.
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Affiliation(s)
- Amber El-Amin
- Center for Health Services Research, Uniformed Services University of Health Sciences, Bethesda, MD, US.
- Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, MD, US.
| | - Tracey Koehlmoos
- Center for Health Services Research, Uniformed Services University of Health Sciences, Bethesda, MD, US
| | - Dahai Yue
- Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, MD, US
| | - Jie Chen
- Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, MD, US
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, US
- Department of Surgery, University of California, Los Angeles, CA, US
| | - Luisa Franzini
- Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, MD, US
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10
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Vervoort D, Elbatarny M, Rocha R, Fremes SE. Reconstruction Technique Options for Achieving Total Arterial Revascularization and Multiple Arterial Grafting. J Clin Med 2023; 12:jcm12062275. [PMID: 36983276 PMCID: PMC10056232 DOI: 10.3390/jcm12062275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/11/2023] [Accepted: 03/14/2023] [Indexed: 03/17/2023] Open
Abstract
Ischemic heart disease is the leading cause of morbidity and mortality worldwide and may require coronary revascularization when more severe or symptomatic. Coronary artery bypass grafting (CABG) is the most common cardiac surgical procedure and can be performed with different bypass conduits and anastomotic techniques. Saphenous vein grafts (SVGs) are the most frequently used conduits for CABG, in addition to the left internal thoracic artery. Outcomes with a single internal thoracic artery and SVGs are favorable, and the long-term patency of SVGs may be improved through novel harvesting techniques, preservation methods, and optimal medical therapy. However, increasing evidence points towards the superiority of arterial grafts, especially in the form of multiple arterial grafting (MAG). Nevertheless, the uptake of MAG remains limited and variable, both as a result of technical complexity and a scarcity of conclusive randomized controlled trial evidence. Here, we present an overview of CABG techniques, harvesting methods, and anastomosis types to achieve total arterial revascularization and adopt MAG. We further narratively summarize the available evidence for MAG versus single arterial grafting to date and highlight remaining gaps and questions that require further study to elucidate the role of MAG in CABG.
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Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S 1A1, Canada
- Division of Cardiac Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Malak Elbatarny
- Division of Cardiac Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Rodolfo Rocha
- Division of Cardiac Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Stephen E. Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S 1A1, Canada
- Division of Cardiac Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Correspondence: ; Tel.: +1-416-480-6073
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11
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Parise O, Parise G, Vaidyanathan A, Occhipinti M, Gharaviri A, Tetta C, Bidar E, Maesen B, Maessen JG, La Meir M, Gelsomino S. Machine Learning to Identify Patients at Risk of Developing New-Onset Atrial Fibrillation after Coronary Artery Bypass. J Cardiovasc Dev Dis 2023; 10:jcdd10020082. [PMID: 36826578 PMCID: PMC9962068 DOI: 10.3390/jcdd10020082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/18/2023] [Accepted: 02/10/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND This study aims to get an effective machine learning (ML) prediction model of new-onset postoperative atrial fibrillation (POAF) following coronary artery bypass grafting (CABG) and to highlight the most relevant clinical factors. METHODS Four ML algorithms were employed to analyze 394 patients undergoing CABG, and their performances were compared: Multivariate Adaptive Regression Spline, Neural Network, Random Forest, and Support Vector Machine. Each algorithm was applied to the training data set to choose the most important features and to build a predictive model. The better performance for each model was obtained by a hyperparameters search, and the Receiver Operating Characteristic Area Under the Curve metric was selected to choose the best model. The best instances of each model were fed with the test data set, and some metrics were generated to assess the performance of the models on the unseen data set. A traditional logistic regression was also performed to be compared with the machine learning models. RESULTS Random Forest model showed the best performance, and the top five predictive features included age, preoperative creatinine values, time of aortic cross-clamping, body surface area, and Logistic Euro-Score. CONCLUSIONS The use of ML for clinical predictions requires an accurate evaluation of the models and their hyperparameters. Random Forest outperformed all other models in the clinical prediction of POAF following CABG.
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Affiliation(s)
- Orlando Parise
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
- Department of Cardiac Surgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
- Correspondence:
| | - Gianmarco Parise
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
| | | | | | - Ali Gharaviri
- Institute of Computational Science, Università della Svizzera Italiana, 6900 Lugano, Switzerland
| | - Cecilia Tetta
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
| | - Elham Bidar
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
| | - Bart Maesen
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
| | - Jos G. Maessen
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
| | - Mark La Meir
- Department of Cardiac Surgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Sandro Gelsomino
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
- Department of Cardiac Surgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
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12
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Marelli A, Beauchesne L, Colman J, Ducas R, Grewal J, Keir M, Khairy P, Oechslin E, Therrien J, Vonder Muhll IF, Wald RM, Silversides C, Barron DJ, Benson L, Bernier PL, Horlick E, Ibrahim R, Martucci G, Nair K, Poirier NC, Ross HJ, Baumgartner H, Daniels CJ, Gurvitz M, Roos-Hesselink JW, Kovacs AH, McLeod CJ, Mulder BJ, Warnes CA, Webb GD. Canadian Cardiovascular Society 2022 Guidelines for Cardiovascular Interventions in Adults With Congenital Heart Disease. Can J Cardiol 2022; 38:862-896. [PMID: 35460862 DOI: 10.1016/j.cjca.2022.03.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/15/2022] [Accepted: 03/30/2022] [Indexed: 12/12/2022] Open
Abstract
Interventions in adults with congenital heart disease (ACHD) focus on surgical and percutaneous interventions in light of rapidly evolving ACHD clinical practice. To bring rigour to our process and amplify the cumulative nature of evidence ACHD care we used the ADAPTE process; we systematically adjudicated, updated, and adapted existing guidelines by Canadian, American, and European cardiac societies from 2010 to 2020. We applied this to interventions related to right and left ventricular outflow obstruction, tetralogy of Fallot, coarctation, aortopathy associated with bicuspid aortic valve, atrioventricular canal defects, Ebstein anomaly, complete and congenitally corrected transposition, and patients with the Fontan operation. In addition to tables indexed to evidence, clinical flow diagrams are included for each lesion to facilitate a practical approach to clinical decision-making. Excluded are recommendations for pacemakers, defibrillators, and arrhythmia-directed interventions covered in separate designated documents. Similarly, where overlap occurs with other guidelines for valvular interventions, reference is made to parallel publications. There is a paucity of high-level quality of evidence in the form of randomized clinical trials to support guidelines in ACHD. We accounted for this in the wording of the strength of recommendations put forth by our national and international experts. As data grow on long-term follow-up, we expect that the evidence driving clinical practice will become increasingly granular. These recommendations are meant to be used to guide dialogue between clinicians, interventional cardiologists, surgeons, and patients making complex decisions relative to ACHD interventions.
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Affiliation(s)
- Ariane Marelli
- McGill University Health Centre, Montréal, Québec, Canada.
| | - Luc Beauchesne
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jack Colman
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Robin Ducas
- St. Boniface General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jasmine Grewal
- St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Erwin Oechslin
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Judith Therrien
- Jewish General Hospital, MAUDE Unit, McGill University, Montréal, Québec, Canada
| | | | - Rachel M Wald
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Candice Silversides
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Lee Benson
- The Hospital for Sick Children, University Health Network, Toronto, Ontario, Canada
| | - Pierre-Luc Bernier
- McGill University Health Centre, Montreal Heart Institute, Montréal, Québec, Canada
| | - Eric Horlick
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Réda Ibrahim
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Krishnakumar Nair
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Nancy C Poirier
- Université de Montréal, CHU-ME Ste-Justine, Institut de Cardiologie de Montréal, Montréal, Québec, Canada
| | - Heather J Ross
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Helmut Baumgartner
- Department of Cardiology III: Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - Curt J Daniels
- The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Michelle Gurvitz
- Boston Adult Congenital Heart Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Adrienne H Kovacs
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | | | | | | | - Gary D Webb
- Cincinnati Children's Hospital Heart Institute, Cincinnati, Ohio, USA
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13
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Lee ME, Kopf GS, Geirsson A, Gruber PJ. Pioneers in congenital cardiac surgery: Dr. William Imon Norwood, Jr, MD, PhD. J Card Surg 2022; 37:2521-2523. [PMID: 35748274 DOI: 10.1111/jocs.16694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/09/2022] [Indexed: 11/29/2022]
Abstract
"Innovation is not only the fountainhead but the life's blood of our specialty, of surgery, of medicine, of business, or of just about anything that is progressing, evolving, and improving. In the absence of innovation there is stagnation and ultimately there is decay. Cardiac surgery, particularly congenital cardiac surgery, must continue to evolve through innovation."
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Affiliation(s)
- Madonna E Lee
- Division of Pediatric Cardiac Surgery and Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Gary S Kopf
- Division of Pediatric Cardiac Surgery and Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Peter J Gruber
- Division of Pediatric Cardiac Surgery and Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
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14
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Plappert L, Edwards S, Senatore A, De Martini A. The Epidemiology of Persons Living with Fontan in 2020 and Projections for 2030: Development of an Epidemiology Model Providing Multinational Estimates. Adv Ther 2022; 39:1004-1015. [PMID: 34936056 PMCID: PMC8866255 DOI: 10.1007/s12325-021-02002-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/16/2021] [Indexed: 12/18/2022]
Abstract
Introduction Fontan surgery is a palliative procedure performed in children with a functionally univentricular heart. Improvements in surgical technique over the past 30 years have increased life expectancy in this rare population. However, the epidemiology of persons living with Fontan is poorly understood. This study aimed to estimate the 2020 and 2030 prevalence of persons living with a Fontan circulation in 11 countries across the US, Europe, Australia and New Zealand, by procedure type: [atriopulmonary connection (AP), lateral tunnel total cavopulmonary connection (LT-TCPC) or extracardiac total cavopulmonary connection (EC-TCPC)]; and age group: [children (< 12 years), adolescents (12–17 years), and adults (≥ 18 years old)] by building an epidemiologic model. Methods The annual number of Fontan surgeries by country in 2010–2020 were extracted from hospital or claims databases, via procedure codes. The epidemiology of persons living with Fontan was modelled by applying these surgery frequencies to mid-year populations from 1972 to 2020 and overlaying an uptake curve. A literature search identified: 30-day mortality rates, long-term survival, and median age at surgery. Averages of these estimates were inputted into the model to project prevalence in 2030. Results The number of persons living with Fontan in 2020 across the 11 countries was estimated to be 47,881 [66 people per million (ppm)], rising to 59,777 (79 ppm) by 2030. In 2020, this population was 55% adults, 17% adolescents and 28% children shifting to 64%, 13% and 23%, respectively, in 2030. Among all persons living with Fontan, 74%/18%/9% are estimated to have EC-TCPC/LT-TCPC/AP, respectively, in 2020, and 83%/14%/4% in 2030. Conclusions According to this epidemiology model, the Fontan population is growing, partly driven by increased survival rates with the more recent LT-TCPC and EC-TCPC procedures (compared with AP). The 2020/2030 prevalence of persons living with Fontan is 66/79 ppm. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-02002-3.
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15
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Commentary: Branch pulmonary artery stenosis after the arterial switch operation: Is prevention better than cure? J Thorac Cardiovasc Surg 2021; 164:329-330. [PMID: 34906394 DOI: 10.1016/j.jtcvs.2021.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 11/20/2022]
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16
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Kumar SR, Mayer JE, Overman DM, Shashidharan S, Wellnitz C, Jacobs JP. The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2021 Update on Outcomes and Research. Ann Thorac Surg 2021; 112:1753-1762. [PMID: 34678276 DOI: 10.1016/j.athoracsur.2021.10.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 10/14/2021] [Indexed: 12/11/2022]
Abstract
The Society of Thoracic Surgeons Congenital Heart Surgery Database is a comprehensive clinical outcomes registry that captures almost all pediatric cardiac surgical operations in the United States. It is the platform for all activities of The Society of Thoracic Surgeons related to the analysis of outcomes and improvement of quality in this subspecialty. This report summarizes current aggregate national outcomes in congenital and pediatric cardiac surgery performed between July 1, 2016, and June 30, 2020. The reported data on aggregate national outcomes are exemplified by an analysis of 10 prespecified benchmark operation groups performed. This report further reviews related activities in the areas of data collection and analysis, quality measurement, performance improvement, and research.
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Affiliation(s)
- S Ram Kumar
- Heart Institute, Children's Hospital Los Angeles/Department of Surgery, University of Southern California, Los Angeles, California.
| | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - David M Overman
- The Children's Heart Clinic at Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | | | | | - Jeffrey P Jacobs
- Congenital Heart Center, Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida
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17
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Atrioventricular Septal Defects: Pathology, Imaging, and Treatment Options. Curr Cardiol Rep 2021; 23:93. [PMID: 34196822 DOI: 10.1007/s11886-021-01523-1] [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] [Accepted: 05/14/2021] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Atrioventricular septal defects (AVSD) represent a broad spectrum of congenital anomalies from simple to the most complex heart defects including some distinct types. Clinical presentation and timing of intervention differ by morphological subset and functional anatomy. Herein, we review morphological variations and characteristics that determine appropriate intervention and provide insights into functional anatomy based on detailed three-dimensional (3D) assessment of AVSDs. RECENT FINDINGS The understanding of functional morphology of AVSDs has improved significantly with detailed 3D echocardiographic evaluation of the atrioventricular junction and valve morphology. As prenatal detection of AVSDs has increased significantly, it has become the most common fetal cardiac diagnosis enabling antenatal counseling and delivery planning. Advances in diagnosis and perioperative care have resulted in optimal outcomes. The diagnosis and management of AVSDs have improved over the years with enhanced understanding of anatomy and perioperative care resulting in optimal short and long-term outcomes.
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18
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van den Bosch E, Bogers AJJC, Roos-Hesselink JW, van Dijk APJ, van Wijngaarden MHEJ, Boersma E, Nijveld A, Luijten LWG, Tanke R, Koopman LP, Helbing WA. Long-term follow-up after transatrial-transpulmonary repair of tetralogy of Fallot: influence of timing on outcome. Eur J Cardiothorac Surg 2021; 57:635-643. [PMID: 31872208 PMCID: PMC7078865 DOI: 10.1093/ejcts/ezz331] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/17/2019] [Accepted: 10/21/2019] [Indexed: 11/14/2022] Open
Abstract
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OBJECTIVES Our goal was to report the long-term serial follow-up after transatrial–transpulmonary repair of tetralogy of Fallot (TOF) and to describe the influence of the timing of the repair on outcome. METHODS We included all patients with TOF who had undergone transatrial–transpulmonary repair between 1970 and 2012. Records were reviewed for patient demographics, operative details and events during the follow-up period (death, pulmonary valve replacement, cardiac reinterventions and hospitalization/intervention for arrhythmias). In patients with elective early primary repair of TOF after 1990, a subanalysis of the optimal timing of TOF repair was performed. RESULTS A total of 453 patients were included (63% male patients; 65% had transannular patch); 261 patients underwent primary elective repair after 1990. The median age at TOF repair was 0.7 years (25th–75th percentile 0.3–1.3) and decreased from 1.7 to 0.4 years from before 1990 to after 2000, respectively (P < 0.001). The median follow-up duration after TOF repair was 16.8 years (9.6–24.7). Events developed in 182 (40%) patients. In multivariable analysis, early repair of TOF (<6 months) [hazard ratio (HR) 3.06; P < 0.001] and complications after TOF repair (HR 2.18; P = 0.006) were found to be predictive for an event. In a subanalysis of the primary repair of TOF after 1990, the patients (n = 125) with elective early repair (<6 months) experienced significantly worse event-free survival compared to patients who had elective repair later (n = 136). In multivariable analysis, early repair (HR 3.00; P = 0.001) and postoperative complications (HR 2.12; P = 0.010) were associated with events in electively repaired patients with TOF. CONCLUSIONS Transatrial–transpulmonary repair of TOF before the age of 6 months may be associated with more events during the long-term follow-up period.
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Affiliation(s)
- Eva van den Bosch
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center, Rotterdam, Netherlands.,Netherlands Heart Institute, Utrecht, Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | | | - Arie P J van Dijk
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Eric Boersma
- Department of Cardiology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Aagje Nijveld
- Department of Cardiothoracic Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Linda W G Luijten
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center, Rotterdam, Netherlands
| | - Ronald Tanke
- Division of Pediatric Cardiology, Department of Pediatrics, Radboud University Medical Center, Nijmegen, Netherlands
| | - Laurens P Koopman
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center, Rotterdam, Netherlands
| | - Willem A Helbing
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center, Rotterdam, Netherlands.,Division of Pediatric Cardiology, Department of Pediatrics, Radboud University Medical Center, Nijmegen, Netherlands
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19
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Steurer MA, Peyvandi S, Costello JM, Moon-Grady AJ, Habib RH, Hill KD, Jacobs ML, Jelliffe-Pawlowski LL, Keller RL, Pasquali SK, Reddy VM, Tabbutt S, Rajagopal S. Association between Z-score for birth weight and postoperative outcomes in neonates and infants with congenital heart disease. J Thorac Cardiovasc Surg 2021; 162:1838-1847.e4. [DOI: 10.1016/j.jtcvs.2021.01.065] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 01/12/2021] [Accepted: 01/15/2021] [Indexed: 12/17/2022]
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20
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Hu R, Zhu H, Qiu L, Hong H, Xu Z, Zhang H, Chen H. Association Between Preoperative Factors and In-hospital Mortality in Neonates After Cardiac Surgery in China. Front Pediatr 2021; 9:670197. [PMID: 34422714 PMCID: PMC8374182 DOI: 10.3389/fped.2021.670197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 07/13/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Little is known about preoperative factors affecting cardiac surgery outcomes of neonates in China. We sought to examine the association between characteristics of neonates with congenital heart disease (CHD) and early postoperative outcomes after cardiac repair in a tertiary care paediatric hospital. Methods: A single-centre retrospective cohort study of neonates who underwent cardiac surgery between January 2006 and December 2019 was performed. Demographic, institutional, and surgical characteristics of neonates were examined and their association with in-hospital mortality was analysed using multivariable logistic regression models. Results: During the study period, we analysed the outcomes of 1,078 neonates. In-hospital mortality decreased to 13.8% in the era 2017-2019. The overall in-hospital mortality rate was 16.3%. Normal weight at surgery [odds ratio (OR), 0.63; 95% confidence interval (CI), 0.47-0.85; P = 0.003] was associated with lower mortality risk. Poor health status (emergent: OR, 3.11; 95% CI, 1.96-4.94; P < 0.001; elective: OR, 1.63; 95% CI, 1.11-2.40; P = 0.013), higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) categories (STAT 5 category: OR, 2.58; 95% CI, 1.04-6.43; P = 0.042), and limited individual surgeon experience (surgeon with 5-10 operations per year: OR, 1.43; 95% CI, 1.06-1.95; P = 0.021) were associated with higher odds of early death. Conclusion: In-hospital mortality after neonatal cardiac surgery remained high in our centre over the past 10 years. Some preoperative aspects, including low-weight at surgery, poor health status, increased surgical complexity, and limited surgeon experience were significantly associated with higher mortality. Based on the observed associations, the necessary practises to be modified, especially in preoperative care, should be identified and assessed in future research.
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Affiliation(s)
- Renjie Hu
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hongbin Zhu
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lisheng Qiu
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Haifa Hong
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhiwei Xu
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Haibo Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hao Chen
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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21
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Hirata Y, Hirahara N, Murakami A, Motomura N, Miyata H, Takamoto S. Status of cardiovascular surgery in Japan: A report based on the Japan Cardiovascular Surgery Database 2017-2018. 1. Congenital heart surgery. Asian Cardiovasc Thorac Ann 2020; 29:289-293. [PMID: 33375819 DOI: 10.1177/0218492320981501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We aimed to analyze the mortality and morbidity associated with congenital heart surgery in Japan. METHODS Data on congenital heart surgeries performed between January 2017 and December 2018 were obtained from Japan Cardiovascular Surgery Database. The 20 most frequent procedures were selected, and mortalities and major morbidities associated with the procedures were analyzed. All procedures were classified into Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery mortality categories, and mortalities in each category were also analyzed. RESULTS The mortality rates in atrial septal defect repair and ventricular septal repair were 0% and 0.2%, respectively. The mortality rates in more complex cases (tetralogy of Fallot repair, complete atrioventricular repair, bidirectional Glenn, and total cavopulmonary connection) were 2%-3%. The mortality rates in systemic-to-pulmonary shunt, total anomalous pulmonary venous connection repair, and the Norwood procedure were 4.9%, 11.1%, and 15.7%, respectively, which were not different from those reported in 2015-2016. The mortalities according to the Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery categories 1-5 were 0.3%, 2.7%, 2.9%, 5.9%, and 15.5%, respectively, and comparable to those of the Society of Thoracic Surgeons database (2013-2016). CONCLUSION The mortality rates and frequency of complications in major surgical procedures for congenital heart disease in Japan in 2017-2018 will play an important role as a basis for trends in Japan and for comparison with results from other countries.
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Affiliation(s)
- Yasutaka Hirata
- Department of Cardiac Surgery, The University of Tokyo School of Medicine, Tokyo, Japan
| | | | - Arata Murakami
- Kanazawa Cardiovascular Hospital, Department of Cardiovascular Surgery, Toho University Sakura Medical Center, Tokyo, Japan
| | - Noboru Motomura
- Kanazawa Cardiovascular Hospital, Department of Cardiovascular Surgery, Toho University Sakura Medical Center, Tokyo, Japan
| | - Hiroaki Miyata
- Department of Health Policy and Management, Keio University
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22
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Kothari P, Nguyen QS, Pagel PS, Choi C. Gradually Progressive Dyspnea and Exercise Intolerance in an Otherwise Active Middle-Aged Woman: Why Was the Presentation of Congenital Heart Disease Delayed? J Cardiothorac Vasc Anesth 2020; 35:1225-1230. [PMID: 33376067 DOI: 10.1053/j.jvca.2020.11.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 11/16/2020] [Accepted: 11/24/2020] [Indexed: 11/11/2022]
Abstract
Patients with congenital heart disease (CHD) increasingly are surviving into adulthood. In the United States alone, there are more than one million adult patients living with CHD with the number increasing about 5% each year. With more than 85% of infants with CHD surviving into adulthood with their disease, encounters with these patients in the operating room for cardiac and noncardiac operative procedures is becoming more commonplace. Most of these patients receive corrective surgery early in life, although some may live with uncorrected CHD with no-to-relatively mild symptoms and present at a later time in life with symptoms of heart failure or pulmonary hypertension. The authors present an adult patient with uncorrected CHD presenting with late onset of heart failure symptoms. The authors also review the patient's complex congenital heart lesion, transesophageal echocardiography findings, and intraoperative management.
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Affiliation(s)
- Perin Kothari
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA.
| | - Quoc-Sy Nguyen
- Department of Anesthesiology, University of California-San Diego, La Jolla, CA
| | - Paul S Pagel
- Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
| | - Christine Choi
- Department of Anesthesiology, University of California-San Diego, La Jolla, CA
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23
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Risk Factors for Peri-Intubation Cardiac Arrest in Pediatric Cardiac Intensive Care Patients: A Multicenter Study. Pediatr Crit Care Med 2020; 21:e1126-e1133. [PMID: 32740187 DOI: 10.1097/pcc.0000000000002472] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Endotracheal intubation is associated with hemodynamic adverse events, including cardiac arrest, especially in patients with cardiac disease. There are only a few studies that have evaluated the rate of and risk factors for endotracheal intubation hemodynamic complications in critically ill pediatric patients. Although some of these studies have assessed hemodynamic complications during intubation in pediatric cardiac patients, the frequency of and risk factors for peri-intubation cardiac arrest have not been adequately described in high acuity cardiac patients. This study aims to describe the frequency of and risk factors for peri-intubation cardiac arrest in critically ill pediatric cardiac patients admitted to specialized cardiac ICUs. DESIGN Multicenter retrospective cohort study. SETTING Three pediatric cardiac ICUs in the United States. PATIENTS Critically ill pediatric patients with congenital or acquired heart disease requiring endotracheal intubation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Endotracheal intubations performed in three cardiac ICUs between January 2015 and December 2017 were reviewed. Clinical variables-including data on patients, clinical providers, and procedure-were evaluated for their association with peri-intubation cardiac arrest. There was a total of 186 intubation events studied, occurring in 151 individual (index) patients. The rates of peri-intubation cardiac arrest and peri-intubation mortality in this cohort were 7% and 1.6%, respectively. Among those patients with moderate or severe systolic dysfunction of the systemic ventricle, peri-intubation cardiac arrest rate was 20.7%. Statistically significant risk factors for peri-intubation cardiac arrest included: significant systolic dysfunction of the systemic ventricle, pre-intubation hypotension, pre-intubation lactate elevation, lower pre-intubation pH, and documented oxygen desaturations (> 10%) during intubation procedure. CONCLUSIONS Our most significant finding was a peri-intubation cardiac arrest rate which was much higher than previously published rates for both cardiac and noncardiac children who underwent endotracheal intubation in ICUs. Peri-intubation mortality was also high in our cohort. Regarding risk factors for peri-intubation arrest, significant systolic dysfunction of the systemic ventricle was strongly associated with cardiac arrest in this cohort.
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24
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Riggs KW, Zafar F, Jacobs ML, Jacobs JP, Thibault D, Guleserian KJ, Chiswell K, Andersen N, Hill KD, Morales DLS, Bryant R, Tweddell JS. Tracheal surgery for airway anomalies associated with increased mortality in pediatric patients undergoing heart surgery: Society of Thoracic Surgeons Database analysis. J Thorac Cardiovasc Surg 2020; 161:1112-1121.e7. [PMID: 33419543 DOI: 10.1016/j.jtcvs.2020.10.149] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 09/24/2020] [Accepted: 10/22/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Airway anomalies are common in children with cardiac disease but with an unquantified impact on outcomes. We sought to define the association between airway anomalies and tracheal surgery with cardiac surgery outcomes using the Society of Thoracic Surgery Congenital Heart Surgery Database. METHODS Index cardiac operations in children aged less than 18 years (January 2010 to September 2018) were identified from the Society of Thoracic Surgery Congenital Heart Surgery Database. Patients were divided on the basis of reported diagnosis of an airway anomaly and subdivided on the basis of tracheal lesion and tracheal surgery. Multivariable analysis evaluated associations between airway disease and outcomes controlling for covariates from the Society of Thoracic Surgery Congenital Heart Surgery Database Mortality Risk Model. RESULTS Of 198,674 index cardiovascular operations, 6861 (3.4%) were performed in patients with airway anomalies, including 428 patients (0.2%) who also underwent tracheal operations during the same hospitalization. Patients with airway anomalies underwent more complex cardiac operations (45% vs 36% Society of Thoracic Surgeons/European Association for Cardiothoracic Surgery Congenital Heart Surgery Mortality category ≥3 procedures) and had a higher prevalence of preoperative risk factors (73% vs 39%; both P < .001). In multivariable analysis, patients with airway anomalies had increased odds of major morbidity and tracheostomy (P < .001). Operative mortality was also increased in patients with airway anomalies, except those with malacia. Tracheal surgery within the same hospitalization increased the odds of operative mortality (adjusted odds ratio, 3.9; P < .0001), major morbidity (adjusted odds ratio, 3.7; P < .0001), and tracheostomy (adjusted odds ratio, 16.7; P < .0001). CONCLUSIONS Patients undergoing cardiac surgery and tracheal surgery are at significantly higher risk of morbidity and mortality than patients receiving cardiac surgery alone. Most of those with unoperated airway anomalies have higher morbidity and mortality, which makes it an important preoperative consideration.
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Affiliation(s)
- Kyle W Riggs
- Division of Cardiothoracic Surgery, Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Cardiothoracic Surgery, Northwell Health, Manhasset, NY.
| | - Farhan Zafar
- Division of Cardiothoracic Surgery, Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Marshall L Jacobs
- Department of Cardiothoracic Surgery, Johns Hopkins School of Medicine, Baltimore, Md
| | | | | | - Kristine J Guleserian
- Division of Cardiothoracic Surgery, Department of Surgery, Nicklaus Children's Hospital, Miami, Fla
| | | | - Nick Andersen
- Duke Children's Pediatric and Congenital Heart Center, Durham, NC
| | - Kevin D Hill
- Duke Clinical Research Institute, Durham, NC; Duke Children's Pediatric and Congenital Heart Center, Durham, NC
| | - David L S Morales
- Division of Cardiothoracic Surgery, Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Roosevelt Bryant
- Division of Cardiothoracic Surgery, Department of Surgery, Phoenix Children's Hospital, Phoenix, Ariz
| | - James S Tweddell
- Division of Cardiothoracic Surgery, Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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25
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Modestini M, Hoffmann L, Niezen C, Armocida B, Vos JJ, Scheeren TWL. Cerebral oxygenation during pediatric congenital cardiac surgery and its association with outcome: a retrospective observational study. Can J Anaesth 2020; 67:1170-1181. [PMID: 32557197 PMCID: PMC7299246 DOI: 10.1007/s12630-020-01733-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 03/25/2020] [Accepted: 05/01/2020] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Non-invasive cerebral oxygen saturation (ScO2) monitoring is an established tool in the intraoperative phase of pediatric congenital cardiac surgery (CCS). This study investigated the association between ScO2 and postoperative outcome by investigating both baseline ScO2 values and intraoperative desaturations from baseline. METHODS All CCS procedures performed in the period 2010-2017 in our institution in which ScO2 was monitored were included in this historical cohort study. Baseline ScO2 was determined after tracheal intubation, before surgical incision. Subgroups were based on cardiac pathology and degree of intracardiac shunting. Poor outcome was defined based on length of stay (LOS) in the intensive care unit (ICU)/hospital, duration of mechanical ventilation (MV), and 30-day mortality. Intraoperatively, ScO2 total time below baseline (TBBL) and ScO2 time-weighted average (TWA) were calculated. RESULTS Data from 565 patients were analyzed. Baseline ScO2 was significantly associated with LOS in ICU (odds ratio [OR] per percentage decrease in baseline ScO2, 0.95; 95% confidence interval [CI], 0.93 to 0.97; P < 0.001), with LOS in hospital (OR, 0.93; 95% CI, 0.91 to 0.96; P < 0.001), with MV duration (OR, 0.92; 95% CI, 0.90 to 0.95; P < 0.001) and with 30-day mortality (OR, 0.94; 95% CI, 0.91 to 0.98; P = 0.007). Cerebral oxygen saturation TWA had no associations, while ScO2 TBBL had only a small association with LOS in ICU (OR, 1.02; 95% CI, 1.01 to 1.03; P < 0.001), MV duration (OR,1.02; 95% CI, 1.01 to 1.03; P = 0.002), and LOS in hospital (OR, 1.02; 95% CI, 1.01 to 1.04; P < 0.001). CONCLUSION In pediatric patients undergoing cardiac surgery, low baseline ScO2 values measured after tracheal intubation were associated with several adverse postoperative outcomes. In contrast, the severity of actual intraoperative cerebral desaturation was not associated with postoperative outcomes. Baseline ScO2 measured after tracheal intubation may help identify patients at increased perioperative risk.
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Affiliation(s)
- Marco Modestini
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Lisa Hoffmann
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- European Medical School Oldenburg-Groningen, Oldenburg, Germany
| | - Caren Niezen
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Benedetta Armocida
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jaap Jan Vos
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Thomas W L Scheeren
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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26
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Ahn SS, Tahara RW, Jones LE, Carr JG, Blebea J. Preliminary Results of the Outpatient Endovascular and Interventional Society National Registry. J Endovasc Ther 2020; 27:956-963. [PMID: 32813592 PMCID: PMC8685594 DOI: 10.1177/1526602820949970] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Purpose To present a new outcomes-based registry to collect data on outpatient endovascular
interventions, a relatively new site of service without adequate historical data to
assess best clinical practices. Quality data collection with subsequent outcomes
analysis, benchmarking, and direct feedback is necessary to achieve optimal care. Materials and Methods The Outpatient Endovascular and Interventional Society (OEIS) established the OEIS
National Registry in 2017 to collect data on safety, efficacy, and quality of care for
outpatient endovascular interventions. Since then, it has grown to include a peripheral
artery disease (PAD) module with plans to expand to include cardiac, venous, dialysis
access, and other procedures in future modules. As a Qualified Clinical Data Registry
approved by the Centers for Medicare and Medicaid Services, this application also
supports new quality measure development under the Quality Payment Program. All
physicians operating in an office-based laboratory or ambulatory surgery center can use
the Registry to analyze de-identified data and benchmark performance against national
averages. Major adverse events were defined as death, stroke, myocardial infarction,
acute onset of limb ischemia, index bypass graft or treated segment thrombosis, and/or
need for urgent/emergent vascular surgery. Results Since Registry inception in 2017, 251 participating physicians from 64 centers located
in 18 states have participated. The current database includes 18,134 peripheral
endovascular interventions performed in 12,403 PAD patients (mean age 72.3±10.2 years;
60.1% men) between January 2017 and January 2020. Cases were performed primarily in an
office-based laboratory (85.1%) or ambulatory surgery center setting (10.4%). Most
frequently observed procedure indications from 16,086 preprocedure form submissions
included claudication (59%), minor tissue loss (16%), rest pain (9%), acute limb
ischemia (5%), and maintenance of patency (3%). Planned diagnostic procedures made up
12.2% of cases entered, with the remainder indicated as interventional procedures
(87.6%). The hospital transfer rate was 0.62%, with 88 urgent/emergent transfers and 24
elective transfers. The overall complication rate for the Registry was 1.87% (n=338),
and the rate of major adverse events was 0.51% (n=92). Thirty-day mortality was 0.03%
(n=6). Conclusion This report describes the current structure, methodology, and preliminary results of
OEIS National Registry, an outcomes-based registry designed to collect quality
performance data with subsequent outcome analysis, benchmarking, and direct feedback to
aid clinicians in providing optimal care.
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Affiliation(s)
- Samuel S Ahn
- DFW Vascular Group, Dallas, TX, USA.,University Vascular Associates, Los Angeles, CA, USA.,TCU School of Medicine, Ft. Worth, TX, USA
| | | | - Lauren E Jones
- Outpatient Endovascular and Interventional Society, Hoffman Estates, IL, USA
| | | | - John Blebea
- Central Michigan University College of Medicine, Saginaw, MI, USA
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27
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Fraser CD, Ravekes W, Thibault D, Scully B, Chiswell K, Giuliano K, Hill KD, Jacobs JP, Jacobs ML, Kutty S, Vricella L, Hibino N. Diaphragm Paralysis After Pediatric Cardiac Surgery: An STS Congenital Heart Surgery Database Study. Ann Thorac Surg 2020; 112:139-146. [PMID: 32763270 DOI: 10.1016/j.athoracsur.2020.05.175] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 05/08/2020] [Accepted: 05/27/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Previous single-center studies of diaphragm paralysis (DP) after pediatric cardiac surgery report incidence of 0.3% to 12.8% and associate DP with respiratory complications, prolonged ventilation and length of stay, and mortality. To better define incidence and associations between DP and various procedures and outcomes, we performed a multicenter study. METHODS The Society of Thoracic Surgeons Congenital Heart Surgery Database was queried to identify children who experienced DP after cardiac surgery (2010-2018; 126 centers). Baseline characteristics and postoperative outcomes were compared between patients with and without DP as well as between patients who underwent plication and those who did not. Associations between center volume and center rates of DP and use of plication were also explored. RESULTS A total of 2214 of 191,463 (1.2%) patients experienced DP. Postoperative DP portended worse outcomes, including mortality (5.6% vs 3.5%; P < .001), major morbidity (37.2% vs 10.7%; P < .001), tracheostomy (7.1% vs 0.9%; P < .001), prolonged mechanical ventilation (38.0% vs 7.8%; P < .001), and 30-day readmission (22.0% vs 10.6%; P < .001). A total of 1105 of 2214 (49.9%) patients with DP underwent plication. Patients who underwent plication were younger, were smaller, had more risk factors, and underwent more complex surgeries. Plication rates varied widely across centers. There was no correlation between center volume and center risk-adjusted rates of DP (r = .05, P = .5), nor frequency of plication (r = .08, P = .4). CONCLUSIONS DP complicating pediatric heart surgery is rare but portends significantly worse outcomes. One-half of patients underwent plication. Center-level risk-adjusted rates of DP and plication are not associated with case volume. Significant variability in plication practices suggests a target for quality improvement.
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Affiliation(s)
- Charles D Fraser
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland.
| | - William Ravekes
- Division of Pediatric Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Dylan Thibault
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Brandi Scully
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Katherine Giuliano
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Kevin D Hill
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Jeffrey P Jacobs
- Division of Thoracic and Cardiovascular Surgery, University of Florida Congenital Heart Center, Gainesville, Florida
| | - Marshall L Jacobs
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Shelby Kutty
- Division of Pediatric Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Luca Vricella
- Division of Pediatric Cardiac Surgery, University of Chicago, Chicago, Illinois
| | - Narutoshi Hibino
- Division of Pediatric Cardiac Surgery, University of Chicago, Chicago, Illinois
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28
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Hirata Y, Hirahara N, Murakami A, Motomura N, Miyata H, Takamoto S. Current Status of Cardiovascular Surgery in Japan : A Report Based on the Japan Cardiovascular Surgery Database in 2017, 2018 1. Congenital Heart Surgery. ACTA ACUST UNITED AC 2020. [DOI: 10.4326/jjcvs.49.151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Yasutaka Hirata
- The Japan Cardiovascular Surgery Database (JCVSD), the Japanese Society for Cardiovascular Surgery
- Department of Cardiac Surgery, The University of Tokyo School of Medicine
| | - Norimichi Hirahara
- The Japan Cardiovascular Surgery Database (JCVSD), the Japanese Society for Cardiovascular Surgery
- Department of Health Policy and Management, School of Medicine, Keio University
| | - Arata Murakami
- The Japan Cardiovascular Surgery Database (JCVSD), the Japanese Society for Cardiovascular Surgery
- Kanazawa Cardiovascular Hospital
| | - Noboru Motomura
- The Japan Cardiovascular Surgery Database (JCVSD), the Japanese Society for Cardiovascular Surgery
- Department of Cardiovascular Surgery, Toho University Sakura Medical Center
| | - Hiroaki Miyata
- The Japan Cardiovascular Surgery Database (JCVSD), the Japanese Society for Cardiovascular Surgery
- Department of Health Policy and Management, School of Medicine, Keio University
| | - Shinichi Takamoto
- The Japan Cardiovascular Surgery Database (JCVSD), the Japanese Society for Cardiovascular Surgery
- Department of Health Policy and Management, School of Medicine, Keio University
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29
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Hirata Y, Shimizu H, Kumamaru H, Takamoto S, Motomura N, Miyata H, Okita Y. Congenital Heart Disease After the Fukushima Nuclear Accident: The Japan Cardiovascular Surgery Database Study. J Am Heart Assoc 2020; 9:e014787. [PMID: 32613886 PMCID: PMC7670522 DOI: 10.1161/jaha.119.014787] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background In March 2011, the Fukushima Daiichi nuclear power plant disaster inflicted radiation damage across the Tohoku region of Northern Japan. The consequent harm to pregnant mothers and newborns was a matter of concern. We performed a registry‐based analysis of the incidence of congenital heart disease during 2010 to 2013 using the Japan Cardiovascular Surgery Database. Methods and Results We selected patients who had complex congenital heart disease and who were born between January 1, 2010 and December 31, 2013 undergoing surgery, and assessed the trend in the number of first‐time surgeries performed for patients aged 2 years and younger by birth year over time. The numbers of first‐time surgeries for birth years 2010 to 2013 were 2978, 2924, 3077, and 2940, and no increasing trend was detected. Additionally, no increasing yearly trend was detected when the number of cases was divided by the total number of births in Japan in each birth month. The mortality of first‐time surgeries performed for complex diseases, which often involves multiple subsequent surgeries, decreased from 4.7% in 2010 to 2.2% in 2013. Conclusions Our analyses showed no increase in the number of patients with congenital heart disease during 2010 to 2013. The yearly increase in the total number of surgeries following the Fukushima Daiichi nuclear disaster in a previous report can be explained by the decline in the mortality of first‐time surgeries for complex cases. Such use of only the increase in the total yearly number of surgeries to claim the effects of a nuclear disaster on the incidence of congenital heart disease is a far too simplistic and dangerous proposition.
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Affiliation(s)
- Yasutaka Hirata
- The Japanese Association for Thoracic Surgery Tokyo Japan.,Department of Cardiac Surgery The University of Tokyo Hospital Tokyo Japan
| | - Hideyuki Shimizu
- The Japanese Association for Thoracic Surgery Tokyo Japan.,Department of Cardiovascular Surgery Keio University Hospital Tokyo Japan
| | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment University of Tokyo Japan
| | | | - Noboru Motomura
- The Japan Cardiovascular Surgery Database Organization Tokyo Japan.,Department of Cardiovascular Surgery Toho University Sakura Medical Center Sakura Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment University of Tokyo Japan
| | - Yutaka Okita
- The Japanese Association for Thoracic Surgery Tokyo Japan.,Takatsuki General Hospital Cardio-Aortic Center Osaka Japan
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30
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Hames DL, Mills KI, Thiagarajan RR, Teele SA. Extracorporeal Membrane Oxygenation in Infants Undergoing Truncus Arteriosus Repair. Ann Thorac Surg 2020; 111:176-183. [PMID: 32335016 DOI: 10.1016/j.athoracsur.2020.03.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 03/12/2020] [Accepted: 03/17/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Infants undergoing truncus arteriosus (TA) repair suffer one of the highest mortality rates of all congenital heart defects. Extracorporeal membrane oxygenation (ECMO) can support patients undergoing TA repair, but little is known about factors contributing to mortality in this cohort. The objective of this study was to identify risk factors for mortality in infants with TA requiring perioperative ECMO. METHODS Data from the Extracorporeal Life Support Organization from 2002 to 2017 for infants less than 60 days old undergoing TA repair were analyzed. Demographics, clinical characteristics, and ECMO characteristics and complications were compared between survivors and nonsurvivors. Multivariable logistic regression was used to evaluate independent risk factors for mortality. RESULTS Of 245 patients analyzed, 92 (37.6%) survived to discharge. Nonsurvivors had a lower weight and a longer ECMO duration. A higher proportion of nonsurvivors suffered complications on ECMO, including mechanical complications, circuit thrombus, bleeding, and need for renal replacement therapy. In multivariable analysis lower weight (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.33-0.95), duration of ECMO (OR, 1.1; 95% CI, 1.02-1.18), need for renal replacement therapy (OR, 3.23; 95% CI, 1.68-6.2), cardiopulmonary resuscitation on ECMO (OR, 11.52; 95% CI, 1.3-102.33), and infection on ECMO (OR, 4.47; 95% CI, 1.2-16.64) were independently associated with mortality. CONCLUSIONS Many factors associated with mortality for infants requiring perioperative ECMO with TA repair are related to complications suffered on ECMO. Thoughtful patient selection and meticulous ECMO management to prevent complications are essential in improving outcomes for these infants.
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Affiliation(s)
- Daniel L Hames
- Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Kimberly I Mills
- Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ravi R Thiagarajan
- Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sarah A Teele
- Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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31
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Seese LM, Turbendian HK, Castrillon CED, Morell VO. The Fate of Homograft Versus Polytetrafluoroethylene Conduits After Neonatal Truncus Arteriosus Repair. World J Pediatr Congenit Heart Surg 2020; 11:141-147. [DOI: 10.1177/2150135119888141] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Despite significant improvement in outcomes with truncus arteriosus (TA) repair, right ventricular outflow tract (RVOT) reconstruction with a right ventricular to pulmonary artery (RV-to-PA) conduit remains a source of long-term reintervention and reoperation. This study evaluated our experience with reintervention in homograft and polytetrafluoroethylene (PTFE) RV-to-PA conduits in neonates. Methods: Primary TA repairs from 2004 to 2016 at a single institution were included. Stratification was based on RVOT reconstruction with PTFE or homograft conduit. Primary outcome was operative conduit replacement. Secondary outcomes included the rates and types of catheter-based conduit interventions. Results: Twenty-eight patients underwent primary TA repair and 89.3% (n = 25) of them had RVOT reconstruction with a homograft (28.0%, n = 7) or PTFE (72.0%, n = 18) conduit. Rates of reoperation for conduit replacement and catheter-based interventions were similar between those with PTFE and homograft conduits (85.7% vs 72.2%, P = .49 and 57.1% vs 83.3%, P = .11, respectively). Additionally, the median time to conduit replacement and catheter-based conduit interventions were comparable. In multivariable analysis, conduit size, but not conduit type, was a predictor of conduit revision (hazard ratio: 1.66, 95% confidence interval: 1.11-2.49, P = .02). At five-year and ten-year follow-up, patients with PTFE conduits had better survival than those with homograft conduits (100.0% vs 71.4%, P = .02); however, no mortalities were associated with conduit reoperations or catheter-based reinterventions. Conclusions: Polytetrafluoroethylene and homograft RVOT reconstruction in neonatal TA repair demonstrate similar durability as defined by reoperation and reintervention rates. The validation of the durability of PTFE conduits in neonatal TA repair requires confirmatory studies in larger cohorts.
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Affiliation(s)
- Laura M. Seese
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Harma K. Turbendian
- Division of Pediatric Cardiothoracic Surgery, University of Pittsburgh Medical Center, The Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
- Division of Pediatric Cardiothoracic Surgery, University of Pittsburgh Medical Center, Wolfson Children’s Hospital, Jacksonville, FL, USA
| | | | - Victor O. Morell
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Pediatric Cardiothoracic Surgery, University of Pittsburgh Medical Center, The Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
- Division of Pediatric Cardiothoracic Surgery, University of Pittsburgh Medical Center, Wolfson Children’s Hospital, Jacksonville, FL, USA
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32
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van den Bosch E, Bossers SSM, Bogers AJJC, Robbers-Visser D, van Dijk APJ, Roos-Hesselink JW, Breur HMPJ, Haas F, Kapusta L, Helbing WA. Staged total cavopulmonary connection: serial comparison of intra-atrial lateral tunnel and extracardiac conduit taking account of current surgical adaptations. Interact Cardiovasc Thorac Surg 2020; 29:453-460. [PMID: 30968115 DOI: 10.1093/icvts/ivz081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 02/01/2019] [Accepted: 02/21/2019] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES Our goals were to compare the outcome of the intra-atrial lateral tunnel (ILT) and the extracardiac conduit (ECC) techniques for staged total cavopulmonary connection (TCPC) and to compare the current modifications of the TCPC technique, i.e. the prosthetic ILT technique with the current ECC technique with a ≥18-mm conduit. METHODS We included patients who had undergone a staged TCPC between 1988 and 2008. Records were reviewed for patient demographics, operative details and events during follow-up (death, surgical and catheter-based reinterventions and arrhythmias). RESULTS Of the 208 patients included, 103 had the ILT (51 baffle, 52 prosthetic) technique and 105 had the ECC technique. Median follow-up duration was 13.2 years (interquartile range 9.5-16.3). At 15 years after the TCPC, the overall survival rate was comparable (81% ILT vs 89% ECC; P = 0.12). Freedom from late surgical and catheter-based reintervention was higher for patients who had ILT than for those who had ECC (63% vs 44%; P = 0.016). However, freedom from late arrhythmia was lower for patients who had ILT than for those who had ECC (71% vs 85%, P = 0.034). In a subgroup of patients who had the current TCPC technique, when we compared the use of a prosthetic ILT with ≥18-mm ECC, we found no differences in freedom from late arrhythmias (82% vs 86%, P = 0.64) or in freedom from late reinterventions (70% vs 52%, P = 0.14). CONCLUSIONS A comparison between the updated prosthetic ILT and current ≥18-mm ECC techniques revealed no differences in late arrhythmia-free survival or late reintervention-free survival. Overall, outcomes after the staged TCPC were relatively good and reinterventions occurred more frequently in the ECC group, whereas late arrhythmias were more common in the ILT group.
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Affiliation(s)
- Eva van den Bosch
- Division of Paediatric Cardiology, Department of Paediatrics, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Radiology, Erasmus University Medical Center, Rotterdam, Netherlands.,Netherlands Heart Institute, Utrecht, Netherlands
| | - Sjoerd S M Bossers
- Division of Paediatric Cardiology, Department of Paediatrics, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Radiology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Arie P J van Dijk
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Hans M P J Breur
- Department of Paediatric Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Felix Haas
- Department of Paediatric Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Livia Kapusta
- Paediatric Cardiology, Dana-Dwek Children's Hospital, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel.,Division of Paediatric Cardiology, Department of Paediatrics, Radboud University Medical Center, Nijmegen, Netherlands
| | - Willem A Helbing
- Division of Paediatric Cardiology, Department of Paediatrics, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Radiology, Erasmus University Medical Center, Rotterdam, Netherlands.,Division of Paediatric Cardiology, Department of Paediatrics, Radboud University Medical Center, Nijmegen, Netherlands
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Fraser CD, Chacon-Portillo MA, Well A, Zea-Vera R, Binsalamah Z, Adachi I, Mery CM, Heinle JS. Twenty-Three-Year Experience With the Arterial Switch Operation: Expectations and Long-Term Outcomes. Semin Thorac Cardiovasc Surg 2020; 32:292-299. [PMID: 31958553 DOI: 10.1053/j.semtcvs.2020.01.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 01/12/2020] [Indexed: 11/11/2022]
Abstract
We aimed to describe the short- and long-term outcomes of patients after an arterial switch operation (ASO) at a single institution during a 23-year period. A retrospective chart review of all patients <18 months of age who underwent an ASO between January 1995 and March 2018 at Texas Children's Hospital, Houston, TX was performed. Primary endpoints include mortality and reintervention. Perioperative mortality was defined as mortality occurring in-hospital and/or <30 days after surgery. Survival and freedom-from-reintervention were analyzed using Kaplan-Meier method, log-rank tests, and Cox regression models. The cohort included 394 patients. Diagnoses included 204 patients (52%) with intact ventricular septum, 137 (35%) with a ventricular septal defect, 17 (4%) with a ventricular septal defect and left ventricular outflow tract obstruction (LVOTO), and 36 (9%) with Taussig-Bing anomaly. Median age at surgery was 8 days (range: 1 day to 17 months) and median weight was 3.4 (range: 0.8-12.0) kg. Overall perioperative mortality was 1.3% (n = 5), 0.3% (n = 1) since 1999. Overall survival at 5, 10, and 15 years was 98.2%, 97.8%, and 97.8%, respectively. Perioperative morality was associated with prematurity (P = 0.012), <2.5 kg (P< 0.001), and longer circulatory arrest (P = 0.024) after univariate analysis. Reintervention was associated with a longer cross-clamp time (P < 0.001), <2.5 kg (P = 0.009), LVOTO resection (P = 0.047), and genetic syndrome (P= 0.011) after multivariable analysis. Current ASO expectations should include a perioperative mortality risk of <1% and good long-term survival. Reinterventions are more frequent in patients <2.5 kg, concomitant LVOTO resection, a genetic syndrome, and longer cross-clamp time.
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Affiliation(s)
- Charles D Fraser
- Texas Center for Pediatric and Congenital Heart Disease, Dell Children's Medical Center, University of Texas Dell Medical School, Austin, Texas.
| | - Martin A Chacon-Portillo
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Andrew Well
- Texas Center for Pediatric and Congenital Heart Disease, Dell Children's Medical Center, University of Texas Dell Medical School, Austin, Texas
| | - Rodrigo Zea-Vera
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Ziyad Binsalamah
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Iki Adachi
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, Dell Children's Medical Center, University of Texas Dell Medical School, Austin, Texas
| | - Jeffrey S Heinle
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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Terol C, Kamphuis VP, Hazekamp MG, Blom NA, Ten Harkel ADJ. Left and Right Ventricular Impairment Shortly After Correction of Tetralogy of Fallot. Pediatr Cardiol 2020; 41:1042-1050. [PMID: 32363435 PMCID: PMC7314721 DOI: 10.1007/s00246-020-02355-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 04/23/2020] [Indexed: 02/05/2023]
Abstract
Surgical repair of Tetralogy of Fallot (ToF) is usually performed in the first months of life with low early postoperative mortality. During long-term follow-up, however, both right (RV) and left ventricular (LV) performances may deteriorate. Tissue Doppler imaging (TDI) and speckle tracking echocardiography (ST) can unmask a diminished RV and LV performance. The objective of the current study was to assess the cardiac performance before and shortly after corrective surgery in ToF patients using conventional, TDI and ST echocardiographic techniques. Thirty-six ToF patients after surgery were included. Transthoracic echocardiography including TDI and ST techniques was performed preoperatively and at hospital discharge after surgery (10 days to 4 weeks after surgery). Median age at surgery was 7.5 months [5.5-10.9]. Regarding the LV systolic function there was a significant decrease in interventricular septum (IVS) S' at discharge as compared to preoperatively (pre IVS S' = 5.4 ± 1.4; post IVS S' = 3.9 ± 1.2; p < 0.001) and in global longitudinal peak strain (GLS) (pre = - 18.3 ± 3.4; post = - 14.2 ± 4.1; p = 0.003); but not in the fractional shortening (FS). Both conventional and TDI parameters showed a decrease in diastolic function at discharge. Tricuspid Annular Plane Systolic Excursion and RV S' were significantly lower before discharge. When assessing the RV diastolic performance, only the TDI demonstrated a RV impairment. There was a negative correlation between age at surgery and postoperative LV GLS (R = - 0.41, p = 0.031). There seems to be an impairment in left and right ventricle performance at discharge after ToF corrective surgery compared to preoperatively. This is better determined with TDI and ST strain imaging than with conventional echocardiography.
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Affiliation(s)
- Covadonga Terol
- Division of Paediatric Cardiology, Department of Paediatrics, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Vivian P. Kamphuis
- Division of Paediatric Cardiology, Department of Paediatrics, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands ,Netherlands Heart Institute, Utrecht, The Netherlands
| | - Mark G. Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Nico A. Blom
- Division of Paediatric Cardiology, Department of Paediatrics, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands ,Division of Paediatric Cardiology, Department of Paediatrics, Academic Medical Centre, Amsterdam, The Netherlands
| | - Arend D. J. Ten Harkel
- Division of Paediatric Cardiology, Department of Paediatrics, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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Red cell transfusion practices after stage 1 palliation: a survey of practitioners from the Pediatric Cardiac Intensive Care Society. Cardiol Young 2019; 29:1452-1458. [PMID: 31722769 DOI: 10.1017/s1047951119002385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Neonates may require increased red cell mass to optimise oxygen content after stage 1 palliation; however, data informing transfusion practices are limited. We hypothesise there is a patient-, provider-, and institution-based heterogeneity in red cell transfusion decision-making after stage 1 palliation. METHODS We conducted an online survey of Pediatric Cardiac Intensive Care Society practitioners in 2016. Respondents answered scenario-based questions that defined transfusion indications and identified haematocrit transfusion thresholds. Respondents were divided into restrictive and liberal groups based on a haematocrit score. Fisher's exact test was used to determine the associations between transfusion likelihood and patient, provider, and institutional characteristics. Bonferroni correction was applied to adjust the p-value to 0.004 for multiple comparisons. RESULTS There was a 21% response rate (116 responses). Most were male (58.6%), attending physicians (85.3%) with >5 year of intensive care experience (88.7%) and subspeciality training in critical care medicine (47.4%). The majority of institutions were academic (96.6%), with a separate cardiac ICU (86.2%), and performed >10 stage 1 palliation cases annually (68.1%). After Bonferroni correction, there were no significant patient, respondent, or institutional differences between the restrictive and liberal groups. No respondent or institutional characteristics influenced transfusion decision-making after stage 1 palliation. CONCLUSIONS Decision-making around red cell transfusion after stage 1 palliation is heterogeneous. We found no clear relationships between patient, respondent, or institutional characteristics and transfusion decision-making among surveyed respondents. Given the lack of existing data informing red cell transfusion after stage 1 palliation, further studies are necessary to inform evidence-based guidelines.
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Purifoy ET, Spray BJ, Riley JS, Prodhan P, Bolin EH. Effect of Trisomy 21 on Postoperative Length of Stay and Non-cardiac Surgery After Complete Repair of Tetralogy of Fallot. Pediatr Cardiol 2019; 40:1627-1632. [PMID: 31494702 DOI: 10.1007/s00246-019-02196-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/23/2019] [Indexed: 12/14/2022]
Abstract
Trisomy 21 (T21) is the most common chromosomal abnormality, and is frequently associated with congenital heart disease. Results of previous studies evaluating the effect of T21 on postoperative outcomes and complications following heart surgery have been mixed. Our goal was to determine if T21 is associated with higher frequency of adverse postoperative outcomes following repair of tetralogy of Fallot (TOF). A query of the Pediatric Health Information System was performed for patients who underwent complete repair of TOF from 2004 to 2015. Patients with a genetic syndrome other than T21 and tracheostomy and/or gastrostomy prior to heart surgery were excluded. Two groups were created on the basis of whether patients received a diagnostic code for T21. The adverse outcomes of interest were postoperative mortality, postoperative length of stay (LOS), postoperative gastrostomy, and postoperative tracheostomy. Univariate and Kaplan-Meier analysis were performed to evaluate outcomes. There were a total of 4790 patients; 430 (9%) patients had T21, and 4360 (91%) patients without a genetic diagnosis. There was no significant difference in mortality before discharge between those with and without T21 (2.3% vs 1.4%; p = 0.155). Patients with T21 had longer postoperative LOS (mean of 19.8 days vs 12.4 days; p < 0.001), and higher rates of postoperative gastrostomy (13.3% vs 5.3%; p < 0.02). There was no significant difference between groups for rates of postoperative tracheostomy (1.9% vs 1.2%; p = 0.276). Kaplan-Meier analysis confirmed that patients with T21 had longer postoperative LOS and greater incidence of gastrostomy.
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Affiliation(s)
- Eric T Purifoy
- Department of Pediatrics, Section of Pediatric Cardiology, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202-3591, USA.
| | - Beverly J Spray
- Biostatistics Core, Arkansas Children's Research Institute, 13 Children's Way, Little Rock, AR, 72202-3591, USA
| | - Joe S Riley
- Biostatistics Core, Arkansas Children's Research Institute, 13 Children's Way, Little Rock, AR, 72202-3591, USA
| | - Parthak Prodhan
- Department of Pediatrics, Section of Pediatric Cardiology, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202-3591, USA
| | - Elijah H Bolin
- Department of Pediatrics, Section of Pediatric Cardiology, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202-3591, USA
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Singh TP, Mehra MR, Gauvreau K. Long-Term Survival After Heart Transplantation at Centers Stratified by Short-Term Performance. Circ Heart Fail 2019; 12:e005914. [PMID: 31718320 DOI: 10.1161/circheartfailure.118.005914] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Center differences in short-term survival after heart transplant (HT) are known. We sought to compare long-term graft survival (freedom from death or retransplantation) at currently active United States HT centers stratified by performance for short-term survival. METHODS We used the Organ Procurement and Transplant Network database to identify subjects ≥18 years old who received primary HT during 2000 to 2014 at US centers active during 2013 and 2014. Follow-up was available until March 2016. Center case-mix was assessed by computing expected 90-day mortality and short-term performance by 90-day standardized mortality ratio (SMR; observed/expected mortality). Centers were stratified by case-mix as transplanting low-, intermediate-, and high-risk patients and by short-term performance as SMR quintiles. Center-level differences in long-term graft survival were assessed by risk-adjusted, mixed-effects Weibull survival models with center as a random effect. RESULTS We analyzed 25 467 HT recipients at 96 centers. Those receiving HT at centers with superior (lower) 90-day SMR had longer graft survival (P for trend <0.001). Survival difference among SMR groups remained significant in 90-day conditional survivors (P for trend <0.001). There was significant center-level variation in risk-adjusted graft survival censored at 5 years (P<0.001) and with all follow-up (P<0.001). Adjusting for 90-day SMR was associated with 62% reduction in center variation in 5-year graft survival and 56% reduction in center variation in overall graft survival. CONCLUSIONS HT recipients at centers with superior short-term outcomes have longer graft survival on long-term follow-up. Allocating resources to improve patient care processes and transplant expertise at high-SMR centers may improve short-term and overall survival after HT.
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Affiliation(s)
- Tajinder P Singh
- Department of Cardiology, Boston Children's Hospital, MA (T.P.S., K.G.).,Department of Pediatrics (T.P.S.), Harvard Medical School, Boston, MA
| | - Mandeep R Mehra
- Department of Medicine (M.R.M.), Harvard Medical School, Boston, MA.,Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA (M.R.M.)
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, MA (T.P.S., K.G.).,Department of Biostatistics, Harvard School of Public Health, Boston, MA (K.G.)
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38
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Dilli D, Akduman H, Orun UA, Tasar M, Tasoglu I, Aydogan S, Citli R, Tak S. Predictive Value of Vasoactive-inotropic Score for Mortality in Newborns Undergoing Cardiac Surgery. Indian Pediatr 2019. [DOI: 10.1007/s13312-019-1639-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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39
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Fernandez FG, Shahian DM, Kormos R, Jacobs JP, D'Agostino RS, Mayer JE, Kozower BD, Higgins RSD, Badhwar V. The Society of Thoracic Surgeons National Database 2019 Annual Report. Ann Thorac Surg 2019; 108:1625-1632. [PMID: 31654621 DOI: 10.1016/j.athoracsur.2019.09.034] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 09/18/2019] [Indexed: 02/07/2023]
Abstract
The Society of Thoracic Surgeons (STS) National Database was established in 1989 as an initiative for quality improvement and patient safety for cardiothoracic surgery. The STS National Database has 4 components, each focusing on a distinct discipline-Adult Cardiac Surgery, General Thoracic Surgery, Congenital Heart Surgery, and mechanical circulatory support with the STS Interagency Registry for Mechanical Circulatory Support (Intermacs)/Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) Database. In December 2015, The Annals of Thoracic Surgery began publishing a monthly series of scholarly articles on outcomes analysis, quality improvement, and patient safety. This article provides the fourth annual summary of the status of the STS National Database.
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Affiliation(s)
- Felix G Fernandez
- Department of General Thoracic Surgery, Emory University, Atlanta, Georgia.
| | - David M Shahian
- Division of Cardiac Surgery and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert Kormos
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Richard S D'Agostino
- Lahey Hospital and Medical Center, Burlington, Massachusetts and Tufts University School of Medicine, Boston, Massachusetts
| | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Robert S D Higgins
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
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40
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Nakayama Y, Shinkawa T, Matsumura G, Hoki R, Kobayashi K, Niinami H. Late Neo–Aortic Valve Regurgitation Long After Arterial Switch Operation. Ann Thorac Surg 2019; 108:1210-1216. [DOI: 10.1016/j.athoracsur.2019.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/23/2019] [Accepted: 04/02/2019] [Indexed: 10/26/2022]
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41
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Alfieris GM, Swartz MF, Algahim M. Commentary: The static use of the transannular patch in the repair of tetralogy of Fallot. J Thorac Cardiovasc Surg 2019; 159:239-240. [PMID: 31635859 DOI: 10.1016/j.jtcvs.2019.09.036] [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: 09/04/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 11/20/2022]
Affiliation(s)
- George M Alfieris
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY.
| | - Michael F Swartz
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Mohamed Algahim
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
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Abstract
OBJECTIVES Surgery of the aortic arch poses risk of recurrent laryngeal nerve injury due to the anatomic proximity and can manifest as vocal cord dysfunction after surgery. We assessed risk factors for vocal cord dysfunction and calculated surgical procedure associated rates in young infants after congenital heart surgery. DESIGN Cross section analysis. SETTING Forty-four children's hospitals reporting administrative data to Pediatric Health Information System. PARTICIPANTS Cardiac surgical patients less than or equal to 90 days old and discharged between January 2004 and June 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Overall, 2,319 of 46,567 subjects (5%) had vocal cord dysfunction, increasing from 4% to 7% over the study period. Of those with vocal cord dysfunction, 75% had unilateral partial paralysis. Vocal cord dysfunction was significantly more common in newborn infants (74%), those with aortic arch procedures (77%) and with greater surgical complexity. Rates of vocal cord dysfunction ranged from 0.7% to 22.4% across surgical procedure groups. Vocal cord dysfunction was significantly associated with greater use of: prolonged mechanical ventilation (53% vs 40%), diaphragmatic plication (3% vs 1%), feeding tube use (32% vs 8%), surgical airways (4% vs 2%), and prolonged length of stay (44 vs 21 d). Vocal cord dysfunction testing increased significantly over the study (6-14 %), and vocal cord dysfunction diagnosis increased almost two-fold (odds ratio, 1.9; 95% CI, 1.7-2.1) comparing the last to first study quarters with the increase in vocal cord dysfunction diagnosis occurring predominately in surgeries to the aortic arch supported by cardiopulmonary bypass. However, aortic procedures without cardiopulmonary bypass and nonaortic arch procedures were common surgeries accounting for 27% and 23% of vocal cord dysfunction cases despite low overall vocal cord dysfunction rates (3.7% and 2.6%). CONCLUSIONS Vocal cord dysfunction complicated all cardiac surgical procedures among infants including those without aortic arch involvement. Increased efforts to determine appropriate indications for prevention, screening and treatment of vocal cord dysfunction among young infants after congenital heart surgery are needed.
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van der Ven JP, van den Bosch E, Bogers AJ, Helbing WA. Current outcomes and treatment of tetralogy of Fallot. F1000Res 2019; 8:F1000 Faculty Rev-1530. [PMID: 31508203 PMCID: PMC6719677 DOI: 10.12688/f1000research.17174.1] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2019] [Indexed: 01/08/2023] Open
Abstract
Tetralogy of Fallot (ToF) is the most common type of cyanotic congenital heart disease. Since the first surgical repair in 1954, treatment has continuously improved. The treatment strategies currently used in the treatment of ToF result in excellent long-term survival (30 year survival ranges from 68.5% to 90.5%). However, residual problems such as right ventricular outflow tract obstruction, pulmonary regurgitation, and (ventricular) arrhythmia are common and often require re-interventions. Right ventricular dysfunction can be seen following longstanding pulmonary regurgitation and/or stenosis. Performing pulmonary valve replacement or relief of pulmonary stenosis before irreversible right ventricular dysfunction occurs is important, but determining the optimal timing of pulmonary valve replacement is challenging for several reasons. The biological mechanisms underlying dysfunction of the right ventricle as seen in longstanding pulmonary regurgitation are poorly understood. Different methods of assessing the right ventricle are used to predict impending dysfunction. The atrioventricular, ventriculo-arterial and interventricular interactions of the right ventricle play an important role in right ventricle performance, but are not fully elucidated. In this review we present a brief overview of the history of ToF, describe the treatment strategies currently used, and outline the long-term survival, residual lesions, and re-interventions following repair. We discuss important remaining challenges and present the current state of the art regarding these challenges.
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Affiliation(s)
- Jelle P.G. van der Ven
- Department of Pediatrics, Division of Pediatric Cardiology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Eva van den Bosch
- Department of Pediatrics, Division of Pediatric Cardiology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
| | - Ad J.C.C. Bogers
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Willem A. Helbing
- Department of Pediatrics, Division of Pediatric Cardiology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
- Department of Pediatrics, Division of Pediatric Cardiology, Radboud UMC - Amalia Children's Hospital, Nijmegen, The Netherlands
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Cantinotti M, Giordano R, Scalese M, Marchese P, Franchi E, Viacava C, Molinaro S, Assanta N, Koestenberger M, Kutty S, Gargani L, Ait-Ali L. Prognostic Value of a New Lung Ultrasound Score to Predict Intensive Care Unit Stay in Pediatric Cardiac Surgery. Ann Thorac Surg 2019; 109:178-184. [PMID: 31400328 DOI: 10.1016/j.athoracsur.2019.06.057] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 05/23/2019] [Accepted: 06/04/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lung ultrasound (LUS) in pediatric cardiac surgery is gaining consensus. We (1) evaluated the prognostic value of a new LUS-score in pediatric cardiac surgery, and (2) compared LUS-score to conventional risk factors including age, The Society of Thoracic Surgeons/European Association of Cardio-Thoracic Surgery (STAT) score, cardiopulmonary bypass time, and prognostic biomarkers including brain natriuretic peptide and cystatin-C. METHODS LUS examinations were performed in 237 children (median age, 0.55 years; interquartile range, 0.09-4.15 years) at 12 to 36 hours after surgery. For each hemithorax, 3 areas (anterior/lateral/posterior) were evaluated in the upper and lower halves, constituting 12 total scanning areas. For each site a score was assigned: 0 (rare B lines), 1 (separated B lines), 2 (coalescent B lines), 3 (loss of aeration), and total LUS score was calculated as sum of all sites. The primary endpoints were intensive care unit length of stay and extubation time. RESULTS The mean total LUS score was 12.88 ± 6.41 (range, 0-26) and was higher in newborns (16.77 ± 5.25) compared with older children (5.36 ± 5.57; P < .001). On univariate analysis, LUS score was associated inversely with age (beta 0.26; P = .004) and body surface area (beta 3.41 P = .006) and positively with brain natriuretic peptide (beta 1.65; P < .001) and cystatin-C (beta 2.41; P < .001). The LUS score, when added as continuous predictor to a conventional risk model (age, STAT score, and cardiopulmonary bypass time) emerged significant both for intensive care unit length of stay (beta 0.145, P = .047) and extubation time (beta 1.644; P = .024). When single quadrants were analyzed, only anterior LUS score was significant (intensive care unit length of stay beta, 0.471; P = .020; extubation time beta 5.530; P = .007). CONCLUSIONS Our data show the prognostic incremental value of a new LUS score over traditional risk factors in pediatric cardiac surgery.
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Affiliation(s)
- Massimiliano Cantinotti
- Fondazione CNR-Regione Toscana G. Monasterio (FTGM), Massa, Pisa, Italy; Institute of Clinical Physiology, National Research Institute, Pisa, Italy
| | - Raffaele Giordano
- Adult and Pediatric Cardiac Surgery, University of Naples Federico II, Naples, Italy.
| | - Marco Scalese
- Institute of Clinical Physiology, National Research Institute, Pisa, Italy
| | - Pietro Marchese
- Fondazione CNR-Regione Toscana G. Monasterio (FTGM), Massa, Pisa, Italy
| | - Eliana Franchi
- Fondazione CNR-Regione Toscana G. Monasterio (FTGM), Massa, Pisa, Italy
| | - Cecilia Viacava
- Fondazione CNR-Regione Toscana G. Monasterio (FTGM), Massa, Pisa, Italy
| | - Sabrina Molinaro
- Institute of Clinical Physiology, National Research Institute, Pisa, Italy
| | - Nadia Assanta
- Fondazione CNR-Regione Toscana G. Monasterio (FTGM), Massa, Pisa, Italy
| | - Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Austria
| | - Shelby Kutty
- Helen B. Taussig Heart Center, Johns Hopkins Hospital and School of Medicine, Baltimore, Maryland
| | - Luna Gargani
- Institute of Clinical Physiology, National Research Institute, Pisa, Italy
| | - Lamia Ait-Ali
- Institute of Clinical Physiology, National Research Institute, Pisa, Italy
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45
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St Louis JD, Tchervenkov CI, Jonas RA, Sandoval N, Zhang H, Jacobs JP, Talwar S, Halees ZA, Finucane K, Kirklin JK. Proceedings From the 3rd Symposium of the World Database for Pediatric and Congenital Heart Surgery. World J Pediatr Congenit Heart Surg 2019; 10:492-498. [PMID: 31307301 DOI: 10.1177/2150135119852320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The World Database for Pediatric and Congenital Heart Surgery was created to provide a resource for centers to be able to perform complex outcomes analyses of children undergoing repair of a congenital heart defect. In just under two years, the World Society for Pediatric and Congenital Heart Surgery (WSPCHS) has amassed over 13,000 procedures from 55 centers into the database. This Proceedings of the 3rd World Database Symposium held at the 6th Scientific Meeting of the WSPCHS summarizes the presentations of international experts in the fields of outcomes analysis and care of children with congenital heart surgery.
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Affiliation(s)
- James D St Louis
- 1 Division of Cardiac Surgery, Children's Mercy-Kansas City, Kansas City, MO, USA
| | - Christo I Tchervenkov
- 2 Division of Pediatric Cardiovascular Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Richard A Jonas
- 3 Department of Cardiovascular Surgery, Children's National Medical Center, Washington, DC, USA
| | - Nestor Sandoval
- 4 Instituto de Cardiopatías Congénitas, Fundacion Cardioinfantil-Insituto de Cardiologia, Universidad del Rosario, Bogotá, Colombia
| | - Hao Zhang
- 5 Department of Cardiothoracic Surgery, Heart Center, Shanghai Children's Medical Center, National Center for Children Health, Shanghai, China
| | - Jeffrey P Jacobs
- 6 Division of Cardiovascular Surgery, Johns Hopkins All Children's Heart Institute, Johns Hopkins All Children's Hospital and Florida Hospital for Children, John Hopkins University, Saint Petersburg, Tampa, Orlando, FL, USA
| | - Sachin Talwar
- 7 All India Institute of Medical Sciences, New Delhi, India
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Cooper DS, Riggs KW, Zafar F, Jacobs JP, Hill KD, Pasquali SK, Swanson SK, Gelehrter SK, Wallace A, Jacobs ML, Morales DLS, Bryant R. Cardiac Surgery in Patients With Trisomy 13 and 18: An Analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database. J Am Heart Assoc 2019; 8:e012349. [PMID: 31237190 PMCID: PMC6662341 DOI: 10.1161/jaha.119.012349] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [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 Congenital heart disease is common in patients with Trisomy 13 (T13) and Trisomy 18 (T18), but offering cardiac surgery to these patients has been controversial. We describe the landscape of surgical management across the United States, perioperative risk factors, and surgical outcomes in patients with T13 and T18. Methods and Results Patients in the Society of Thoracic Surgeons Congenital Heart Surgery Database with T13 and T18 who underwent cardiac surgery (2010-2017) were included. There were 343 operations (T13: n=73 and T18: n=270) performed on 304 patients. Among 125 hospitals, 87 (70%) performed at least 1 operation and 26 centers (30%) performed ≥5 T13/T18 operations. Operations spanned the full spectrum of complexity with 29% (98/343) being in the highest categories of estimated risk. The operative mortality rate was 15%, with a 56% complication rate. Preoperative mechanical ventilation was associated with an odds ratio of mortality >8 for both patients with T13 and T18 (both P<0.012) while presence of a gastrostomy tube (odds ratio, 0.3; P=0.03) or prior cardiac surgery (odds ratio, 0.2; P=0.02) was associated with better survival in patients with T18 but not patients with T13. Conclusions Data from this nationally representative sample indicate that most centers offer surgical intervention for both patients with T13 and T18, even in highly complex patients. However, the overall mortality rate was high in this select patient cohort. The association of preoperative mechanical ventilation with mortality suggests that this subset of patients with T13 and T18 should perhaps not be considered surgical candidates. This information is valuable to clinicians and families for counseling and deciding what interventions to offer.
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Affiliation(s)
- David S Cooper
- 1 Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,2 Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Kyle W Riggs
- 1 Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Farhan Zafar
- 1 Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,3 Department of Surgery University of Cincinnati College of Medicine Cincinnati OH
| | - Jeffrey P Jacobs
- 4 Johns Hopkins School of Medicine Baltimore MD.,5 Johns Hopkins All Children's Hospital St. Petersburg FL
| | | | - Sara K Pasquali
- 7 C.S. Mott Children's Hospital University of Michigan Ann Arbor MI
| | - Sara K Swanson
- 8 Brenner Children's Hospital Wake Forest Baptist Medical Center Winston-Salem NC
| | | | | | - Marshall L Jacobs
- 4 Johns Hopkins School of Medicine Baltimore MD.,5 Johns Hopkins All Children's Hospital St. Petersburg FL
| | - David L S Morales
- 1 Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,3 Department of Surgery University of Cincinnati College of Medicine Cincinnati OH
| | - Roosevelt Bryant
- 1 Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH.,3 Department of Surgery University of Cincinnati College of Medicine Cincinnati OH
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Shahian DM, Fernandez FG, Badhwar V. The Society of Thoracic Surgeons National Database at 30: Honoring Our Heritage, Celebrating the Present, Evolving for the Future. Ann Thorac Surg 2019; 107:1259-1266. [DOI: 10.1016/j.athoracsur.2019.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 02/19/2019] [Indexed: 12/01/2022]
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Erez E, Erez E, Golender J, Mafra I, Shapira OM, Marzouqa B. Surgical Treatment of Palestinian Patients With Congenital Heart Disease in a Medical Center in Israel: Challenges and Outcome. EClinicalMedicine 2019; 10:42-48. [PMID: 31193909 PMCID: PMC6543193 DOI: 10.1016/j.eclinm.2019.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The treatment of congenital heart disease patients in the West Bank and Gaza involves both medical and political challenges. Understanding the difficulties faced in treating the Palestinian population is an important step to improving surgical care, better allocating resources and overcoming the region's unique problems. METHODS The Hadassah Medical Center congenital heart disease database over the 2011-2017 period was analyzed. There were 872 operations performed in patients with Israeli health insurance and 207 operations in Palestinian patients. Patient characteristics and surgical outcome were compared between the two groups using standard statistical practices. FINDINGS The Society of Thoracic Surgeons Complexity Scores were significantly higher in the Palestinian patients, p = 0.003 (d = 0.27, 95% CI, 0.12 to 0.42). Israeli neonates had surgery at an average age of 9.5 ± 7.8 days as compared to Palestinian neonates with an average age of 15.7 ± 8.2 days, p < 0.001 (d = 0.78, 95% CI, 0.41 to 1.15), a finding indicative of a possible delay of treatment. Overall in hospital mortality was not significantly different. Late mortality was significantly higher for the Palestinian 5.4% (9/168) compared to Israeli patients 2% (14/698), p = 0.015 (RR = 2.67, 95% CI, 1.18 to 6.07). INTERPRETATION The findings suggest that Palestinian patients receive later treatment and poorer follow-up care than Israeli patients. Despite the political challenges in the region surgical results are excellent and comparable between the two groups. The challenges described are not unique to congenital heart disease and may affect many medical fields. We believe that extensive collaborations between Israeli and Palestinian physicians may be key to improving the Palestinian medical care. FUNDING None.
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Affiliation(s)
- Eldad Erez
- Cardiothoracic Surgery Department Hadassah Medical Center, Hebrew University School of Medicine, Jerusalem, Israel
- Corresponding author.
| | - Ely Erez
- Technion, Israel Institute of Technology, School of Medicine, Haifa, Israel
| | - Julius Golender
- Congenital Heart Institute Hadassah Medical Center, Hebrew University School of Medicine, Jerusalem, Israel
| | - Ibraheem Mafra
- Cardiothoracic Surgery Department Hadassah Medical Center, Hebrew University School of Medicine, Jerusalem, Israel
| | - Oz M. Shapira
- Cardiothoracic Surgery Department Hadassah Medical Center, Hebrew University School of Medicine, Jerusalem, Israel
| | - Bisher Marzouqa
- Cardiothoracic Surgery Department Hadassah Medical Center, Hebrew University School of Medicine, Jerusalem, Israel
- Cardiothoracic Surgery Department, Alahli Hospital, Hebron, West Bank, Israel
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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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50
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Jacobs JP, Mayer JE, Pasquali SK, Hill KD, Overman DM, St. Louis JD, Kumar SR, Backer CL, Tweddell JS, Dearani JA, Jacobs ML. The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2019 Update on Outcomes and Quality. Ann Thorac Surg 2019; 107:691-704. [DOI: 10.1016/j.athoracsur.2018.12.016] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 12/10/2018] [Indexed: 12/20/2022]
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