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Arsdell GV. The Keys to Unleashing Potential. Braz J Cardiovasc Surg 2021; 36:I-II. [PMID: 34882363 PMCID: PMC8641776 DOI: 10.21470/1678-9741-2021-0961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Affiliation(s)
- Glen Van Arsdell
- Chief of the Department of Congenital Heart Surgery, University of California, Los Angeles, United States of America E-mail:
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Miana LA, Nathan M, Tenório DF, Manuel V, Guerreiro G, Fernandes N, Campos CVD, Gaiolla PV, Cassar RS, Turquetto A, Amato L, Canêo LF, Daroda LL, Jatene MB, Jatene FB. Translation and Validation of the Boston Technical Performance Score in a Developing Country. Braz J Cardiovasc Surg 2021; 36:589-598. [PMID: 34787990 PMCID: PMC8597612 DOI: 10.21470/1678-9741-2021-0485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction The Technical Performance Score (TPS) was developed and subsequently refined at the Boston Children's Hospital. Our objective was to translate and validate its application in a developing country. Methods The score was translated into the Portuguese language and approved by the TPS authors. Subsequently, we studied 1,030 surgeries from June 2018 to October 2020. TPS could not be assigned in 58 surgeries, and these were excluded. Surgical risk score was evaluated using Risk Adjustment in Congenital Heart Surgery (or RACHS-1). The impact of TPS on outcomes was studied using multivariable linear and logistic regression adjusting for important perioperative covariates. Results Median age and weight were 2.2 (interquartile range [IQR] = 0.5-13) years and 10.8 (IQR = 5.6-40) kilograms, respectively. In-hospital mortality was 6.58% (n=64), and postoperative complications occurred in 19.7% (n=192) of the cases. TPS was categorized as 1 in 359 cases (37%), 2 in 464 (47.7%), and 3 in 149 (15.3%). Multivariable analysis identified TPS class 3 as a predictor of longer hospital stay (coefficient: 6.6; standard error: 2.2; P=0.003), higher number of complications (odds ratio [OR]: 1.84; 95% confidence interval [CI]: 1.1-3; P=0.01), and higher mortality (OR: 3.2; 95% CI: 1.4-7; P=0.004). Conclusion TPS translated into the Portuguese language was validated and showed to be able to predict higher mortality, complication rate, and prolonged postoperative hospital stay in a high-volume Latin-American congenital heart surgery program. TPS is generalizable and can be used as an outcome assessment tool in resource diverse settings.
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Affiliation(s)
- Leonardo A Miana
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Davi Freitas Tenório
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Valdano Manuel
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil.,Cardiovascular Surgery Division, Clínica Girassol, Luanda, Angola
| | - Gustavo Guerreiro
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Natália Fernandes
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Carolina Vieira de Campos
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Paula V Gaiolla
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Renata Sá Cassar
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Aida Turquetto
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Luciana Amato
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Luiz Fernando Canêo
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | | | - Marcelo Biscegli Jatene
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Fabio B Jatene
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
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Implementation of a "threat and error" model in complex neonatal cardiac surgery patients to identify quality improvement opportunities. Cardiol Young 2020; 30:860-865. [PMID: 32476642 DOI: 10.1017/s1047951120001201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Neonates undergoing surgery for congenital heart disease are vulnerable to adverse events. Conventional quality improvement processes centring on mortality and significant morbidity leave a gap in the identification of systematic processes that, though not directly linked to an error, may still contribute to adverse outcomes. Implementation of a multidisciplinary "flight path" process for surgical patients may be used to identify modifiable threats and errors and generate action items, which may lead to quality improvement. METHODS A retrospective review of our neonatal "flight path" initiative was performed. Within 72 hours of a cardiac surgery, a meeting of the multidisciplinary patient care team occurs. A "flight path" is generated, graphically illustrating the patient's hospital course. Threats, errors, or unintended consequences are identified. Action items are generated, and a working group is formed to address the items. A patient's flight path is updated weekly until discharge. The errors and action items are logged into a database, which is analysed quarterly to identify trends. RESULTS Thirty one patients underwent flight path review over a 1-year period; 22.5% (N = 7) of patients had an error-free "flight." Eleven action items were generated - four from identified errors and seven from identified threats. Nine action items were completed. CONCLUSIONS Flight path reviews of congenital cardiac patients can be generated with few resources and aid in the detection of quality improvement opportunities. The regular multidisciplinary meetings that occur as a part of the flight path review process can promote inter-professional teamwork.
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Luo S, Haller C, Fan CPS, Moss K, Manlhiot C, Xie W, Moinshaghaghi A, Haranal M, Schwartz S, Caldarone C, Van Arsdell GS, Honjo O. Can We Still Improve Survival Outcomes of Neonatal Biventricular Repairs? Ann Thorac Surg 2020; 111:199-205. [PMID: 32268140 DOI: 10.1016/j.athoracsur.2020.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 02/21/2020] [Accepted: 03/02/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND We sought to identify modifiable factors to improve survival of neonatal biventricular repair by analyzing the cause of death and predictors of mortality and reintervention in the last 2 decades. METHODS Between 1995 and 2016, 991 consecutive neonates were included. The cohort was divided by era: era I was from 1995 to 1999, era II 2000 to 2007, and era III 2008 to 2016. The Kaplan-Meier method was used to estimate freedom from death and reintervention. Univariable and multivariable Cox regression was applied to assess predictors for mortality or reintervention in the contemporary cohorts (2000-2016). RESULTS Median age was 8 days (range, 5-13), and median body weight at operation was 3.3 kg (range, 2.9-3.6). The most common diagnosis was transposition with intact ventricular septum (32%), followed by transposition with ventricular septal defect (14.5%), and simple left-to-right shunt lesion (10.9%). There was significant improvement in survival from era I to eras II and III but no difference between eras II and III (1 year: 82.1% vs 89.4% vs 89.6%, respectively; P < .001). The most common cause of death was sudden death in eras I and III and cardiac in era II. Multivariable analysis revealed preoperative (P = .005)/postoperative (P < .001) extracorporeal membrane oxygenation and postoperative renal replacement (P < .001) as independent predictors for mortality. The reintervention rates were comparable between eras II and III (P = .53). Atrioventricular septal defects and common atrial trunk were identified as predictors for reintervention. CONCLUSIONS Survival after neonatal biventricular repair remained unchanged. Preventing sudden death, myocardial protection, and minimizing residual lesions are potential targets to improve outcomes.
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Affiliation(s)
- Shuhua Luo
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Cardiovascular Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Christoph Haller
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Chun-Po Steve Fan
- Cardiovascular Data Management Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Kasey Moss
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Cedric Manlhiot
- Cardiovascular Data Management Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Wenli Xie
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ali Moinshaghaghi
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Maruti Haranal
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Steven Schwartz
- Division of Cardiac Critical Care, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Glen S Van Arsdell
- Children's Heart Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Osami Honjo
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Martin E, Del Nido PJ, Nathan M. Technical performance scores are predictors of midterm mortality and reinterventions following congenital mitral valve repair. Eur J Cardiothorac Surg 2018; 52:218-224. [PMID: 28398542 DOI: 10.1093/ejcts/ezx074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 02/25/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The Technical Performance Score (TPS) has been shown to be predictive of postoperative mortality, morbidities and reinterventions following various cardiac procedures in children. We hypothesized that TPS is also a predictor of mitral valve repair outcomes. METHODS A review of patients who underwent mitral valve repair from January 2000 to December 2013 was performed. Primary repair of complete atrioventricular defect was excluded. The scores were determined according to previously published criteria based on the need for reintervention and predischarge echocardiograms: Class 1 (no residua), Class 2 (minor residua) or Class 3 (pacemaker implantation, major residua or reintervention for major residua prior to discharge). Cox proportional hazard models and Kaplan-Meier estimator were used. RESULTS A total of 587 patients underwent mitral repair (median age 2.6 years). Median follow-up duration was 3 years. There were 125 (21.3%) post-discharge mitral reinterventions and freedom from reintervention was 85.2%, 78.2% and 69.4% at 1, 2 and 5 years, respectively. Both TPS Class 2 [hazard ratio (HR) 3.6, 95% confidence interval (CI) 1.4-10.0; P = 0.02] and Class 3 (HR 8.7, 95% CI 3.0-25.1; P < 0.001) were associated with post-discharge reinterventions. There were 31 late deaths/transplantations, and transplant-free survival at 1, 2 and 5 years was 97.8%, 95.3% and 93.2%. TPS 3 was associated with decreased post-discharge transplant-free survival (HR 5.5, 95% CI 1.2-25.0; P = 0.03). Post-discharge mitral reintervention was not associated with increased mortality. CONCLUSIONS The TPS is a strong predictor of midterm mortality and post-discharge mitral reintervention in congenital patients who underwent mitral repair.
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Affiliation(s)
- Elisabeth Martin
- Division of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Université Laval, Quebec City, Quebec, Canada.,Department of Cardiac Surgery, Children's Hospital Boston and Harvard Medical School, Boston, MA, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Children's Hospital Boston and Harvard Medical School, Boston, MA, USA
| | - Meena Nathan
- Department of Cardiac Surgery, Children's Hospital Boston and Harvard Medical School, Boston, MA, USA
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Bhat PN, Costello JM, Aiyagari R, Sharek PJ, Algaze CA, Mazwi ML, Roth SJ, Shin AY. Diagnostic errors in paediatric cardiac intensive care. Cardiol Young 2018; 28:675-682. [PMID: 29409553 PMCID: PMC7271069 DOI: 10.1017/s1047951117002906] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
IntroductionDiagnostic errors cause significant patient harm and increase costs. Data characterising such errors in the paediatric cardiac intensive care population are limited. We sought to understand the perceived frequency and types of diagnostic errors in the paediatric cardiac ICU. METHODS Paediatric cardiac ICU practitioners including attending and trainee physicians, nurse practitioners, physician assistants, and registered nurses at three North American tertiary cardiac centres were surveyed between October 2014 and January 2015. RESULTS The response rate was 46% (N=200). Most respondents (81%) perceived that diagnostic errors harm patients more than five times per year. More than half (65%) reported that errors permanently harm patients, and up to 18% perceived that diagnostic errors contributed to death or severe permanent harm more than five times per year. Medication side effects and psychiatric conditions were thought to be most commonly misdiagnosed. Physician groups also ranked pulmonary overcirculation and viral illness to be commonly misdiagnosed as bacterial illness. Inadequate care coordination, data assessment, and high clinician workload were cited as contributory factors. Delayed diagnostic studies and interventions related to the severity of the patient's condition were thought to be the most commonly reported process breakdowns. All surveyed groups ranked improving teamwork and feedback pathways as strategies to explore for preventing future diagnostic errors. CONCLUSIONS Paediatric cardiac intensive care practitioners perceive that diagnostic errors causing permanent harm are common and associated more with systematic and process breakdowns than with cognitive limitations.
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Affiliation(s)
- Priya N Bhat
- 1Department of Pediatrics,Divisions of Pediatric Cardiology and Critical Care Medicine,Washington University School of Medicine,St. Louis,Missouri,USA
| | - John M Costello
- 2Department of Pediatrics,Divisions of Pediatric Cardiology and Critical Care Medicine,Northwestern University Feinberg School of Medicine,Chicago,Illinois,USA
| | - Ranjit Aiyagari
- 3Department of Pediatrics,Division of Pediatric Cardiology,University of Michigan School of Medicine,Ann Arbor,Michigan,USA
| | - Paul J Sharek
- 4Department of Pediatrics,Division of Hospitalist Medicine,Stanford University School of Medicine,Palo Alto,California,USA
| | - Claudia A Algaze
- 5Department of Pediatrics,Division of Pediatric Cardiology,Stanford University School of Medicine,Palo Alto,California,USA
| | - Mjaye L Mazwi
- 2Department of Pediatrics,Divisions of Pediatric Cardiology and Critical Care Medicine,Northwestern University Feinberg School of Medicine,Chicago,Illinois,USA
| | - Stephen J Roth
- 5Department of Pediatrics,Division of Pediatric Cardiology,Stanford University School of Medicine,Palo Alto,California,USA
| | - Andrew Y Shin
- 4Department of Pediatrics,Division of Hospitalist Medicine,Stanford University School of Medicine,Palo Alto,California,USA
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8
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Impact of Patient Characteristics and Anatomy on Results of Norwood Operation for Hypoplastic Left Heart Syndrome. Ann Thorac Surg 2015; 100:591-8. [DOI: 10.1016/j.athoracsur.2015.03.106] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 03/23/2015] [Accepted: 03/25/2015] [Indexed: 11/19/2022]
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9
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Hickey EJ, Nosikova Y, Pham-Hung E, Gritti M, Schwartz S, Caldarone CA, Redington A, Van Arsdell GS. National Aeronautics and Space Administration “threat and error” model applied to pediatric cardiac surgery: Error cycles precede ∼85% of patient deaths. J Thorac Cardiovasc Surg 2015; 149:496-505; discussion 505-7. [DOI: 10.1016/j.jtcvs.2014.10.058] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 09/19/2014] [Accepted: 10/06/2014] [Indexed: 11/26/2022]
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Alsoufi B, Slesnick T, McCracken C, Ehrlich A, Kanter K, Schlosser B, Maher K, Sachdeva R, Kogon B. Current Outcomes of the Norwood Operation in Patients With Single-Ventricle Malformations Other Than Hypoplastic Left Heart Syndrome. World J Pediatr Congenit Heart Surg 2014; 6:46-52. [DOI: 10.1177/2150135114558069] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Subsequent to increased experience with the Norwood operation in children with hypoplastic left heart syndrome (HLHS), its application has expanded to allow palliation of single-ventricle (SV) malformations other than HLHS. We describe current palliation outcomes in this group of SV patients. Methods: Between 2002 and 2012, 65 of the 303 Norwood operations were performed in non-HLHS SV patients. Competing risk analysis modeled events after Norwood and after subsequent Glenn and examined risk factors affecting outcomes. Results: Competing risk analysis showed that one year following Norwood, 24% of patients had died or received transplantation, 72% had undergone Glenn, and 4% were alive awaiting Glenn/Kawashima. Five years following Glenn, 9% of patients had died, 68% had undergone Fontan, and 23% were alive awaiting Fontan. Overall seven-year survival following Norwood was 68%. On multivariable analysis, mortality risk factors were unplanned cardiac reoperation (hazard ratio [HR]: 4.0 [1.5-10.6], P = .006), right dominant ventricle morphology (HR: 3.3 [1.3-8.3], P = .012), and postoperative extracorporeal membrane oxygenation (HR: 3.1 [1.1-9.0], P = .035). Conclusions: Operative death and interstage mortality continue to be problematic following Norwood palliation for non-HLHS SV variants. Outcomes seem comparable to those reported for HLHS, however they are influenced by underlying pathology; children with dominant left ventricle morphology (tricuspid atresia and double inlet left ventricle) have superior survival compared to those with dominant right ventricle morphology (mitral atresia, unbalanced atrioventricular septal defect, and most patients with atrial isomerism). Unplanned reoperations for technical imperfections diminish survival. Large multicenter studies might be warranted to better identify high-risk patients and provide guidance toward improving their survival.
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Affiliation(s)
- Bahaaldin Alsoufi
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Timothy Slesnick
- Department of Pediatrics, Division of Cardiology, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Courtney McCracken
- Department of Pediatrics, Division of Cardiology, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Alexandra Ehrlich
- Department of Pediatrics, Division of Cardiology, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Kirk Kanter
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Brian Schlosser
- Department of Pediatrics, Division of Cardiology, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Kevin Maher
- Department of Pediatrics, Division of Cardiology, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Ritu Sachdeva
- Department of Pediatrics, Division of Cardiology, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Brian Kogon
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
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Alsoufi B, Wolf M, Botha P, Kogon B, McCracken C, Ehrlich A, Kanter K, Deshpande S. Late Outcomes of Infants Supported by Extracorporeal Membrane Oxygenation Following the Norwood Operation. World J Pediatr Congenit Heart Surg 2014; 6:9-17. [DOI: 10.1177/2150135114558072] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Hospital survival for infants who require extracorporeal membrane oxygenation (ECMO) following the Norwood operation is 30% to 60%. However, little is known about late outcomes of hospital survivors and their ability to progress through subsequent palliative stages. Methods: Between 2002 and 2012, 38 (13.4%) of the 284 neonates with hypoplastic left heart syndrome or other single ventricle variants received ECMO support following Norwood. We examined factors affecting hospital death and compared postdischarge events between hospital survivors who received postoperative ECMO (n = 16 of 38) and a control of hospital survivors who did not receive ECMO (220 of 246). Results: Unplanned cardiac reoperation was the only predictor of postoperative ECMO requirement. Overall, 22 (58%) of the 38 patients were weaned from ECMO support and 16 (42%) of the 38 survived to hospital discharge. The ECMO duration was a significant factor for hospital mortality (odds ratio = 1.52 per 1-day increase [1.03-2.24], P = .035). Following discharge, 15 (94%) of the 16 underwent Glenn and 1 (6%) of the 16 had interstage mortality. In the control group, 194 (88%) of the 220 underwent Glenn and 26 (12%) of the 220 had interstage mortality or received transplantation ( P = .499). Following Glenn, 3 (20%) of the 15 patients had interstage mortality or received transplantation and 12 (80%) of the 15 proceeded to Fontan or were alive awaiting Fontan. In the control group, 23 (12%) of the 194 had interstage mortality or received transplantation and 171 (88%) proceeded to Fontan or were alive awaiting Fontan ( P = .357). Overall, 81% of hospital survivors were alive 5 years following discharge in both ECMO and non-ECMO groups. Conclusions: ECMO support following Norwood is associated with high probability of hospital death. Nonetheless, interstage mortality, progression to subsequent palliative stages, intermediate survival, and freedom from heart transplantation are comparable to those in patients who did not require postoperative ECMO support.
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Affiliation(s)
- Bahaaldin Alsoufi
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael Wolf
- Division of Cardiology, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Phil Botha
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Brian Kogon
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Courtney McCracken
- Division of Cardiology, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Alexandra Ehrlich
- Division of Cardiology, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Kirk Kanter
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Shriprasad Deshpande
- Division of Cardiology, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
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12
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Bacha E. Are errors ubiquitous in cardiac surgery? J Thorac Cardiovasc Surg 2014; 149:411. [PMID: 25486975 DOI: 10.1016/j.jtcvs.2014.11.022] [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: 11/09/2014] [Accepted: 11/10/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Emile Bacha
- Division of Cardiothoracic Surgery, Morgan Stanley Children's Hospital of New York, Columbia University, New York, NY.
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Mascio CE, Austin EH, Jacobs JP, Jacobs ML, Wallace AS, He X, Pasquali SK. Perioperative mechanical circulatory support in children: an analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database. J Thorac Cardiovasc Surg 2013; 147:658-64: discussion 664-5. [PMID: 24246548 DOI: 10.1016/j.jtcvs.2013.09.075] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Revised: 08/29/2013] [Accepted: 09/30/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Analyses of mechanical circulatory support (MCS) in pediatric heart surgery have primarily focused on single-center outcomes or narrow applications. We describe the patterns of use, patient characteristics, and MCS-associated outcomes across a large multicenter cohort. METHODS Patients (aged <18 years) in the Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database (2000-2010) were included. The characteristics and outcomes of those receiving postoperative MCS were described, and bayesian hierarchical models were used to examine variations in the adjusted MCS rates across institutions. RESULTS Of 96,596 operations (80 centers), MCS was used in 2.4%. The MCS patients were younger (13 vs 195 days, P < .0001) and more often had STS-defined preoperative risk factors (57.2% vs 32.7%, P < .0001). The operations with the greatest MCS rates included the Norwood procedure (17%) and complex biventricular repairs (arterial switch, ventricular septal defect, and arch repair [14%]). More than one half of the MCS patients did not survive to hospital discharge (53.2% vs 2.9% of non-MCS patients; P < .0001). MCS-associated mortality was greatest for truncus arteriosus and Ross-Konno operations (both 71%). The hospital-level MCS rates adjusted for patient characteristics and case mix varied by 15-fold across institutions, with both high- and low-volume hospitals having substantial variation in MCS rates. CONCLUSIONS Perioperative MCS use varied widely across centers. The MCS rates were greatest overall for the Norwood procedure and complex biventricular repairs. Although MCS can be a life-saving therapy, more than one half of MCS patients will not survive to hospital discharge, with mortality >70% for some operations. Future studies aimed at better understanding the appropriate indications, optimal timing, and management of MCS could help to reduce the variation in MCS use across hospitals and improve outcomes.
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Affiliation(s)
- Christopher E Mascio
- Department of Thoracic and Cardiovascular Surgery, University of Louisville, Louisville, Ky.
| | - Erle H Austin
- Department of Thoracic and Cardiovascular Surgery, University of Louisville, Louisville, Ky
| | - Jeffrey P Jacobs
- Johns Hopkins Children's Heart Surgery, All Children's Hospital and Florida Hospital for Children, St Petersburg, Tampa, and Orlando, Fla
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | | | - Xia He
- Duke Clinical Research Institute, Durham, NC
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Mich
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de Leval MR. "Errare humanum est, perseverare autem diabolicum"--Lucius Annaeus Seneca, 4 BC to 45 AD. J Thorac Cardiovasc Surg 2013; 145:1475-6. [PMID: 23587471 DOI: 10.1016/j.jtcvs.2013.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 03/14/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Marc R de Leval
- Harley Street Clinic, Congenital Heart Centre, London, United Kingdom.
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