Technical Performance Scores are strongly associated with early mortality, postoperative adverse events, and intensive care unit length of stay-analysis of consecutive discharges for 2 years

Echocardiographic image collection and evaluation in infants with CHD: lessons learned from the imaging core lab for the Residual Lesion Score study

Many factors affect patient outcome after congenital heart surgery, including the complexity of the heart disease, pre-operative status, patient specific factors (prematurity, nutritional status and/or presence of comorbid conditions or genetic syndromes), and post-operative residual lesions. The Residual Lesion Score is a novel tool for assessing whether specific residual cardiac lesions after surgery have a measurable impact on outcome. The goal is to understand which residual lesions can be tolerated and which should be addressed prior to leaving the operating room. The Residual Lesion Score study is a large multicentre prospective study designed to evaluate the association of Residual Lesion Score to outcomes in infants undergoing surgery for CHD. This Pediatric Heart Network and National Heart, Lung, and Blood Institute-funded study prospectively enrolled 1,149 infants undergoing 5 different congenital cardiac surgical repairs at 17 surgical centres. Given the contribution of echocardiographic measurements in assigning the Residual Lesion Score, the Residual Lesion Score study made use of a centralised core lab in addition to site review of all data. The data collection plan was designed with the added goal of collecting image quality information in a way that would permit us to improve our understanding of the reproducibility, variability, and feasibility of the echocardiographic measurements being made. There were significant challenges along the way, including the coordination, de-identification, storage, and interpretation of very large quantities of imaging data. This necessitated the development of new infrastructure and technology, as well as use of novel statistical methods. The study was successfully completed, but the size and complexity of the population being studied and the data being extracted required more technologic and human resources than expected which impacted the length and cost of conducting the study. This paper outlines the process of designing and executing this complex protocol, some of the barriers to implementation and lessons to be considered in the design of future studies.

Predictors of Serious Adverse Events and High-Level Cardiorespiratory Support in Patients Undergoing Transcatheter Pulmonary Vein Interventions

Patients with pulmonary vein stenosis (PVS) often require frequent transcatheter pulmonary vein (PV) interventions for management of restenosis. Predictors of serious adverse events (AEs) and need for high-level cardiorespiratory support (mechanical ventilation, vasoactive support, and/or extracorporeal membrane oxygenation) 48 h after transcatheter PV interventions have not been reported. This is a single-center retrospective cohort analysis of patients with PVS who underwent transcatheter PV interventions from 3/1/2014 to 12/31/2021. Univariate and multivariable analyses were performed using generalized estimating equations to account for within-patient correlation. 240 patients underwent 841 catheterizations involving PV interventions (median 2 catheterizations per patient [1,3]). At least one serious AE was reported in 100 (12%) cases, the most common of which were pulmonary hemorrhage (n = 20) and arrhythmia (n = 17). There were 14 severe/catastrophic AEs (1.7% of cases) including three strokes and one patient death. On multivariable analysis, age less than 6 months, low systemic arterial saturation (< 95% in patients with biventricular [BiV] physiology, < 78% in single ventricle [SV] physiology), and severely elevated mean PA pressure (≥ 45 mmHg in BiV, ≥ 17 mmHg in SV) were associated with SAEs. Age less than 1 year, hospitalization prior to catheterization, and moderate-severe RV dysfunction were associated with high-level support after catheterization. Serious AEs during transcatheter PV interventions in patients with PVS are common, although major events such as stroke or death are uncommon. Younger patients and those with abnormal hemodynamics are more likely to experience serious AEs and require high-level cardiorespiratory support after catheterization.

A Narrative Review of Multiinstitutional Data Registries of Pediatric Congenital Heart Disease in Pediatric Cardiac Anesthesia and Critical Care Medicine

Congenital heart disease (CHD) is one of the most common birth anomalies. While the care of children with CHD has improved over recent decades, children with CHD who undergo general anesthesia remain at increased risk for morbidity and mortality. Electronic health record systems have enabled institutions to combine data on the management and outcomes of children with CHD in multicenter registries. The application of descriptive analytics methods to these data can improve clinicians' understanding and care of children with CHD. This narrative review covers efforts to leverage multicenter data registries relevant to pediatric cardiac anesthesia and critical care to improve the care of children with CHD.

Development of the Residual Lesion Score for congenital heart surgery: the RAND Delphi methodology

BACKGROUND AND OBJECTIVE

The Residual Lesion Score is a novel tool for assessing the achievement of surgical objectives in congenital heart surgery based on widely available clinical and echocardiographic characteristics. This article describes the methodology used to develop the Residual Lesion Score from the previously developed Technical Performance Score for five common congenital cardiac procedures using the RAND Delphi methodology.

METHODS

A panel of 11 experts from the field of paediatric and congenital cardiology and cardiac surgery, 2 co-chairs, and a consultant were assembled to review and comment on validity and feasibility of measuring the sub-components of intraoperative and discharge Residual Lesion Score for five congenital cardiac procedures. In the first email round, the panel reviewed and commented on the Residual Lesion Score and provided validity and feasibility scores for sub-components of each of the five procedures. In the second in-person round, email comments and scores were reviewed and the Residual Lesion Score revised. The modified Residual Lesion Score was scored independently by each panellist for validity and feasibility and used to develop the "final" Residual Lesion Score.

RESULTS

The Residual Lesion Score sub-components with a median validity score of ≥7 and median feasibility score of ≥4 that were scored without disagreement and with low absolute deviation from the median were included in the "final" Residual Lesion Score.

CONCLUSION

Using the RAND Delphi methodology, we were able to develop Residual Lesion Score modules for five important congenital cardiac procedures for the Pediatric Heart Network's Residual Lesion Score study.

Acute Cardiac Care for Neonatal Heart Disease

This manuscript is one component of a larger series of articles produced by the Neonatal Cardiac Care Collaborative that are published in this supplement of Pediatrics. In this review article, we summarize the contemporary physiologic principles, evaluation, and management of acute care issues for neonates with complex congenital heart disease. A multidisciplinary team of authors was created by the Collaborative's Executive Committee. The authors developed a detailed outline of the manuscript, and small teams of authors were assigned to draft specific sections. The authors reviewed the literature, with a focus on original manuscripts published in the last decade, and drafted preliminary content and recommendations. All authors subsequently reviewed and edited the entire manuscript until a consensus was achieved. Topics addressed include cardiopulmonary interactions, the pathophysiology of and strategies to minimize the development of ventilator-induced low cardiac output syndrome, common postoperative physiologies, perioperative bleeding and coagulation, and common postoperative complications.

Comparison of Intraoperative and Discharge Residual Lesion Severity in Congenital Heart Surgery

BACKGROUND

While the predischarge technical performance score (DC-TPS) is significantly associated with outcomes after congenital cardiac surgery, the utility of the intraoperative TPS (IO-TPS) remains unknown.

METHODS

This was a single-center retrospective review of consecutive patients who underwent congenital cardiac surgery from January 2011 to December 2019. Intraoperative and predischarge echocardiograms were used to assign IO-TPS and DC-TPS, respectively, for each index operation (class 1, no residua; class 2, minor residua; class 3, major residua). Anatomic modules identifying the principal residual lesion were assigned to all class 2/3 patients. Overall and module-specific TPS comparisons were made. Multivariable regression models with IO-TPS and DC-TPS as separate predictors of postoperative outcomes were compared.

RESULTS

Of 6201 patients, overall agreement between IO-TPS and DC-TPS was observed in 4251 patients (68.6%); scores were likelier to be worse at discharge (P < .001). Paired comparative analyses revealed that among patients with at least class 2 atrioventricular and semilunar valve residua, IO-TPS was likelier to worsen than improve (both P < .001). Class 3 patients had a higher risk of in-hospital/early mortality (IO-TPS: odds ratio, 7.5; 95% CI, 2.4-23; DC-TPS: odds ratio, 6.6; 95% CI, 3.0-15), postdischarge/late mortality (IO-TPS: hazard ratio [HR], 3.1, 95% CI, 1.3-7.1; DC-TPS: HR, 2.3; 95% CI, 1.2-4.4), and late unplanned reintervention (IO-TPS: HR, 2.8; 95% CI, 1.9-4.0; DC-TPS: HR, 3.4; 95% CI, 2.8-4.2) vs class 1 (all P < .05). IO- and DC-TPS models were equivalent fits for predicting early and late mortality; the latter was a marginally better fit for late reintervention.

CONCLUSIONS

IO-TPS and DC-TPS are both important adjuncts for quality improvement in congenital cardiac surgery.

Postoperative morbidities with infant cardiac surgery and toddlers' neurodevelopment

OBJECTIVE

To evaluate the relationship between morbidities after infant cardiac surgery and neurodevelopment and behaviour at age 2-3 years.

DESIGN/SETTING

A prospective cohort follow-up study, in four paediatric cardiac centres. We excluded children with known syndromes. Home-based neurodevelopmental assessments using the Bayley Scales of Infant and Toddler Development 3rd Edition (Bayley-III) were undertaken in 81 children and secondary outcome measures of development and behaviour were completed by parents. A further 41 families completed the secondary outcome measures remotely.

RESULTS

Children were grouped as multiple morbidities/extracorporeal life support (ECLS) (n=19), single morbidities (n=36) and no morbidities (n=59). Group comparisons found that children with multiple morbidities/ECLS, compared with no morbidities, had: (a) lower adjusted mean scores for core Bayley-III composites (none reached the level of statistical significance), with mean differences of cognitive -6.1 (95% CI -12.4 to 0.1) p=0.06, language -9.1 (95% CI -18.6 to 0.3) p=0.06 and motor -4.4 (95% CI -12.0 to 3.1) p=25; (b) greater adjusted odds of at least one low or borderline Bayley-III composite result 4.0 (95% CI 1.0 to 16.0) (p=0.05); (c) greater adjusted risk of an abnormal Ages and Stages Questionnaire (ASQ) result 5.3 (95% CI 1.3 to 21.1) (p=0.03) and a borderline ASQ result 4.9 (95% CI 1.0 to 25.0) (p=0.05); and no difference in the risk of an abnormal Strengths and Difficulties Questionnaire result 1.7 (95% CI 0.3 to 10.4) p=0.58. These outcomes were not statistically different between the single morbidity and no morbidity groups.

CONCLUSIONS

Children who experience multiple morbidities/ECLS after infant heart surgery are at a greater risk of neurodevelopmental difficulties than their peers who had no complications and should be prioritised for neurodevelopmental follow-up.

The number of postoperative surgical or diagnostic procedures following congenital heart surgery correlates with both mortality and hospital length of stay

BACKGROUND

Outcomes for congenital heart disease have dramatically improved over the past several decades. However, there are patients who encounter intraoperative or postoperative complications and ultimately do not survive. It was our hypothesis that the number of postoperative procedures (including surgical and unplanned diagnostic procedures) would correlate with hospital length of stay and operative mortality.

METHODS

This was a retrospective review of 938 consecutive patients undergoing congenital heart surgery at a single institution over a 2-year timeframe. The number of postoperative surgical and unplanned diagnostic procedures were counted and the impact on hospital length of stay and mortality was assessed.

RESULTS

581 of the 938 (62%) patients had zero postoperative diagnostic or surgical procedures. These patients had a median length of stay of 6 days with a single operative mortality (0.2%). 357 of the 938 (38%) patients had one or more postoperative diagnostic or surgical procedures. These patients had a total of 1586 postoperative procedures. There was a significant correlation between the number of postoperative procedures and both hospital length of stay and mortality (p < .001). Patients who required 10 or more postoperative procedures had a median hospital length of stay of 89 days and had a 50% mortality. There were no survivors in patients who had 15 or more postoperative procedures.

CONCLUSIONS

The data demonstrate that the number of postoperative procedures was highly correlated with both hospital length of stay and mortality.

Digital solution for follow-up in congenital cardiac surgery

BACKGROUND

In this era of public scrutiny, there is an ongoing need for innovative methods for patient follow-up.

OBJECTIVES

As part of a quality initiative, we developed an automated post-operative follow-up system for patients following discharge after cardiac surgery at Boston Children's Hospital.

METHODS

Discharge Communication (DisCo) is a web-based system developed at Boston Children's Hospital. An automated text and e-mail with a link to a health status survey are sent at 30 days and 1 year post-discharge in English/Spanish. If there is no response, surveys are completed via phone calls to the patient/patient's physician or chart review. Responses are stored in the DisCo database and the patient's medical record. Patients who underwent cardiac surgery and survived to hospital discharge from October, 2016 received the surveys.

RESULTS

Overall, 3345 30-day and 2563 1-year surveys were sent between October, 2016 and June, 2020. Of 3345 30-day surveys, there were 3191 responses (95%). Of 2563 1-year surveys, there were 1807 responses (71%). Most patients/families responded directly to the link at 30 days (65% for paediatrics/75% for adults) and at 1 year (72% for paediatrics/78% for adults). Multi-variable logistic regression revealed that higher complexity of cardiac lesion, presence of major non-cardiac anomalies and presence of major residua were associated with readmission and catheter/surgical reinterventions. Non-cardiac anomalies were associated with increased need for services for learning, development or behaviour.

CONCLUSIONS

DisCo provides a successful web-based health status assessment of patients following congenital cardiac surgery. It helps to identify high-risk patients who need closer follow-up.

Long-Term Outcomes of Patients Requiring Unplanned Repeated Interventions After Surgery for Congenital Heart Disease

BACKGROUND

Unplanned catheter-based or surgical reinterventions after congenital heart operations are independently associated with operative mortality and increased postoperative length of stay.

OBJECTIVES

This study assessed the long-term outcomes of transplant-free survivors of hospital discharge requiring predischarge reinterventions after congenital cardiac surgery.

METHODS

Data from patients who required predischarge reinterventions in the anatomic area of repair after congenital cardiac surgery and survived to hospital discharge at a quaternary referral center from January 2011 to December 2019 were retrospectively reviewed. Previously published echocardiographic criteria were used to assess the severity of persistent residual lesions at discharge (Grade 1, no residua; Grade 2, minor residua; and Grade 3, major residua). Outcomes included postdischarge (late) mortality or transplant and unplanned reintervention. Associations between predischarge residual lesion severity and outcomes were assessed by using Cox or competing risk models, adjusting for baseline patient characteristics, case complexity, and preoperative risk factors.

RESULTS

Among the 408 patients who met entry criteria, there were 58 (14.2%) postdischarge deaths or transplants and 208 (51.0%) late reinterventions at a median follow-up of 3.0 years (IQR: 1.1-6.8 years). Greater predischarge residual lesion severity was associated with worse transplant-free survival and freedom from reintervention (both, P < 0.05). On multivariable analyses, Grade 3 patients had an increased risk of postdischarge mortality or transplant (HR: 4.8; 95% CI: 2.0-11; P < 0.001) and late reintervention (subdistribution HR: 2.1; 95% CI: 1.4-3.1; P < 0.001) vs Grade 1 patients.

CONCLUSIONS

Among transplant-free survivors requiring predischarge reinterventions after congenital cardiac surgery, those with persistent major residua have significantly worse long-term outcomes. These high-risk patients warrant closer surveillance.

Translation and Validation of the Boston Technical Performance Score in a Developing Country

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.

Impact of Major Residual Lesions on Outcomes After Surgery for Congenital Heart Disease

BACKGROUND

Many factors affect outcomes after congenital cardiac surgery.

OBJECTIVES

The RLS (Residual Lesion Score) study explored the impact of severity of residual lesions on post-operative outcomes across operations of varying complexity.

METHODS

In a prospective, multicenter, observational study, 17 sites enrolled 1,149 infants undergoing 5 common operations: tetralogy of Fallot repair (n = 250), complete atrioventricular septal defect repair (n = 249), arterial switch operation (n = 251), coarctation or interrupted arch with ventricular septal defect (VSD) repair (n = 150), and Norwood operation (n = 249). The RLS was assigned based on post-operative echocardiography and clinical events: RLS 1 (trivial or no residual lesions), RLS 2 (minor residual lesions), or RLS 3 (reintervention for or major residual lesions before discharge). The primary outcome was days alive and out of hospital within 30 post-operative days (60 for Norwood). Secondary outcomes assessed post-operative course, including major medical events and days in hospital.

RESULTS

RLS 3 (vs. RLS 1) was an independent risk factor for fewer days alive and out of hospital (p ≤ 0.008) and longer post-operative hospital stay (p ≤ 0.02) for all 5 operations, and for all secondary outcomes after coarctation or interrupted arch with VSD repair and Norwood (p ≤ 0.03). Outcomes for RLS 1 versus 2 did not differ consistently. RLS alone explained 5% (tetralogy of Fallot repair) to 20% (Norwood) of variation in the primary outcome.

CONCLUSIONS

Adjusting for pre-operative factors, residual lesions after congenital cardiac surgery impacted in-hospital outcomes across operative complexity with greatest impact following complex operations. Minor residual lesions had minimal impact. These findings may provide guidance for surgeons when considering short-term risks and benefits of returning to bypass to repair residual lesions.

Predicting and Surviving Prolonged Critical Illness After Congenital Heart Surgery

OBJECTIVES

Prolonged critical illness after congenital heart surgery disproportionately harms patients and the healthcare system, yet much remains unknown. We aimed to define prolonged critical illness, delineate between nonmodifiable and potentially preventable predictors of prolonged critical illness and prolonged critical illness mortality, and understand the interhospital variation in prolonged critical illness.

DESIGN

Observational analysis.

SETTING

Pediatric Cardiac Critical Care Consortium clinical registry.

PATIENTS

All patients, stratified into neonates (≤28 d) and nonneonates (29 d to 18 yr), admitted to the pediatric cardiac ICU after congenital heart surgery at Pediatric Cardiac Critical Care Consortium hospitals.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 2,419 neonates and 10,687 nonneonates from 22 hospitals. The prolonged critical illness cutoff (90th percentile length of stay) was greater than or equal to 35 and greater than or equal to 10 days for neonates and nonneonates, respectively. Cardiac ICU prolonged critical illness mortality was 24% in neonates and 8% in nonneonates (vs 5% and 0.4%, respectively, in nonprolonged critical illness patients). Multivariable logistic regression identified 10 neonatal and 19 nonneonatal prolonged critical illness predictors within strata and eight predictors of mortality. Only mechanical ventilation days and acute renal failure requiring renal replacement therapy predicted prolonged critical illness and prolonged critical illness mortality in both strata. Approximately 40% of the prolonged critical illness predictors were nonmodifiable (preoperative/patient and operative factors), whereas only one of eight prolonged critical illness mortality predictors was nonmodifiable. The remainders were potentially preventable (postoperative critical care delivery variables and complications). Case-mix-adjusted prolonged critical illness rates were compared across hospitals; six hospitals each had lower- and higher-than-expected prolonged critical illness frequency.

CONCLUSIONS

Although many prolonged critical illness predictors are nonmodifiable, we identified several predictors to target for improvement. Furthermore, we observed that complications and prolonged critical care therapy drive prolonged critical illness mortality. Wide variation of prolonged critical illness frequency suggests that identifying practices at hospitals with lower-than-expected prolonged critical illness could lead to broader quality improvement initiatives.

Factors associated with unplanned reinterventions and their relation to early mortality after pediatric cardiac surgery

OBJECTIVE

Unplanned reintervention (uRE) is used as an indicator of patient morbidity and quality of care in pediatric cardiac surgery. We investigated associated factors and early mortality after uREs.

METHODS

Morbidity data were prospectively collected in 5 UK centers between 2015 and 2017; uRE included surgical cardiac, interventional transcatheter cardiac, permanent pacemaker, and diaphragm plication procedures. Mortality (30-day and 6-month) in uRE/no-uRE patients was reported before and after matching. Predicted 30-day mortality was calculated using the Partial Risk Adjustment in Surgery score.

RESULTS

A total of 3090 procedures (2861 patients) were included (median age, 228 days). There were 146 uREs, resulting in an uRE rate of 4.7%. Partial Risk Adjustment in Surgery score, 30-day mortality and 6-month mortality in uRE and no-uRE groups were 2.4% versus 1.3%, 8.9% versus 1%, and 17.1% versus 2.4%, respectively. After matching, mortality at 6 months remained higher in uRE compared with no-uRE (12.2% vs 1.4%; P = .02; 74 pairs). In the uRE group, 21 out of 25 deaths at 6 months occurred when at least 1 additional postoperative complication was present. In multivariable analysis, neonatal age (P = .002), low weight (P = .009), univentricular heart (P < .001), and arterial shunt (P < .001) were associated with increased risk of uRE, but Partial Risk Adjustment in Surgery score was not (only in univariable analysis).

CONCLUSIONS

uREs are a relatively frequent complication after pediatric cardiac surgery and are associated with some patient characteristics, but not the Partial Risk Adjustment in Surgery risk score. Early mortality was higher after uRE, independent of preoperative factors, but linked to other postoperative complications.

Technical Performance Score: A Predictor of Outcomes After the Norwood Procedure

BACKGROUND

The Technical Performance Score (TPS) can predict outcomes after congenital cardiac surgery. We sought to validate TPS as a predictor of both short- and long-term outcomes of the Norwood procedure.

METHODS

We conducted a retrospective review of patients who underwent the Norwood procedure from 1997 to 2017. We assigned TPS (class 1, no residua; class 2, minor residua; class 3, major residua or reintervention for major residua before discharge) based on subcomponent scores from discharge echocardiograms or unplanned reinterventions, or both. Multivariable Cox or competing risk analysis, adjusted for preoperative patient- and procedure-related covariates, examined the association of TPS with postoperative hospital length of stay, transplant-free survival, and postdischarge reinterventions.

RESULTS

Among 500 patients, 319 (64%) were male, 54 (11%) were premature, 56 (11%) had noncardiac anomalies/syndromes, 146 (29%) had preoperative risk factors, and 480 (96%) were assigned TPS. On multivariable analysis, class 3 had greater hazard for reinterventions in transplant-free survivors (class 3: subdistribution hazard ratio [HR], 2.06; 95% confidence interval [CI] 1.34-3.16; P = .001) and was associated with increased hospital length of stay vs class 1 (HR, 0.25; 95% CI, 0.18-0.34; P < .001). Transplant-free survival after Norwood surgery was shorter for both class 2 (HR, 2.48; 95% CI, 1.68-3.66; P < .001) and class 3 (HR, 3.29; 95% CI, 2.18-4.95; P < .001).

CONCLUSIONS

TPS predicts early and late outcomes after Norwood. Absence of residual lesions results in improved long-term prognosis for single-ventricle patients. TPS may improve outcomes after Norwood by identifying patients warranting closer follow-up and potentially earlier reintervention.

The Pediatric Heart Network Residual Lesion Score Study: Design and objectives

OBJECTIVES

The Residual Lesion Score (RLS) was developed as a novel tool for assessing residual lesions after congenital heart operations based on widely available clinical and echocardiographic characteristics. The RLS ranks postoperative findings as follows: Class 1 (no/trivial residua), Class 2 (minor residua), or Class 3 (major residua or reintervention before discharge for residua). The multicenter prospective RLS study aims to analyze the influence of residual lesions on outcomes in common congenital cardiac operations. We hypothesize that RLS will predict postoperative adverse events, resource utilization, mortality, and reinterventions by 1 year postoperatively.

METHODS

The study cohort consisted of infants aged ≤12 months undergoing definitive surgery for complete atrioventricular septal defect, tetralogy of Fallot, dextro-transposition of the great arteries with or without intact ventricular septum, single ventricle (Norwood procedure), and coarctation or interrupted/hypoplastic arch with ventricular septal defect. Children with major congenital or acquired extracardiac anomalies that could independently affect the primary end point, which was number of days alive and out of the hospital within 30 days of surgery (60 days for Norwood procedure), were excluded. Secondary outcomes included ≥1 early major postoperative adverse event; days of intensive care unit and hospital stay, and initial and total ventilator time; mortality/transplant after discharge; unplanned reinterventions after discharge; and cost. All analyses will be performed separately by surgical operation.

CONCLUSIONS

This is the first multicenter prospective validation of a tool for surgical outcome assessment and quality improvement specific to congenital heart surgery.

Technical Performance Score's Association With Arterial Switch Operation Outcomes

BACKGROUND

Outcomes after the arterial switch operation (ASO) for dextro-transposition of the great arteries have improved significantly since its inception in the 1980s. This study reviews contemporaneous outcomes and predictors for late reinterventions after ASO.

METHODS

We retrospectively reviewed patients who underwent ASO for dextro-transposition of the great arteries from 1997 to 2017. Technical performance score (TPS) class (class 1, trivial or no residua; class 2, minor residua; class 3, major residua or reintervention) was assigned at discharge based on echocardiographic evaluation of components of the ASO. Multivariable Cox regression identified patient- and procedure-specific factors associated with postdischarge reinterventions.

RESULTS

Among 598 patients, 410 (69%) underwent ASO and 188 (31%) underwent ASO with ventricular septal defect repair. Median age at surgery was 5 days (interquartile range, 3 to 7); median follow-up time was 8.2 years; 408 (68%) were male; 50 (8.3%) were premature; and 10 (1.7%) had noncardiac anomalies or syndromes. Survival to hospital discharge was 98% (n = 591). Among 349 patients with follow-up, freedom from unplanned reintervent2ion at 5 years was 99% for TPS class 1, compared with 84% for class 2 and 30% for class 3. On multivariable Cox regression, classes 2 and 3 had significantly higher hazard for reintervention (class 2 hazard ratio 10.6; 95% confidence interval, 2.5 to 44.2; P = .001; class 3 hazard ratio 58.2, 95% confidence interval, 13.1 to 259; P < .001).

CONCLUSIONS

At our center, ASO was associated with relatively low mortality. Class 2 and class 3 TPS were the most important independent predictors of reinterventions after discharge. Therefore, TPS can serve as a tool for identifying high-risk patients who warrant closer follow-up.

The Impact of Post-Graduate Year of Primary Surgeon on Technical Performance Score in Tetralogy of Fallot Repair

BACKGROUND

The aim of this study was to assess the impact of surgeon years of experience on clinical outcomes of tetralogy of Fallot (TOF) repair using technical performance score (TPS), and to investigate the possibility of safe operations by surgical trainees.Methods and Results:We assessed the cases of 159 consecutive patients who underwent TOF repair between 2001 and 2015. Thirteen different primary surgeons performed operations with 41 different first assistants. The primary surgeon and first assistant mean postgraduate years were 19.1±5.1 years (range, 5.7-31.6 years) and 11.2±6.3 years (range, 3.2-36.3 years), respectively. TPS was assigned using pre-discharge echocardiography based on original criteria. Logistic regression analysis was used to examine the factors associated with TPS. TPS could be scored for all patients, 16 of whom were graded as having optimal (10%), 119 as adequate (75%), and 24 as having inadequate (15%) TPS. None of the preoperative and perioperative variables affected TPS. Although neither the primary surgeon nor the first assistant postgraduate years was associated with TPS independently, total primary surgeon and first assistant postgraduate years correlated with TPS (OR, 1.07; 95% CI: 1.01-1.13, P=0.031).

CONCLUSIONS

Primary surgeon postgraduate years was not associated with TPS for TOF repair. TOF repair can be performed adequately and safely by surgical trainees under the support of highly experienced supervisors.

Late Arterial Switch Surgery Under ECMO Support in a Patient with Transposition of the Great Arteries with Intact Ventricular Septum: a Case Report

A 30-month-old male patient with transposition of the great arteries with intact ventricular septum (TGA/IVS) is presented. Arterial switch operation (ASO) was performed in the light of echocardiographic and angiographic findings. The patient remained under extracorporeal membrane oxygenation support for seven days postoperatively, and his cardiac functions returned to normal at the postoperative 10^th day. He was discharged at the postoperative 20^th day. The present case, which presents one of the most advanced ages at operation for TGA/IVS among previously reported cases, is used to discuss late ASO in this study.

Long-Term Survival of Patients With Coarctation Repaired During Infancy (from the Pediatric Cardiac Care Consortium)

Patients who undergo coarctation repair during infancy have excellent early survival but long-term survival is unknown. We aimed to describe the long-term survival of patients with coarctation repaired during infancy and determine predictors of mortality. We performed a retrospective cohort study using data from the Pediatric Cardiac Care Consortium for patients with coarctation who underwent surgical repair before 12 months of age between 1982 and 2003. Long-term transplant-free survival was obtained by linkage with the National Death Index and the Organ Sharing Procurement Network. Kaplan Meier survival plots were constructed, and univariate and multivariable analyses were performed to determine predictors of mortality. We identified 2,424 coarctation patients who met inclusion criteria. At 20 years postoperatively, 94.5% of all patients and 95.8% of those discharged after initial operation remained alive, respectively. Significant multivariable predictors of mortality included surgical weight <2.5 kg (hazard ratio [HR] 3.70, 95% confidence interval [CI] 2.19 to 6.24), presence of a genetic syndrome (HR 2.40, 95% CI 1.13 to 5.10), and repair before 1990 (HR 1.91, 95% CI 1.09 to 3.34). None of the other factors examined including age at repair, gender, coarctation type, or surgical approach were found to be statistically significant. Over half of the deaths were due to the underlying congenital heart disease or other cardiovascular etiology. Overall long-term survival of patients who undergo coarctation repair during infancy is excellent. However, patients do experience small continued survival attrition throughout early adulthood. Ongoing monitoring of this cohort is necessary to assess late mortality risk.

Accurate Prediction of Congenital Heart Surgical Length of Stay Incorporating a Procedure-Based Categorical Variable

OBJECTIVES

There is increasing demand for the limited resource of Cardiac ICU care. In this setting, there is an expectation to optimize hospital resource use without restricting care delivery. We developed methodology to predict extended cardiac ICU length of stay following surgery for congenital heart disease.

DESIGN

Retrospective analysis by multivariable logistic regression of important predictive factors for outcome of postoperative ICU length of stay greater than 7 days.

SETTING

Cardiac ICU at Boston Children's Hospital, a large, pediatric cardiac surgical referral center.

PATIENTS

All patients undergoing congenital heart surgery at Boston Children's Hospital from January 1, 2010, to December 31, 2015.

INTERVENTIONS

No study interventions.

MEASUREMENTS AND MAIN RESULTS

The patient population was identified. Clinical variables and Congenital Heart Surgical Stay categories were recorded based on surgical intervention performed. A model was built to predict the outcome postoperative ICU length of stay greater than 7 days at the time of surgical intervention. The development cohort included 4,029 cases categorized into five Congenital Heart Surgical Stay categories with a C statistic of 0.78 for the outcome ICU length of stay greater than 7 days. Explanatory value increased with inclusion of patient preoperative status as determined by age, ventilator dependence, and admission status (C statistic = 0.84). A second model was optimized with inclusion of intraoperative factors available at the time of postoperative ICU admission, including cardiopulmonary bypass time and chest left open (C statistic 0.87). Each model was tested in a validation cohort (n = 1,008) with equivalent C statistics.

CONCLUSIONS

Using a model comprised of basic patient characteristics, we developed a robust prediction tool for patients who will remain in the ICU longer than 7 days after cardiac surgery, at the time of postoperative ICU admission. This model may assist in patient counseling, case scheduling, and capacity management. Further examination in external settings is needed to establish generalizability.

Factors Associated With Mortality in Children Who Successfully Wean From Extracorporeal Membrane Oxygenation

OBJECTIVES

Extracorporeal membrane oxygenation is an established therapy for cardiac and respiratory failure unresponsive to usual care. Extracorporeal membrane oxygenation mortality remains high, with ongoing risk of death even after successful decannulation. We describe occurrence and factors associated with mortality in children weaned from extracorporeal membrane oxygenation.

DESIGN

Retrospective cohort study.

SETTING

Two hundred five extracorporeal membrane oxygenation centers reporting to the Extracorporeal Life Support Organization.

SUBJECTS

Eleven thousand ninety-six patients, less than 18 years, supported with extracorporeal membrane oxygenation during 2007-2013, who achieved organ recovery before decannulation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Primary outcome was hospital mortality less than or equal to 30 days post extracorporeal membrane oxygenation decannulation. Among 11,096 patients, indication for extracorporeal membrane oxygenation cannulation was respiratory (6,206; 56%), cardiac (3,663; 33%), or cardiac arrest (extracorporeal cardiopulmonary resuscitation, 1,227; 11%); the majority were supported with venoarterial extracorporeal membrane oxygenation at some stage in their course (8,576 patients; 77%). Mortality was 13%. Factors associated with mortality included younger age (all < 1 yr categories compared with older, p < 0.05), lower weight among neonates (≤ 3 vs > 3 kg; p < 0.001), mode of extracorporeal membrane oxygenation support (venoarterial extracorporeal membrane oxygenation compared with venovenous extracorporeal membrane oxygenation, p < 0.001), longer admission to extracorporeal membrane oxygenation cannulation time (≥ 28 vs < 28 hr; p < 0.001), cardiac and extracorporeal cardiopulmonary resuscitation compared with respiratory extracorporeal membrane oxygenation (both p < 0.001), extracorporeal membrane oxygenation duration greater than or equal to 135 hours (p < 0.001), preextracorporeal membrane oxygenation hypoxemia (PO2 ≤ 43 vs > 43 mm Hg; p < 0.001), preextracorporeal membrane oxygenation acidemia (p < 0.001), and extracorporeal membrane oxygenation complications, particularly cerebral or renal (both p < 0.001).

CONCLUSIONS

Despite extracorporeal membrane oxygenation decannulation for organ recovery, 13% of patients die in hospital. Mortality is associated with patient factors, preextracorporeal membrane oxygenation illness severity, and extracorporeal membrane oxygenation management. Evidence-based strategies to optimize readiness for extracorporeal membrane oxygenation decannulation and postextracorporeal membrane oxygenation decannulation care are needed.

Predictors of Postoperative Rehabilitation Therapy Following Congenital Heart Surgery

Background

Patients with congenital heart disease are at risk of motor, cognitive, speech, and feeding difficulties after cardiac surgery. Rehabilitation therapy could improve functional outcomes in this population if applied in the acute postcardiac surgical in‐hospital stay. However, information on the types of acute postcardiac surgery therapy needs in children is scarce. Our goal was to describe rehabilitation therapy following congenital heart surgery and pre/intraoperative factors associated with need for therapy.

Methods and Results

This is a retrospective cohort study of patients <18 years undergoing heart surgery at our center from January 1, 2013 to January 31, 2015. Demographic, and pre‐, intra‐, and postoperative clinical and rehabilitation therapy (physical, occupational, speech, feeding therapy, and neurodevelopment intervention) data were collected. Need for rehabilitation therapy in the acute postoperative period, particularly following palliative repair, was the outcome variable in a multivariable logistic regression model to identify independent pre‐ and intraoperative factors associated with therapy. A total of 586 out of 1415 (41%) subjects received rehabilitation therapy postsurgery. Certain subgroups had increased rehabilitation therapy use such as neonates (80%). On multivariable analysis, palliative repair, prematurity, genetic syndrome, presurgical hospital stay of more than 1 day, and prolonged cardiopulmonary bypass time were independently associated with rehabilitation therapy.

Conclusions

Nearly half of patients who underwent post–congenital heart surgery received rehabilitation therapy. Frequency of use and types of therapy vary according to patient characteristics; however, certain pre‐ and intraoperative factors are associated with need for rehabilitation therapy, and may aid decision‐making for appropriate resource allocation.

Technical performance scores are predictors of midterm mortality and reinterventions following congenital mitral valve repair

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.

Revisiting the utility of technical performance scores following tetralogy of Fallot repair

OBJECTIVE

Although an important quality metric, current technical performance scores may not be generalizable and may omit operative factors that influence outcomes. We examined factors not included in current technical performance scores that may contribute to increased postoperative length of stay, major complications, and cost after primary repair of tetralogy of Fallot.

METHODS

This is a retrospective single site study of patients younger than age 2 years with tetralogy of Fallot undergoing complete repair between 2007 and 2015. Medical record data and discharge echocardiograms were reviewed to ascertain component and composite technical performance scores. Primary outcomes included postoperative length of stay, major complications, and total hospital costs. Multivariable logistic and linear regression identified determinants of each outcome.

RESULTS

Patient population (n = 115) had a median postoperative length of stay of 8 days (interquartile range, 6-10 days), and a median total cost of $71,147. Major complications occurred in 33 patients (29%) with 1 death. Technical performance scores assigned were optimum in 28 patients (25%), adequate in 59 patients (52%), and inadequate in 26 patients (23%). Neither technical performance score components nor composite scores were associated with increased postoperative length of stay. Optimum or adequate repairs versus inadequate had equal risk of a complication (P = .79), and equivalent mean total cost ($100,000 vs $187,000; P = .25). Longer cardiopulmonary bypass time per 1-minute increase (P < .01) was associated with longer postoperative length of stay and reintervention (P = .02). The need to return to bypass also increased total cost (P < .01).

CONCLUSIONS

Current tetralogy of Fallot technical performance scores were not associated with selected outcomes in our postoperative population. Although returning to bypass and bypass length are not included as components in the current score, these are important factors influencing complications and resource use in our population. Revisions anticipated from a prospective trial should consider including these variables.

Duration of Mechanical Ventilation and Perioperative Care Quality After Neonatal Cardiac Operations

BACKGROUND

This study was conducted to determine whether the duration of mechanical ventilation (DOMV) could be used to benchmark the overall quality of care after neonatal congenital heart operations.

METHODS

Children aged younger than 30 days undergoing cardiac operations were reviewed. Technical adequacy was assessed using the Technical Performance Score (TPS), a previously validated tool for determining the adequacy of a palliative or corrective surgical procedure that uses echocardiography criteria and need for unplanned reintervention to determine technical adequacy. Preoperative risk factors and postoperative complications were determined using The Society of Thoracic Surgeons Congenital Heart Surgery Database definitions. Surgical complexity was assessed using The Society of Thoracic Surgeons-European Association of Cardio-Thoracic Surgery (STAT) Mortality Categories. We explored associations between preoperative risk factors, STAT category, TPS, and postoperative complications with DOMV.

RESULTS

Of 601 patients studied, 49 were not included in the multivariable analysis due to a STAT nonclassifiable operation or unmeasured TPS, or both. Multiple risk factors were associated with longer DOMV, including weight (p = 0.005), The Society of Thoracic Surgeons Congenital Heart Surgery Database preoperative factors (p = 0.005), STAT mortality category (p < 0.001), TPS (p < 0.001), and The Society of Thoracic Surgeons Congenital Heart Surgery Database-defined complications (p < 0.001). Multivariable regression showed that preoperative factors increased DOMV by 1.23 days (p = 0.01), class 3 TPS by 2.16 days (p < 0.001), and postoperative complications by 2.03 days (p < 0.001), with adjusted R² = 0.42.

CONCLUSIONS

Neonates with major residual lesions and postoperative complications have prolonged DOMV. DOMV may reflect the quality of care after congenital heart operations.

Role of human factors in pediatric cardiac surgery

According to the Institute of Healthcare Improvement, “human factors” refers to the discipline of engineering that details the interface of people, equipment and the environment in which they work. Issues that impact human performance and increase the risk of error include factors that directly enable decision making, such as perception, attention, memory, reasoning, judgement and factors that directly enable decision execution, such as communication and the ability to carry out the intended action. 

Tetralogy of Fallot and Its Variants

OBJECTIVES

The objectives of this review are to discuss the anatomy, pathophysiology, surgical repair, and perioperative management strategies for tetralogy of Fallot and its variants.

DATA SOURCE

MEDLINE and PubMed.

CONCLUSIONS

Significant refinements have been made in the repair strategy for tetralogy of Fallot, based on improved understanding of postrepair physiology. Important considerations for timing and technique of surgery and perioperative management have been presented, and continued evolution is expected. Expanded use of the pulmonary valve reconstruction technique outlined herein, whatever the age of repair, may improve long-term outcome.

Influence of Age and Weight on Technical Repair of Tetralogy of Fallot

BACKGROUND

We have previously shown that early primary repair of tetralogy of Fallot can be performed without increased morbidity or resource utilization. The technical performance score (TPS) is a self-assessment tool used to identify patients at risk of poor postoperative outcomes. We hypothesized that adequate technical repair can be obtained regardless of the patient's preoperative age or size.

METHODS

A retrospective review of all tetralogy of Fallot patients repaired between September 2004 and December 2013 was performed. The postoperative predischarge echocardiogram was reviewed to assign a TPS rating of optimal, adequate, or inadequate. The TPS groups were compared by univariate analysis using the Kruskal-Wallis test for continuous variables and χ(2) analysis for categoric variables. Multivariable logistic regression analysis was performed to identify independent predictors of inadequate TPS.

RESULTS

Among 167 patients (1 operative mortality), TPS was optimal in 88, adequate in 62, and inadequate in 17. Patients with worse TPS had longer ventilation time (p = 0.031), hospital length of stay (p = 0.036), and higher hospital charges (p = 0.005). Multivariable regression analysis revealed discontinuous branch pulmonary arteries (odds ratio 18.24, 95% confidence interval: 1.42 to 234, p = 0.015) as the only independent predictor of inadequate TPS. Younger age at repair (p = 0.245) and smaller weight (p = 0.260) were not associated with inadequate TPS.

CONCLUSIONS

Technical adequacy of tetralogy of Fallot repair is affected by anatomic subsets (discontinuous branch pulmonary arteries) and not by the patient's age or size. Worse TPS is associated with higher postoperative morbidity and hospital charges. Younger age and size should not be a deterrent for early primary repair.

Surgical Quality Predicts Length of Stay in Patients with Congenital Heart Disease

Historically, the primary marker of quality for congenital cardiac surgery has been postoperative mortality. The purpose of this study was to determine whether additional markers (10 surgical metrics) independently predict length of stay (LOS), thereby providing specific targets for quality improvement. Ten metrics (unplanned ECMO, unplanned cardiac catheterization, revision of primary repair, delayed closure, mediastinitis, reexploration for bleeding, complete heart block, vocal cord paralysis, diaphragm paralysis, and change in preoperative diagnosis) were defined in 2008 and subsequently collected from 1024 consecutive index congenital cardiac cases, yielding 990 cases. Four patient characteristics and 22 case characteristics were used for risk adjustment. Univariate and multivariable analyses were used to determine independent associations between each metric and postoperative LOS. Increased LOS was independently associated with revision of the primary repair (p = 0.014), postoperative complete heart block requiring a permanent pacemaker (p = 0.001), diaphragm paralysis requiring plication (p < 0.001), and unplanned postoperative cardiac catheterization (p < 0.001). Compared with patients without each metric, LOS was 1.6 (95 % CI 1.1-2.2, p = 0.014), 1.7 (95 % CI 1.2-2.3, p = 0.001), 1.8 (95 % CI 1.4-2.3, p < 0.001), and 2.0 (95 % CI 1.7-2.4, p < 0.001) times as long, respectively. These effects equated to an additional 4.5-7.8 days in hospital, depending on the metric. The other 6 metrics were not independently associated with increased LOS. The quality of surgery during repair of congenital heart disease affects outcomes. Reducing the incidence of these 4 specific surgical metrics may significantly decrease LOS in this population.

Impact of Variability in Echocardiographic Interpretation on Assessment of Adequacy of Repair Following Congenital Heart Surgery: A Pilot Study

Technical Performance Score (TPS) is based largely on the presence and magnitude of residual lesions on postoperative echocardiograms; this score correlates with outcomes following repair of congenital heart defects. We evaluated reader variability for echocardiographic components of TPS for complete repair of tetralogy of Fallot (TOF) and arterial switch operation (ASO) in two centers and measured its effect on TPS. Postoperative echocardiograms were evaluated in 67 children (39 TOF and 28 ASO). Two readers (one per center) interpreted each echocardiogram. Reader variability in image quality assessments and measurements was compared using weighted kappa (κ), percent agreement, and intra-class correlation. TPS class (1 optimal-no residua, 2 adequate-minor residua, 3 inadequate-major residua) was assigned for each echocardiographic review by an independent investigator. The effect of reader interpretation variability on TPS classification was measured. There was strong agreement for TPS between the two readers (κ = 0.88). The readers were concordant for TPS classes for 57 children (85%) and discordant for classes 2 (minor residua) versus 3 (major residua) in six (9%). Coronary arteries and branch pulmonary arteries were frequently suboptimally visualized. Although inter-reader agreement for TPS was strong, inter-reader variation in echocardiographic interpretations had a small, but important effect on TPS for TOF and ASO, particularly for the distinction between minor and major residua. Further studies of generalizability and reproducibility of TPS and refinement of scoring modules may be needed before it can be used as a tool to assess pediatric cardiac surgical performance and outcomes.

Impact of prenatal diagnosis in survivors of initial palliation of single ventricle heart disease: analysis of the National Pediatric Cardiology Quality Improvement Collaborative database

Among infants with single ventricle congenital heart disease (SVD) requiring Stage I palliation (S1P), the impact of prenatal diagnosis (PD) on outcomes has been variably characterized. We investigated the impact of PD in a large multi-center cohort of survivors of S1P in the National Pediatric Cardiology Quality Improvement Collaborative (NPCQIC) registry. Retrospective analysis of demographic and outcomes data among infants enrolled in the NPCQIC database; eligibility includes SVD requiring S1P and survival to discharge. From 43 contributing surgical centers, 591 infants had data available through time of BDG (519) or interstage death (55). Median gestational age was 39 weeks (31-46), and 66% had variants of hypoplastic left heart syndrome. PD was made in 445 (75%), with significant variation by center (p = 0.004). While infants with PD had slightly lower gestational age at birth (p < 0.001), there were no differences in birth weight, the presence of major syndromes or other organ system anomalies. Those without PD were more likely to have atrioventricular valve regurgitation (p = .002), ventricular dysfunction (p = 0.06), and pre-operative risk factors including acidosis (p < 0.001), renal insufficiency (p = 0.007), and shock (p = 0.05). Post-operative ventilation was shorter in the PD group (9 vs. 12 d, p = 0.002). Other early post-operative outcomes, interstage course, and outcomes at BDG were similar between groups. In a large cohort of infants with SVD surviving to hospital discharge after S1P, PD showed significant inter-site variation and was associated with improved pre-operative status and shorter duration of mechanical ventilation. The significance of such associations merits further study.

Technical performance score as predictor for post-discharge reintervention in valve-sparing tetralogy of Fallot repair

Recognition of late problems following repair of tetralogy of Fallot (TOF) with a transannular patch has stimulated modifications to preserve pulmonary valve (PV) function. This study assesses the ability of technical performance score (TPS) to determine the need for post-discharge reinterventions (RIs) in valve-sparing TOF repair. We retrospectively reviewed 157 patients following valve-sparing repair of TOF from 2007-2012. We assigned TPS as Class 1 (optimal), Class 2 (adequate), or Class 3 (inadequate) based on discharge echo and clinical criteria. Preoperative, discharge, and follow-up PV Z scores and post-discharge RIs were documented. Reasons for Class 2 or 3 designation were right ventricular outflow tract (RVOT) gradient in 52, pulmonary regurgitation in 13, residual ventricular septal defects in 7, both RVOT gradient and ventricular septal defects in 13, and both RVOT gradient and pulmonary regurgitation in 37 patients. Median follow-up was 19.6 (range: 0.1-86.1) months. Class 3 patients had a significantly longer median intensive care unit and hospital stay compared with Class 1 (3 vs 2 days [P = 0.015] and 7 vs 5 days [P < 0.001], respectively). Post-discharge RIs were significantly lower in Class 1 vs Class 2 and Class 3 (P = 0.003). Class 1 patients had significantly larger PV Z scores compared with Class 2 or Class 3 patients (P < 0.001). TPS is associated with post-discharge RI rate after valve-sparing TOF repair. Preoperative PV Z score is highly correlated with Class I TPS. Patient selection based on preoperative PV Z scores may help determine if valve-sparing approach is appropriate, thus minimizing the need for RIs.

Technical performance score is associated with outcomes after the Norwood procedure

OBJECTIVES

The technical performance score (TPS) has been reported in a single center study to predict the outcomes after congenital cardiac surgery. We sought to determine the association of the TPS with outcomes in patients undergoing the Norwood procedure in the Single Ventricle Reconstruction trial.

METHODS

We calculated the TPS (class 1, optimal; class 2, adequate; class 3, inadequate) according to the predischarge echocardiograms analyzed in a core laboratory and unplanned reinterventions that occurred before discharge from the Norwood hospitalization. Multivariable regression examined the association of the TPS with interval to first extubation, Norwood length of stay, death or transplantation, unplanned postdischarge reinterventions, and neurodevelopment at 14 months old.

RESULTS

Of 549 patients undergoing a Norwood procedure, 356 (65%) had an echocardiogram adequate to assess atrial septal restriction or arch obstruction or an unplanned reintervention, enabling calculation of the TPS. On multivariable regression, adjusting for preoperative variables, a better TPS was an independent predictor of a shorter interval to first extubation (P=.019), better transplant-free survival before Norwood discharge (P<.001; odds ratio, 9.1 for inadequate vs optimal), shorter hospital length of stay (P<.001), fewer unplanned reinterventions between Norwood discharge and stage II (P=.004), and a higher Bayley II psychomotor development index at 14 months (P=.031). The TPS was not associated with transplant-free survival after Norwood discharge, unplanned reinterventions after stage II, or the Bayley II mental development index at 14 months.

CONCLUSIONS

TPS is an independent predictor of important outcomes after Norwood and could serve as a tool for quality improvement.