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Bhamidipati CM, Garcia IC, Kim B, McGrath LB, Khan AM, Broberg CS, Muralidaran A, Shen I. Racial Disparity: The Adult Congenital Heart Disease Surgery Perspective. Pediatr Cardiol 2024; 45:1275-1283. [PMID: 36580104 DOI: 10.1007/s00246-022-03087-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/21/2022] [Indexed: 12/30/2022]
Abstract
The influence of race and ethnicity on clinical outcomes in medicine are widely acknowledged. However, the effect of race on adult congenital heart disease (ACHD) surgery is not known. We sought to evaluate the possible association between race and outcomes following ACHD operations. Discharge records for patients who underwent ACHD surgery between 2005 and 2014, were isolated from an all-payer voluntary database in the United States. Hierarchical case-mix regression models and sensitivity analyses examined any complication, in-hospital mortality, and discharge disposition (home/non-home) by race (white-WP, black-BP, non-white non-black-NWNB). Of the 174,370 patients (WP: 80.8%, BP: 5.8%, NWNB: 13.4%), black patients were youngest to undergo surgery (WP: 57.9 ± 15.8 years, BP: 50.2 ± 16.1 years, NWNB: 51.6 ± 16.9 years, P < 0.0001), the most likely to have a comorbidity (WP: 70.3%, BP: 74.3%, NWNB: 68.6%, P < 0.0001), and most likely to have had a post-operative cardiac complication (WP: 9.4%, BP: 15.3%, NWNB: 10.9%, P < 0.0001). BP had similar odds of having any complication (AOR = 0.99, 95%CI = 0.94-1.04), while NWNB had significantly decreased odds of a major complication (AOR = 0.90, 95%CI = 0.87-0.93). BP had equivalent in-hospital mortality compared to WP (AOR = 1.03, 95%CI = 0.91-1.18), while NWNB had significantly increased odds of in-hospital mortality (AOR = 1.29, 95%CI = 1.18-1.41). Among survivors, BP were less likely to discharge home (AOR = 0.88, 95%CI = 0.82-0.94), and NWNB were more likely to discharge home than WP (AOR = 1.26, 95%CI = 1.19-1.33). Race and clinical outcomes are associated among patients undergoing surgery for ACHD. Understanding why and how these factors are impactful will help improve care for this complex population.
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Affiliation(s)
- Castigliano M Bhamidipati
- Cardiac Surgery, Division of Cardiothoracic Surgery, Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code: L353, Portland, OR, 97239, USA.
| | - Ibett Colina Garcia
- Adult Congenital Heart Disease, Division of Cardiology, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Bohye Kim
- Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Lidija B McGrath
- Adult Congenital Heart Disease, Division of Cardiology, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Abigail M Khan
- Adult Congenital Heart Disease, Division of Cardiology, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Craig S Broberg
- Adult Congenital Heart Disease, Division of Cardiology, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Ashok Muralidaran
- Pediatric Cardiac Surgery, Division of Cardiothoracic Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Irving Shen
- Pediatric Cardiac Surgery, Division of Cardiothoracic Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR, USA
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Cohen MI, Cohen JE, St Louis J. Health Care Expenditures in Cardiac Children: The Time to Act Is Now. J Am Coll Cardiol 2023; 81:1618-1620. [PMID: 37076216 DOI: 10.1016/j.jacc.2023.03.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/06/2023] [Indexed: 04/21/2023]
Affiliation(s)
| | | | - James St Louis
- Inova L.J. Murphy Children's Hospital, Fairfax, Virginia, USA
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3
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Erickson LA, Ricketts A, Swanson T, Weiner J, Hasnie UA, Bonessa K, Noel-Macdonnell J, Russell CL. Determinants of Length of Stay after Neonatal Cardiac Surgery Using Path Analysis. West J Nurs Res 2023; 45:306-315. [PMID: 36217759 DOI: 10.1177/01939459221129037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
After neonatal cardiac surgery, families, and the health care team strive for exclusive oral feedings before hospital discharge. With the hypothesis that exclusive oral feedings would reduce the length of stay (LOS), a multidimensional path analysis was used to examine a cross-section of 280 neonates from 2009 to 2013. Buttigieg, Abela, and Pace's theoretical framework of structural and process-related determinants of LOS was modeled with hypothesis-driven correlation and directionality. The recursive path model had a good global and local fit with outcome variances of 26% for exclusive oral feeding and LOS. In the full cohort and model groups (single and biventricular), when controlling for covariances: sepsis, birth distance, necrotizing enterocolitis, genetic differences, specialty consults, the age at which neonatal cardiac surgery occurred (β = .23, p ≤ .001) and the duration of postoperative intubation (β = .47, p ≤ .001) more significantly influenced the LOS than intermediate mediation of exclusive oral feedings at discharge.
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Affiliation(s)
- Lori A Erickson
- Children's Mercy Kansas City, Kansas City, MO, USA.,University of Missouri-Kansas City, Kansas City, MO, USA
| | - Amy Ricketts
- Children's Mercy Kansas City, Kansas City, MO, USA.,University of Missouri-Kansas City, Kansas City, MO, USA
| | - Tara Swanson
- University of Missouri-Kansas City, Kansas City, MO, USA
| | - Julie Weiner
- Children's Mercy Kansas City, Kansas City, MO, USA.,University of Missouri-Kansas City, Kansas City, MO, USA
| | - Usman A Hasnie
- University of Missouri-Kansas City, Kansas City, MO, USA.,Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Nathan M, Sengupta A. Cost Containment in the Single Ventricle Population. JACC. ADVANCES 2022; 1:100033. [PMID: 38939309 PMCID: PMC11198688 DOI: 10.1016/j.jacadv.2022.100033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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Lopez KN, Baker-Smith C, Flores G, Gurvitz M, Karamlou T, Nunez Gallegos F, Pasquali S, Patel A, Peterson JK, Salemi JL, Yancy C, Peyvandi S. Addressing Social Determinants of Health and Mitigating Health Disparities Across the Lifespan in Congenital Heart Disease: A Scientific Statement From the American Heart Association. J Am Heart Assoc 2022; 11:e025358. [PMID: 35389228 PMCID: PMC9238447 DOI: 10.1161/jaha.122.025358] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite the overall improvement in life expectancy of patients living with congenital heart disease (congenital HD), disparities in morbidity and mortality remain throughout the lifespan. Longstanding systemic inequities, disparities in the social determinants of health, and the inability to obtain quality lifelong care contribute to poorer outcomes. To work toward health equity in populations with congenital HD, we must recognize the existence and strategize the elimination of inequities in overall congenital HD morbidity and mortality, disparate health care access, and overall quality of health services in the context of varying social determinants of health, systemic inequities, and structural racism. This requires critically examining multilevel contributions that continue to facilitate health inequities in the natural history and consequences of congenital HD. In this scientific statement, we focus on population, systemic, institutional, and individual-level contributions to health inequities from prenatal to adult congenital HD care. We review opportunities and strategies for improvement in lifelong congenital HD care based on current public health and scientific evidence, surgical data, experiences from other patient populations, and recognition of implicit bias and microaggressions. Furthermore, we review directions and goals for both quantitative and qualitative research approaches to understanding and mitigating health inequities in congenital HD care. Finally, we assess ways to improve the diversity of the congenital HD workforce as well as ethical guidance on addressing social determinants of health in the context of clinical care and research.
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Ghandour HZ, Vervoort D, Welke KF, Karamlou T. Regionalization of congenital cardiac surgical care: what it will take. Curr Opin Cardiol 2022; 37:137-143. [PMID: 34654032 DOI: 10.1097/hco.0000000000000940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Decentralized, inconsistent healthcare delivery results in variable outcomes and wastes nearly one trillion dollars annually in the United States (US). Congenital heart surgery (CHS) is not immune due to high, variable costs and inconsistent outcomes across hospitals. Many European countries and Canada have addressed these issues by regionalizing CHS. Centralizing resources lowers costs, reduces in-hospital mortality and improves long-term survival. Although the impact on travel distance for patients is limited, the effect on healthcare disparities requires study. This review summarizes current data and integrates these into paths to regionalization through health policy, research, and academic collaboration. RECENT FINDINGS There are too many CHS programs in the US with unnecessarily high densities of centers in certain regions. This distribution lowers center and surgeon case volumes, creates redundancy, and increases variation in costs and outcomes. Simultaneously, adhering to suboptimal allocation impedes the understanding of optimal regionalization models to optimize congenital cardiac care delivery. SUMMARY CHS regionalization models developed for the US increase surgeon and center volume, decrease healthcare spending, and improve patient outcomes without substantially increasing travel distance. Regionalization in countries with few or no existing CHS programs is yet to be explored, but may be associated with more efficient spending and procedural complexity expansion.
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Affiliation(s)
- Hiba Z Ghandour
- Department of Thoracic & Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Dominique Vervoort
- Institute of Health Policy, Management and Evaluation
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Karl F Welke
- Division of Pediatric Cardiothoracic Surgery, Atrium Health Levine Children's Hospital Charlotte, North Carolina
| | - Tara Karamlou
- Department of Pediatric Cardiac Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Dewan KC, Zhou G, Koroukian SM, Gillinov AM, Roselli EE, Svensson LG, Johnston D, Bakaeen F, Soltesz EG. Failure to Rescue After Cardiac Surgery at Minority-Serving Hospitals: Room for Improvement. Ann Thorac Surg 2021; 114:2180-2187. [PMID: 34838742 DOI: 10.1016/j.athoracsur.2021.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 11/07/2021] [Accepted: 11/12/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite living closer to high-performing centers, minority patients reportedly receive care at lower-quality hospitals. Investigating opportunities for improvement at minority-serving hospitals may help attenuate disparities in care among cardiothoracic surgery patients. We sought to investigate the relationship between hospital quality and failure-to-rescue (FTR). METHODS Over 451,000 cardiac surgery patients from 2000-2011 at minority-serving hospitals (MSH) were identified from the Nationwide Inpatient Sample. After stratifying patients by hospital mortality quartile, outcomes at poorly performing MSH were compared to those at high-performing MSH. Propensity-score matching was used for comparisons. RESULTS Though patients at poorly performing centers were more likely black, there were no significant differences in admission status (urgent vs elective), income, insurance, or risk before matching. There were no differences in comorbidities between low- and high-performing MSH including chronic lung disease, coagulopathy, hypertension, and renal failure. While complications remained similar across mortality quartiles (29%, 32%, 31%, 36% respectively; p<0.0001), FTR increased in a stepwise manner (5.4%, 8.7%, 11.2%, 15.5%; p<0.0001). The same was true after propensity-score matching - FTR nearly tripled in the highest-mortality centers (14.4% vs 5.3%; p<0.0001) while complications only increased 1.2-fold from 31.1% to 36.7% (p=0.0058). This finding persisted even when stratified by procedure type and by complication. CONCLUSIONS Improving timely management of complications after cardiac surgery may serve as a promising opportunity for increasing quality of care at MSH. When considering centralization of care in cardiac surgery, equal emphasis should be placed on collaboration between tertiary care centers and low-quality MSH to mitigate disparities in care.
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Affiliation(s)
- Krish C Dewan
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Guangjin Zhou
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Douglas Johnston
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Faisal Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
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Non-invasive biomarkers of Fontan-associated liver disease. JHEP Rep 2021; 3:100362. [PMID: 34693238 PMCID: PMC8517550 DOI: 10.1016/j.jhepr.2021.100362] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/12/2021] [Accepted: 09/05/2021] [Indexed: 02/07/2023] Open
Abstract
Background & Aims Fontan-associated liver disease (FALD) has emerged as an important morbidity following surgical palliation of single ventricle congenital heart disease. In this study, non-invasive biomarkers that may be associated with severity of FALD were explored. Methods A retrospective cohort of paediatric patients post-Fontan who underwent liver biopsy at a high volume at a paediatric congenital heart disease centre was reviewed. Results Among 106 patients, 66% were male and 69% were Hispanic. The mean age was 14.4 ± 3.5 years, and biopsy was performed 10.8 ± 3.6 years post-Fontan. The mean BMI was 20.8 ± 5 kg/m2, with 27.4% meeting obesity criteria. Bridging fibrosis was observed in 35% of patients, and 10.4% of all patients had superimposed steatosis. Bridging fibrosis was associated with lower platelet counts (168.3 ± 58.4 vs. 203.9 ± 65.8 K/μl for congestive hepatic fibrosis score [CHFS] 0–2b, p = 0.009), higher bilirubin (1.7 ± 2.2 vs. 0.9 ± 0.7 mg/dl, p = 0.0090), higher aspartate aminotransferase-to-platelet ratio index [APRI] and fibrosis-4 [FIB-4] scores (APRI: 0.5 ± 0.3 vs. 0.4 ± 0.1, p <0.01 [AUC: 0.69] and FIB-4: 0.6 ± 0.4 vs. 0.4 ± 0.2, p <0.01 [AUC: 0.69]), and worse overall survival (median 2 years follow-up post-biopsy, p = 0.027). Regression modelling of temporal changes in platelet counts before and after biopsy correlated with fibrosis severity (p = 0.005). Conclusions In this large, relatively homogeneous adolescent population in terms of age, ethnicity, and Fontan duration, bridging fibrosis was observed in 35% of patients within the first decade post-Fontan. Bridging fibrosis was associated with worse survival. Changes in platelet counts, even years before biopsy, and APRI/FIB-4 scores had modest discriminatory power in identifying patients with advanced fibrosis. Steatosis may represent an additional risk factor for disease progression in obese patients. Further prospective studies are necessary to develop strategies to screen for FALD in the adolescent population. Lay summary In this study, the prevalence of Fontan-associated liver disease (FALD) in the young adult population and clinical variables that may be predictive of fibrosis severity or adverse outcomes were explored. Several lab-based, non-invasive markers of bridging fibrosis in FALD were identified, suggesting that these values may be followed as a prognostic biomarker for FALD progression in the adolescent population. FALD is universal within 10 years post-Fontan, with 35% of patients having bridging fibrosis. Of our adolescent patient population, 10% had concomitant hepatic steatosis, which was associated with obesity. Regression modelling demonstrates that temporal changes in platelet counts correlate with severity of fibrosis in FALD. AST-to-platelet ratio index and FIB-4 scores correlate with bridging fibrosis with a high specificity. Bridging fibrosis in FALD is associated with worse survival.
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Key Words
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- APRI, AST-to-platelet ratio index
- AST, aspartate aminotransferase
- BMI, body mass index
- BNP, brain natriuretic peptide
- BUN, blood urea nitrogen
- CBC, complete blood count
- CHFS, congestive hepatic fibrosis score
- CHLT, combined heart–liver transplantation
- CVP, central venous pressure
- Congenital heart disease
- Congestive hepatopathy
- ECMO, extracorporeal membrane oxygenation
- FALD, Fontan-associated liver disease
- FIB-4, fibrosis-4
- GFR, glomerular filtration rate
- GGT, gamma-glutamyl transferase
- INR, international normalised ratio
- IQR, interquartile range
- LVAD, left ventricular assist device
- MELD, model of end-stage liver disease
- MELD-Na, MELD-sodium
- MELD-XI, MELD without INR
- NAFLD, non-alcoholic fatty liver disease
- PELD, paediatric end-stage liver disease
- PT, prothrombin time
- PTT, partial thromboplastin time
- TTE, transthoracic echocardiograms
- Univentricular heart disease
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Karamlou T, Hawke JL, Zafar F, Kafle M, Tweddell JS, Najm HK, Frebis JR, Bryant RG. Widening our Focus: Characterizing Socioeconomic and Racial Disparities in Congenital Heart Disease. Ann Thorac Surg 2021; 113:157-165. [PMID: 33872577 DOI: 10.1016/j.athoracsur.2021.04.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 03/26/2021] [Accepted: 04/05/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Socioeconomic and racial (SER) disparities among congenital heart disease (CHD) patients may limit access to high-quality care. We characterized national SER landscape, its relationship to early outcomes, and identified interactions among determinants mitigating adverse outcome. METHODS The Pediatric Health Information System (PHIS) database queried patients (age < 26 years) with CHD between 2016-2018. ICD-10 codes were mapped to diagnostic categories for complexity adjustment. Correlational and hierarchical regression analyses identified risk-factors and characterized interactions. RESULTS N=166,599 unique admissions from 52 hospitals were identified, 58,395 having interventions. Median age was 0 years (IQR=4 years). Race/Ethnicity was predominantly White (59%), Hispanic (20%), and Black (16%). Median neighborhood household income (NHI) was $41,082, and varied among hospitals. Patient NHI had a parabolic relationship with mortality, with both higher and lower values having increased risk. Black patients had significantly higher mortality, and this relationship was potentiated by lower NHI and complexity. Length of hospital stay (LOS) was longer among Black neonates (median 51 days; IQR 93) compared to neonates of other ethnic groups (median 32 days; IQR 71), P<0.0001. Care pathways including permanent feeding tubes were also more prevalent among Black neonates (17.8%) compared to White neonates (15%), P=0.02. CONCLUSIONS Interactions among SER disparities modify CHD outcomes. Specific hospitals have more SER fragile patients, but may have developed care pathways that prolong LOS to mitigate risk among Black neonates. Adverse outcomes among SER disadvantaged patients are magnified in complex CHD, suggesting tangible benefits to targeted resource allocation and population health initiatives.
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Affiliation(s)
- Tara Karamlou
- Division of Pediatric Cardiac Surgery, Cleveland Clinic Children's and the Heart Vascular Institute, Cleveland, OH.
| | - Jesse L Hawke
- James A. Anderson Center for Clinical Systems Excellence, Cincinnati Children's Hospital, Cincinnati, OH
| | - Farhan Zafar
- Division of Pediatric Cardiothoracic Surgery, Cincinnati Children's Hospital
| | - Mahendra Kafle
- James A. Anderson Center for Clinical Systems Excellence, Cincinnati Children's Hospital, Cincinnati, OH
| | - James S Tweddell
- Division of Pediatric Cardiothoracic Surgery, Cincinnati Children's Hospital
| | - Hani K Najm
- Division of Pediatric Cardiac Surgery, Cleveland Clinic Children's and the Heart Vascular Institute, Cleveland, OH
| | - James R Frebis
- James A. Anderson Center for Clinical Systems Excellence, Cincinnati Children's Hospital, Cincinnati, OH
| | - Roosevelt G Bryant
- Division of Pediatric Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ
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Karamlou T, Johnston DR, Backer CL, Roselli EE, Welke KF, Caldarone CA, Svensson LG. Access or excess? Examining the argument for regionalized cardiac care. J Thorac Cardiovasc Surg 2020; 160:813-819. [DOI: 10.1016/j.jtcvs.2019.12.125] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 12/20/2019] [Accepted: 12/31/2019] [Indexed: 12/24/2022]
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Najm HK, Karamlou T, Ahmad M, Hassan S, Yaman M, Stewart R, Pettersson G. Biventricular Conversion in Unseptatable Hearts: "Ventricular Switch". Semin Thorac Cardiovasc Surg 2020; 33:172-180. [PMID: 32858218 DOI: 10.1053/j.semtcvs.2020.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/20/2020] [Indexed: 11/11/2022]
Abstract
Patients with complex systemic and pulmonary venous anatomy, common atrioventricular canal defects and conotruncal anomalies have traditionally been routed to univentricular palliation and labeled as "unseptatable." This report describes our initial experience in septation/biventricular conversion ("ventricular switch"), utilizing the left ventricle (LV) as the subpulmonary ventricle, essentially recapitulating the physiology of congenitally corrected transposition of the great arteries. Five consecutive patients with challenging anatomic configuration underwent septation. All patients were severely cyanotic and had important functional limitations. All patients required complex atrial septation. Ventricular septation was precluded by fixed pulmonary vascular resistance in 2 patients. Systemic venous return was diverted to the morphologic LV as part of physiological 2V (n = 4) or 1.5 V repair (n = 1). Median conversion age was 9 years (range 11 months-46 years). Four patients had 12 previous cardiac surgical procedures in preparation for univentricular repair elsewhere. Three dimensional-printed heart models evaluated feasibility of septation. All patients are alive at a median follow-up of 0.6 years (range 0.08-2.7 years). Median hospital stay was 13 (range 10-60) days. LV recruitment improved functional status and significantly increased systemic oxygen saturation in all patients (79 ± 7% vs 95 ± 5%, P = 0.003). We report a novel paradigm for successfully utilizing both ventricles with the morphologic LV as the subpulmonary ventricle, in a complex population thought to be unseptatable. This approach is versatile and can likely be extrapolated to other complex anatomic configurations. Although we utilized this strategy in patients of variable age, earlier ventricular switch may yield the best results.
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Affiliation(s)
- Hani K Najm
- Division of Pediatric Cardiac Surgery, Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery, Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Munir Ahmad
- Division of Pediatric Cardiac Surgery, Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Saad Hassan
- Division of adult Cardiothoracic Surgery, Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Malek Yaman
- Division of adult Cardiothoracic Surgery, Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Robert Stewart
- Division of Pediatric Cardiac Surgery, Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Pediatric Cardiac Surgery, Congenital Heart Center, Akron Children's Hospital, Akron, Ohio
| | - Gosta Pettersson
- Division of Pediatric Cardiac Surgery, Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Pediatrics and Pediatric Cardiology, Pediatric Institute, Cleveland Clinic, Cleveland, Ohio
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Karamlou T, Najm HK. Evolution of care pathways for babies with hypoplastic left heart syndrome: integrating mechanistic and clinical process investigation, standardization, and collaborative study. J Thorac Dis 2020; 12:1174-1183. [PMID: 32274198 PMCID: PMC7139006 DOI: 10.21037/jtd.2019.10.75] [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: 12/13/2022]
Abstract
Since initial descriptions of staged palliation for hypoplastic left heart syndrome (HLHS) in the 1980’s, much has been learned about the pathophysiology of the single ventricle circulation. New therapies that leverage systems biology and clinical derivatives have been developed. While in-hospital mortality and morbidity for babies with HLHS have continued to improve, there remains a long (and daresay winding) road ahead to achieve ideal outcomes. Important variation in even these abbreviated in-hospital metrics persists among institutions and currently utilized prediction models explain only a small amount of this variation. Moreover, long-term survival and neurodevelopmental health for patients with HLHS are infrequently reported and remain suboptimal despite improved in-hospital outcomes. This focused review will describe the evolution of national outcomes for HLHS over time and the potential factors motivating improved time-related mortality. Emerging modifiable risk-factors that hold promise in terms of moving the needle for long-term success, including social determinants of health and the delineation of genetic profiles, will be discussed. Specifically, this review will integrate contemporary data based on the first murine HLHS models that suggest a genetically elicited modular phenotype with environmental factors known to impact the initial durability of surgical therapies. A comprehensive approach to the management of HLHS, which leverages both proactive transplantation and hybrid palliation, in addition to traditional Norwood palliation, will be emphasized to extend and match management to the complete spectrum of patient risk-profiles. Finally, we will explore the critical role that national collaboratives and quality reporting initiatives have played in improving outcomes and shifting the focus to more meaningful long-term survival and neurodevelopment.
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Affiliation(s)
- Tara Karamlou
- Division of Pediatric Cardiac Surgery, Cleveland Clinic Heart Vascular Institute, Cleveland, OH, USA
| | - Hani K Najm
- Division of Pediatric Cardiac Surgery, Cleveland Clinic Heart Vascular Institute, Cleveland, OH, USA
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13
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d'Udekem Y. Fontan outcomes: Is being educated as good as being wealthy and healthy? J Thorac Cardiovasc Surg 2018; 155:1732-1733. [PMID: 29331176 DOI: 10.1016/j.jtcvs.2017.12.050] [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: 11/28/2017] [Accepted: 12/13/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Yves d'Udekem
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Pediatrics of the University of Melbourne, Melbourne, Victoria, Australia.
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