1
|
Schwarzbart C, Burri M, Kido T, Heinisch PP, Vodiskar J, Strbad M, Cleuziou J, Hager A, Ewert P, Hörer J, Ono M. Outcome after stage 1 palliation in non-hypoplastic left heart syndrome patients as a univentricular palliation. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 63:6984720. [PMID: 36629467 DOI: 10.1093/ejcts/ezad004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 07/06/2022] [Accepted: 01/10/2023] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Studies focused on infants with univentricular heart undergoing stage I palliation other than the Norwood procedure remain a topic of great interest. This study evaluated the outcome of infants who underwent systemic to pulmonary shunt (SPS) or pulmonary artery banding (PAB). METHODS Infants who underwent SPS or PAB as stage I palliation between 1994 and 2019 were included. Survival and late systemic ventricular function were evaluated. RESULTS Out of 242 patients, 188 underwent SPS (77.7%) and 54 PAB (22.3%). Main diagnosis included tricuspid atresia, unbalanced atrioventricular septal defects, double inlet left ventricles and single ventricles with other morphology. Thirty-eight patients died before stage II palliation (15.7%). Stage II palliation was performed in 182 patients (75.2%), and mortality between stages II and III was 11 (5.6%). Stage III palliation was performed in 160 (66.1%) patients. Survival at 1, 5 and 15 years after stage I procedure was 81.9, 77.1 and 76.2%, respectively, and similar between both procedures (P = 0.97). Premature birth [P = 0.03, hazard ratio (HR) = 2.1], heterotaxy (P = 0.006, HR = 2.4) and dominant right ventricle (P = 0.015, HR = 2.2) were factors associated to mortality. Unbalanced atrioventricular septal defect (P = 0.005, HR = 4.6) was a factor associated to systemic ventricular dysfunction. CONCLUSIONS In patients with univentricular heart who underwent SPS and PAB as stage I palliation, survival at 15 years was 76%, regardless of th chosen approach. Premature birth, heterotaxy and dominant right ventricle were associated to mortality.
Collapse
Affiliation(s)
- Carina Schwarzbart
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Department of Cardiac Surgery, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Takashi Kido
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Department of Cardiac Surgery, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Paul Philipp Heinisch
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Department of Cardiac Surgery, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Janez Vodiskar
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Department of Cardiac Surgery, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Martina Strbad
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Department of Cardiac Surgery, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Julie Cleuziou
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Department of Cardiac Surgery, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Alfred Hager
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Peter Ewert
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Department of Cardiac Surgery, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Department of Cardiac Surgery, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| |
Collapse
|
3
|
Percutaneous Endoscopic Gastrostomy Enhances Interstage Growth in Infants With Hypoplastic Left Heart Syndrome. Pediatr Crit Care Med 2021; 22:e213-e223. [PMID: 33055529 DOI: 10.1097/pcc.0000000000002596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Infants with hypoplastic left heart syndrome undergoing staged palliation commonly experience chronic growth failure and malnutrition. Greater patient weight at stage 2 palliation (Glenn) is thought to be associated with improved perioperative outcomes. We aimed to compare weight for age z score and interstage growth velocity in children with and without a percutaneous endoscopic gastrostomy prior to Glenn and hypothesize that those with a percutaneous endoscopic gastrostomy experience-enhanced interstage growth and reduced malnutrition rates. DESIGN Single-center, retrospective cohort study. SETTING A total of 259-bed, quaternary, pediatric referral center. PATIENTS Infants with hypoplastic left heart syndrome from 2007 to 2016 with and without percutaneous endoscopic gastrostomy insertion after initial palliation (Norwood). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Primary outcomes were weight for age z score (at birth, Norwood, Norwood discharge, and Glenn), interstage growth velocity, and moderate-to-severe malnutrition (weight for age z score<-2) rates. Secondary outcomes were lengths of stay, mechanical ventilation rates after Glenn, and mortality. Statistical analyses included chi-square, Wilcoxon rank-sum, student's t, paired testing, and exploratory logistic regression. Of the 69 infants studied, 47 (68%) had percutaneous endoscopic gastrostomy insertion at a median of 156 (interquartile range, 115-158) days prior to Glenn. Among children with and without percutaneous endoscopic gastrostomy, we observed no differences in demographics, comorbidities, cardiothoracic surgical times, postoperative Glenn outcomes (length of stay, mechanical ventilation rate, peak 24-hr lactate, nitric oxide use, extracorporeal life support rate, or mortality), weight for age z score at birth, and weight for age z score at Norwood. At the time of percutaneous endoscopic gastrostomy insertion, weight for age z score was -2.5 ± 1.3 and subsequent growth velocity increased from 8 ± 7 to 40 ± 59 g/d (p < 0.01). From Norwood discharge to the date of Glenn, weight for age z score increased in infants with percutaneous endoscopic gastrostomy (-2.5 ± 1.1 to -1.5 ± 1.4 [p < 0.01]) with a large reduction in moderate-to-severe malnutrition rates (76-36%; p < 0.01). In general, weight for age z score at the time of Glenn was associated with reduced postoperative mortality (odds ratio, 0.3; 95% CI, 0.09-0.95; p = 0.04). CONCLUSIONS Infants undergoing palliation for hypoplastic left heart syndrome with percutaneous endoscopic gastrostomy insertion prior to Glenn had improved growth velocity and dramatically reduced rates of moderate-to-severe malnutrition rates (40% reduction). In addition, we noted weight for age z score at when Glenn was associated with improved postoperative Glenn survival. No complications from percutaneous endoscopic gastrostomy were noted. Placement of a percutaneous endoscopic gastrostomy improved weight for age z score, enhanced interstage growth, and reduced malnutrition rates for this at-risk population of malnourished children.
Collapse
|
4
|
Percutaneous Endoscopic Gastrostomy After Cardiothoracic Surgery in Children Less Than 2 Months Old: An Assessment of Long-Term Malnutrition Status and Gastrostomy Outcomes. Pediatr Crit Care Med 2020; 21:50-58. [PMID: 31568238 DOI: 10.1097/pcc.0000000000002129] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Infants with critical congenital heart disease undergoing cardiothoracic surgery commonly experience chronic malnutrition and growth failure. We sought to determine whether placement of a percutaneous endoscopic gastrostomy was associated with reduced moderate-severe malnutrition status and to describe percutaneous endoscopic gastrostomy-related clinical and safety outcomes in this population. DESIGN Single-center, retrospective cohort study. SETTING Two hundred fifty-nine-bed, tertiary care, pediatric referral center. PATIENTS Children with congenital heart disease less than 2 months old undergoing cardiothoracic surgery from 2007 to 2013 with and without percutaneous endoscopic gastrostomy. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Primary outcomes were weight for age z scores during hospitalization, at 6 months, and 1 year after cardiothoracic surgery. Secondary outcomes were frequency of percutaneous endoscopic gastrostomy revision, percutaneous endoscopic gastrostomy complications, and mortality. Statistical analyses included Wilcoxon rank-sum, Fisher exact, and Student t tests. Two hundred twenty-two subjects met study criteria, and 77 (35%) had percutaneous endoscopic gastrostomy placed at a mean of 45 ± 31 days after cardiothoracic surgery. No differences were noted for demographics, comorbidities, and weight for age z score at birth and at the time of cardiothoracic surgery. The percutaneous endoscopic gastrostomy cohort had greater Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery risk category (4 [4-5] vs 4 [2-4]) and length of stay (71 d [49-101 d] vs 26 d [15-42 d]). Mean weight for age z score at the time of percutaneous endoscopic gastrostomy was -2.8 ± 1.3. Frequency of moderate-severe malnutrition (weight for age z score, ≤ -2) was greater in children with percutaneous endoscopic gastrostomy at discharge (78% vs 48%), 6 months (61% vs 16%), and 1 year (41% vs 2%). Index mortality was lower in children with percutaneous endoscopic gastrostomy at 30 days (8% vs 0%) and hospital discharge (19% vs 4%). However, no mortality differences were observed after discharge. Growth velocity after percutaneous endoscopic gastrostomy was greater (44 ± 19 vs 10 ± 9 g/d). Children tolerated percutaneous endoscopic gastrostomy without hemodynamic compromise, minor percutaneous endoscopic gastrostomy complications, and anticipated percutaneous endoscopic gastrostomy revisions. Children without mortality had percutaneous endoscopic gastrostomy removal at a median duration of 253 days (133-545 d). Children with univentricular physiology had improved in-hospital mean growth velocity (6.3 vs 24.4 g/d; p < 0.01) and reduced 1-year rate moderate-severe malnutrition (66.7% vs 36.9%; p < 0.01) after percutaneous endoscopic gastrostomy placement. CONCLUSIONS Percutaneous endoscopic gastrostomy placement was well tolerated and associated with improved postoperative growth velocity in children with critical congenital heart disease undergoing cardiothoracic surgery less than 2 months old. These findings were also noted in our subanalysis of children with univentricular physiology. Persistent rates of moderate-severe malnutrition were noted at 1-year follow-up. Although potential index mortality benefit was observed, definitive data are still needed.
Collapse
|
5
|
Impact of Gestational Age on Surgical Outcomes in Patients With Functionally Single Ventricle. Ann Thorac Surg 2019; 109:1260-1266. [PMID: 31580862 DOI: 10.1016/j.athoracsur.2019.08.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 06/26/2019] [Accepted: 08/19/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Younger gestational age (GA) is known to be associated with worse outcomes after congenital cardiac surgery. We sought to determine the impact of GA on surgical outcomes of single-ventricle palliation. METHODS Among the 284 patients with functionally single ventricle who were born between January 2005 and December 2014, 50 neonates were born prematurely (GA < 37 weeks) and 113 neonates in the early term period (37 weeks ≤ GA < 39 weeks). Initial palliation was required in 251 patients, whereas 33 patients received primary bidirectional cavopulmonary anastomosis (BCPA). RESULTS BCPA and the completion Fontan operation were performed in 200 and 169 patients, respectively. Overall survival at 5 years were 62.5% ± 2.9%. On Cox regression younger GA (hazard ratio, 1.14 per 1-week decrease; P = .007) was identified as a risk factor for increased interstage mortality (ISM) between initial palliation and BCPA. On subgroup analysis of the preterm or early-term patients with initial palliation (n = 145), younger postmenstrual age at initial palliation was associated with increased ISM before BCPA (hazard ratio, 1.18; P = .005). After BCPA, however, younger GA did not increase the risk of ISM between BCPA and the Fontan operation (P = .47). CONCLUSIONS Younger GA is a risk factor for ISM between initial palliation and BCPA. Deferral of initial palliation may be beneficial to decrease the risk of ISM in patients who were born at preterm or early term. Adverse effects of younger GA on survival disappeared once BCPA was performed.
Collapse
|
7
|
Zaidi SJ, Lefaiver CA, Muangmingsuk S, Cui VW, Roberson DA, Penk J. Right Ventricular Longitudinal Shortening Before and After Stage I Surgical Palliation Correlates with Outcomes. Pediatr Cardiol 2018; 39:526-532. [PMID: 29184979 DOI: 10.1007/s00246-017-1783-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 11/22/2017] [Indexed: 11/28/2022]
Abstract
Quantification of right ventricular function is difficult, but important, in patients with single ventricles. Tissue motion annular displacement (TMAD) is an echocardiographic tool that measures displacement of the tricuspid valve relative to the apex. We evaluated TMAD, lateral annular displacement (LAD), and fractional area change (FAC) for correlation with outcomes. We measured TMAD, LAD, FAC, and other variables that may affect prognosis in patients with single right ventricle physiology pre- and post-Stage I palliation and correlated them with outcomes up to the Glenn procedure. Intra- and inter-observer variability for TMAD measurements were 2.7% (1.2-3.5%) and 6.1% (3.3-8.1%), respectively. Sixty-six subjects met the inclusion criteria. Pre-Stage I TMAD was 13.7% (SD 3.9%). TMAD had a linear relationship with FAC (r2 = 0.76). There was a correlation between TMAD and hospital stay (p = 0.044) and ECMO/arrest (p = 0.024). LAD correlated with ECMO/arrest (p = 0.045) and mortality/transplant (p = 0.049). FAC correlated with in-hospital mortality (p = 0.028). Post-Stage I TMAD was 11.8% (SD 3.7%). TMAD, LAD, and FAC all correlated with in-hospital mortality and mortality/transplant. In multivariate models, TMAD was independently predictive of weight for age Z score pre-Glenn. TMAD, FAC, and LAD correlate with clinically significant outcomes after the first-stage palliation. TMAD correlated with more outcomes than FAC and was the only measure that was independently predictive of any outcome. TMAD is a reproducible measure of RV function in this population. TMAD has prognostic value before and after first-stage palliation and may outperform more traditional measures.
Collapse
Affiliation(s)
- S Javed Zaidi
- Pediatric Cardiology, Advocate Children's Hospital, Chicago, IL, USA. .,Advocate Bromenn Medical Center, 1302 Franklin Av, Suite 1100, Normal, IL, 61761, USA.
| | - Cheryl A Lefaiver
- Pediatric Cardiology, Advocate Children's Hospital, Chicago, IL, USA
| | | | - Vivian W Cui
- Pediatric Cardiology, Advocate Children's Hospital, Chicago, IL, USA
| | - David A Roberson
- Pediatric Cardiology, Advocate Children's Hospital, Chicago, IL, USA
| | - Jamie Penk
- Pediatric Cardiology, Advocate Children's Hospital, Chicago, IL, USA
| |
Collapse
|