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Levine JC, Colan S, Trachtenberg F, Marcus E, Ferguson M, Parthiban A, Taylor C, Dragulescu A, Goot B, Lacro RV, McFarland C, Narasimhan S, O'Connor M, Schamberger M, Srivistava S, Taylor M, Nathan M. Echocardiographic image collection and evaluation in infants with CHD: lessons learned from the imaging core lab for the Residual Lesion Score study. Cardiol Young 2024; 34:570-575. [PMID: 37605979 DOI: 10.1017/s1047951123003037] [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] [Indexed: 08/23/2023]
Abstract
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.
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Affiliation(s)
- Jami C Levine
- Department Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven Colan
- Department Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Edward Marcus
- Department Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew Ferguson
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Anitha Parthiban
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Carolyn Taylor
- Department of Pediatrics, Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - Andreea Dragulescu
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Benjamin Goot
- Department of Pediatrics, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ronald V Lacro
- Department Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Carol McFarland
- Department of Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Shanthi Narasimhan
- Department of Pediatric Cardiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, MN, USA
| | - Matthew O'Connor
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Marcus Schamberger
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Shubhika Srivistava
- Department of Pediatrics, Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - Michael Taylor
- Department of Pediatrics, Cincinnati Children's Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Meena Nathan
- Department Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Alifu A, Wang H, Chen R. Technical performance scores associate with early prognosis of tetralogy of Fallot repair. Front Pediatr 2024; 12:1274913. [PMID: 38357504 PMCID: PMC10864547 DOI: 10.3389/fped.2024.1274913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/11/2024] [Indexed: 02/16/2024] Open
Abstract
Objective This study aimed to investigate the relationship between technical performance scores (TPS) and the early prognosis of tetralogy of Fallot repair (TOF). Methods A retrospective study was conducted on TOF repair patients at our center from Oct 2017 to Oct 2022. Patients were classified into Class 1 (no residua), Class 2 (minor residua), or Class 3 (major residua) based on TPS derived from predischarge echocardiograms and need for reintervention. Statistical methods were used to assess the association between TPS and early prognosis. Results A total of 75 TOF repair patients (40% female, 60% male) were analyzed and categorized into TPS1 (24%), TPS2 (53.3%), and TPS3 (22.6%) based on pre-discharge echocardiographic findings. The median follow-up time was 7.0 months. The multivariable Cox regression analysis indicated that TPS3 scores are associated with a 12.68-fold increase in risk compared to TPS1 and TPS2 scores [95% CI = 12.68 (0.9∼179.28), P = 0.06]. The Spearman rank correlation analysis revealed a weak positive correlation between TPS classification and low cardiac output syndrome (r = 0.26, P = 0.03). However, there were no significant differences in ICU stay or duration of mechanical ventilation among the groups. Conclusion TPS3 after intracardiac TOF repair is associated with higher risk of early re-intervention, highlighting the importance of close follow-up and monitoring in this patient population. Patients who develop low cardiac output syndrome in the early postoperative period may have residual defects that require prompt identification.
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Affiliation(s)
| | | | - Renwei Chen
- Department of Cardiothoracic Surgery, Hainan Women and Children’s Medical Center, Haikou, Hainan, China
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Capecci L, Mainwaring RD, Collins RT, Sidell D, Martin E, Lamberti JJ, Hanley FL. The number of postoperative surgical or diagnostic procedures following congenital heart surgery correlates with both mortality and hospital length of stay. J Card Surg 2022; 37:3028-3035. [PMID: 35917407 DOI: 10.1111/jocs.16817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/23/2022] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Lou Capecci
- Divisions of Pediatric Cardiac Surgery, Pediatric Cardiology, and Pediatric Otorhinolaryngology, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Stanford, California, USA
| | - Richard D Mainwaring
- Divisions of Pediatric Cardiac Surgery, Pediatric Cardiology, and Pediatric Otorhinolaryngology, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Stanford, California, USA
| | - R Thomas Collins
- Division of Pediatric Cardiology, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Stanford, California, USA
| | - Doug Sidell
- Division of Pediatric Otorhinolaryngology, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Stanford, California, USA
| | - Elisabeth Martin
- Divisions of Pediatric Cardiac Surgery, Pediatric Cardiology, and Pediatric Otorhinolaryngology, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Stanford, California, USA
| | - John J Lamberti
- Divisions of Pediatric Cardiac Surgery, Pediatric Cardiology, and Pediatric Otorhinolaryngology, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Stanford, California, USA
| | - Frank L Hanley
- Divisions of Pediatric Cardiac Surgery, Pediatric Cardiology, and Pediatric Otorhinolaryngology, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Stanford, California, USA
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Sengupta A, Gauvreau K, Kohlsaat K, Colan SD, Newburger JW, Del Nido PJ, Nathan M. Long-Term Outcomes of Patients Requiring Unplanned Repeated Interventions After Surgery for Congenital Heart Disease. J Am Coll Cardiol 2022; 79:2489-2499. [PMID: 35738709 DOI: 10.1016/j.jacc.2022.04.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/25/2022] [Accepted: 04/04/2022] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Katherine Kohlsaat
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
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Liu J, Jiang X, Peng B, Li S, Yan J, Wang Q, Liu Z. Association of Pulmonary Valve Morphology Differences With Outcomes in Tetralogy of Fallot Repair With Right Ventricular Outflow Tract Incision. Front Cardiovasc Med 2021; 8:695876. [PMID: 34422925 PMCID: PMC8372408 DOI: 10.3389/fcvm.2021.695876] [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] [Received: 04/15/2021] [Accepted: 07/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Current observational studies may not have large samples to investigate the relationship between pulmonary valve (PV) morphology differences and outcomes after complete repair for tetralogy of Fallot (TOF) by right ventricular outflow tract (RVOT) incision. This study aimed to assess the impact of PV morphology differences on outcomes after complete repair for TOF. Methods: This is a retrospective cohort study. Consecutive patients who underwent TOF repair with RVOT incision at Fuwai Hospital from January 2012 to December 2017 were included and compared according to PV morphology differences (unicuspid or bicuspid was abnormal morphology, while the tricuspid valve was normal morphology). The primary outcome was defined as a composite of death, or reintervention, or significant annular peak gradient (APG), or significant pulmonary regurgitation (PR), whichever occurred first. Multivariable Cox model analysis was used to assess the relationships between PV morphology differences and outcomes. Subgroup analysis and Propensity-score analysis were performed as sensitivity analyses to assess the robustness of our results. Results: The cohort included a total of 1,861 patients with primary diagnosis of TOF, with 1,688 undergoing CR-TOF with RVOT incision. The median age was 318 days [interquartile range (IQR): 223-534 days], a median weight of 8.9 kg (IQR: 7.6-10.5 kg) and 60.0% (1,011) were male. Complete follow-up data were available for 1,673 CR-TOF patients with a median follow-up duration of 49 months. Adjusted risks for the primary outcome and significant APG were lower for patients with normal PV morphology at follow up [adjusted hazard ratio (HR): 0.68; 95% CI: 0.46-0.98; adjusted HR: 0.22; 95% CI: 0.07-0.71, respectively]. The trend for the primary outcome during follow-up remained unchanged, even in subgroups and propensity score matching analyses. Conclusions: In this analysis of data from a large TOF cohort, patients with normal tricuspid PVs were associated with a decreased risk of the primary outcome and a lower risk of significant APG, as compared with patients with abnormal unicuspid or bicuspid PVs.
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Affiliation(s)
- Jinyang Liu
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xianchao Jiang
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Peng
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shoujun Li
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Yan
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiang Wang
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Cardiac Surgery, Yunnan Fuwai Cardiovascular Hospital, Beijing, China
| | - Zhimin Liu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Jiang X, Peng B, Liu J, Zhang H, Li S, Yan J, Wang Q. Impact of operator experience and volume on outcomes after complete repair for tetralogy of Fallot. Eur J Cardiothorac Surg 2021; 60:105-112. [PMID: 33724399 DOI: 10.1093/ejcts/ezab060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/05/2021] [Accepted: 01/15/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this study was to assess the impact of individual operator experience on outcomes after complete repair for tetralogy of Fallot. METHODS This is a retrospective cohort study. Consecutive patients who underwent TOF repair at a single institution were included and compared according to whether the primary operator was an experienced, high-volume operator (defined as an operator who performed at least 20 surgical procedures for congenital heart disease defined as complex by the Risk Adjustment for Congenital Heart Surgery classification per year for at least 3 consecutive years). The primary outcome was defined as a composite of death, or reintervention, or significant annular peak gradient, or significant pulmonary regurgitation. Multivariable logistic regression and Cox proportional-hazards model analyses were used to assess the relationships between operator experience and outcomes. RESULTS From January 2012 to December 2017, a total of 1760 patients with primary diagnosis of TOF underwent TOF repair by 37 operators. Of these, 5 operators (13.5%) were considered experienced, and 32 (86.5%) were considered less experienced. Complete follow-up data were available for 1728 complete repair for TOF patients with a median follow-up duration of 49 months; in 611 patients (35.4%), the surgery was performed by experienced operators, and in 1117 patients (64.6%), the surgery was performed by less experienced operators. Adjusted risks for the primary outcome and significant pulmonary regurgitation were lower for patients who were treated by experienced operators, both at discharge [adjusted odds ratio 0.67, 95% confidence interval (CI) 0.50-0.90; adjusted odds ratio 0.54, 95% CI 0.37-0.78, respectively] and at follow-up (adjusted hazard ratio 0.82, 95% CI 0.68-0.97; adjusted hazard ratio 0.70, 95% CI 0.56-0.87, respectively). The trend for the primary outcome during follow-up remained unchanged, even in most subgroups. CONCLUSIONS Increased surgeon experience is associated with improved risk-adjusted outcomes. These results have potentially important implications for individual training, quality improvement and hospital programmes in the context of complete repair for TOF. REGISTRATION NUMBER http://www.chictr.org.cn number, ChiCTR2000033234.
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Affiliation(s)
- Xianchao Jiang
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Peng
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinyang Liu
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Heng Zhang
- Department of Cardiac Surgery, Yunnan Fuwai Cardiovascular Hospital, Kunming, China
| | - Shoujun Li
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Yan
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiang Wang
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Cardiac Surgery, Yunnan Fuwai Cardiovascular Hospital, Kunming, China
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Nathan M, Levine JC, Van Rompay MI, Lambert LM, Trachtenberg FL, Colan SD, Adachi I, Anderson BR, Bacha EA, Eckhauser A, Gaynor JW, Graham EM, Goot B, Jacobs JP, John R, Kaltman JR, Kanter KR, Mery CM, LuAnn Minich L, Ohye R, Overman D, Pizarro C, Raghuveer G, Schamberger MS, Schwartz SM, Narasimhan SL, Taylor MD, Wang K, Newburger JW. Impact of Major Residual Lesions on Outcomes After Surgery for Congenital Heart Disease. J Am Coll Cardiol 2021; 77:2382-2394. [PMID: 33985683 PMCID: PMC8245007 DOI: 10.1016/j.jacc.2021.03.304] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/04/2021] [Accepted: 03/22/2021] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.
| | - Jami C Levine
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria I Van Rompay
- HealthCore, New England Research Institutes, Watertown, Massachusetts, USA
| | - Linda M Lambert
- Division of Pediatric Cardiology, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | | | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Iki Adachi
- Division of Congenital Heart Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Brett R Anderson
- Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York, USA
| | - Emile A Bacha
- Division of Cardiothoracic Surgery, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York, USA
| | - Aaron Eckhauser
- Division of Pediatric Cardiothoracic Surgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - J William Gaynor
- Division of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Eric M Graham
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Benjamin Goot
- Division of Pediatric Cardiology, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jeffrey P Jacobs
- Division of Cardiac Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA; Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Rija John
- Division of Congenital Heart Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Jonathan R Kaltman
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Kirk R Kanter
- Division of Pediatric Cardiac Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, Dell Children's Medical Center, University of Texas Dell Medical School, Austin, Texas, USA
| | - L LuAnn Minich
- Division of Pediatric Cardiology, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Richard Ohye
- Division of Pediatric Cardiac Surgery, C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - David Overman
- Division of Cardiovascular Surgery, Children's Minnesota, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, Minnesota, USA
| | - Christian Pizarro
- Division of Cardiac Surgery, Nemours Cardiac Center, Alfred I duPont Hospital for Children, Wilmington, Delaware, USA
| | - Geetha Raghuveer
- Heart Center, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Marcus S Schamberger
- Division of Pediatric Cardiology, Riley Hospital for Children, Indiana University, Indianapolis, Indiana, USA
| | - Steven M Schwartz
- Division of Cardiac Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shanthi L Narasimhan
- Division of Pediatric Cardiology, Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Michael D Taylor
- Division of Pediatric Cardiology, Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio, USA
| | - Ke Wang
- HealthCore, New England Research Institutes, Watertown, Massachusetts, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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Jiang X, Liu J, Peng B, Zhang H, Li S, Yan J, Wang Q. Impact of Annulus-Sparing on Surgical Adequacy of Pulmonary Valve in Complete Repair of Tetralogy of Fallot with Right Ventricular Outflow Tract Incision. Pediatr Cardiol 2021; 42:379-388. [PMID: 33156379 DOI: 10.1007/s00246-020-02493-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 10/30/2020] [Indexed: 11/24/2022]
Abstract
Today, strategy of repair remains controversial and rare analyses on annular integrity associated with outcomes in complete repair by RVOT incision were performed in a large TOF cohort in China. This is a retrospective cohort study involving patients with TOF who had undergone complete repair by RVOT incision between January 2012 and December 2017 in Fuwai hospital. The primary outcome was a composite of reintervention, significant pulmonary regurgitation (PR) and significant annular peak gradient (APG). Multivariate Cox proportional-hazards model analyses were used to assess the relationships between annular integrity and outcomes. In total, 1673 survival patients with the median age of 318 days were included, and 1002 were male. During a median follow-up of 49 months, 538 participants developed the primary outcome (27 reinterventions). Multivariate Cox analyses showed that compared with AS, TAP was associated with an increased risk of primary outcome (adjusted HR, 1.94 [95% CI 1.60-2.37]) and the results remained unchanged even in most subgroups defined. In secondary outcomes analyses, TAP is associated with a higher risk of reintervention (adjusted HR, 3.32 [95% CI 1.25-8.79]) and significant PR (adjusted HR, 2.51 [95% CI 2.00-3.16]). However, TAP is not associated with a decreased risk of significant APG (adjusted HR, 1.33 [95% CI 0.94-1.88]). PVA integrity preservation is important in complete repair of TOF with RVOT incision. TAP is associated with a higher risk of reintervention and significant PR, and with a similar risk of significant APG. Significant APG in AS patients at discharge has a downtrend over time.
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Affiliation(s)
- Xianchao Jiang
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167A, Beilishilu, Xi Cheng District, Beijing, China
| | - Jinyang Liu
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167A, Beilishilu, Xi Cheng District, Beijing, China
| | - Bo Peng
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167A, Beilishilu, Xi Cheng District, Beijing, China
| | - Heng Zhang
- Department of Cardiac Surgery, Yunnan Fuwai Cardiovascular Hospital, Kunming, China
| | - Shoujun Li
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167A, Beilishilu, Xi Cheng District, Beijing, China
| | - Jun Yan
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167A, Beilishilu, Xi Cheng District, Beijing, China
| | - Qiang Wang
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167A, Beilishilu, Xi Cheng District, Beijing, China. .,Department of Cardiac Surgery, Yunnan Fuwai Cardiovascular Hospital, Kunming, China.
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9
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O'Byrne ML, DeCost G, Katcoff H, Savla JJ, Chang J, Goldmuntz E, Groeneveld PW, Rossano JW, Faerber JA, Mercer-Rosa L. Resource Utilization in the First 2 Years Following Operative Correction for Tetralogy of Fallot: Study Using Data From the Optum's De-Identified Clinformatics Data Mart Insurance Claims Database. J Am Heart Assoc 2020; 9:e016581. [PMID: 32691679 PMCID: PMC7792257 DOI: 10.1161/jaha.120.016581] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Despite excellent operative survival, correction of tetralogy of Fallot frequently is accompanied by residual lesions that may affect health beyond the incident hospitalization. Measuring resource utilization, specifically cost and length of stay, provides an integrated measure of morbidity not appreciable in traditional outcomes. Methods and Results We conducted a retrospective cohort study, using de‐identified commercial insurance claims data, of 269 children who underwent operative correction of tetralogy of Fallot from January 2004 to September 2015 with ≥2 years of continuous follow‐up (1) to describe resource utilization for the incident hospitalization and subsequent 2 years, (2) to determine whether prolonged length of stay (>7 days) in the incident hospitalization was associated with increased subsequent resource utilization, and (3) to explore whether there was regional variation in resource utilization with both direct comparisons and multivariable models adjusting for known covariates. Subjects with prolonged incident hospitalization length of stay demonstrated greater resource utilization (total cost as well as counts of outpatient visits, hospitalizations, and catheterizations) after hospital discharge (P<0.0001 for each), though the number of subsequent operative and transcatheter interventions were not significantly different. Regional differences were observed in the cost of incident hospitalization as well as subsequent hospitalizations, outpatient visits, and the costs associated with each. Conclusions This study is the first to report short‐ and medium‐term resource utilization following tetralogy of Fallot operative correction. It also demonstrates that prolonged length of stay in the initial hospitalization is associated with increased subsequent resource utilization. This should motivate research to determine whether these differences are because of modifiable factors.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA.,Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research University of Pennsylvania Philadelphia PA
| | - Grace DeCost
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Hannah Katcoff
- Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA
| | - Jill J Savla
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Joyce Chang
- Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA.,Division of Rheumatology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Elizabeth Goldmuntz
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
| | - Peter W Groeneveld
- Division of General Internal Medicine Department of Medicine Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,Corporal Michael J. Crescenz VA Medical Center Philadelphia PA
| | - Joseph W Rossano
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA.,Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA
| | - Jennifer A Faerber
- Center for Pediatric Clinical Effectiveness The Children's Hospital of Philadelphia PA
| | - Laura Mercer-Rosa
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania Philadelphia PA
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10
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Nathan M, Trachtenberg FL, Van Rompay MI, Gaynor W, Kanter K, Ohye R, Bacha EA, Tweddell J, Schwartz SM, Minich LL, Mery CM, Colan SD, Levine J, Lambert LM, Newburger JW. The Pediatric Heart Network Residual Lesion Score Study: Design and objectives. J Thorac Cardiovasc Surg 2020; 160:218-223.e1. [PMID: 31870553 PMCID: PMC7225045 DOI: 10.1016/j.jtcvs.2019.10.146] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 10/28/2019] [Accepted: 10/30/2019] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass.
| | | | | | - William Gaynor
- Division of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Kirk Kanter
- Division of Pediatric Cardiac Surgery, Children's Health Care of Atlanta, Atlanta, Ga
| | - Richard Ohye
- Division of Pediatric Cardiac Surgery, C. S. Mott Children's Hospital, Ann Arbor, Mich
| | - Emile A Bacha
- Division of Cardiothoracic Surgery, New York Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - James Tweddell
- Division of Pediatric Cardiac Surgery, Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
| | - Steven M Schwartz
- Division of Cardiac Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - L LuAnn Minich
- Division of Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School/ Dell Children's Medical Center, Austin, Tex
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Jami Levine
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Linda M Lambert
- Division of Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
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11
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Shimada M, Hoashi T, Iida J, Ichikawa H. The Impact of Post-Graduate Year of Primary Surgeon on Technical Performance Score in Tetralogy of Fallot Repair. Circ J 2020; 84:495-500. [PMID: 32023573 DOI: 10.1253/circj.cj-19-0800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Masatoshi Shimada
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Takaya Hoashi
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Jun Iida
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
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12
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Lushaj EB, Bartlett HL, Lamers LJ, Arndt S, Hermsen J, Ralphe JC, Anagnostopoulos PV. Technical Performance Score Predicts Perioperative Outcomes in Complex Congenital Heart Surgery Performed in a Small-to-Medium-Volume Program. Pediatr Cardiol 2020; 41:88-93. [PMID: 31676956 DOI: 10.1007/s00246-019-02226-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/15/2019] [Indexed: 11/29/2022]
Abstract
As the quality of surgical outcomes depend on many factors, the development of validated tools to assess the different aspects of complex multidisciplinary teams' performance is crucial. The Technical Performance Score (TPS) has only been validated to correlate with outcomes in large-volume surgical programs. Here we assess the utility of TPS in correlation to perioperative outcomes for complex congenital heart surgeries (CHS) performed in a small-to-medium-volume program. 673 patients underwent CHS from 4/2012 to 12/2017 at our institution. Of those, 122 were STAT 4 and STAT 5. TPS was determined for each STAT 4 and STAT 5 operation using discharge echocardiogram: 1 = optimal, 2 = adequate, 3 = inadequate. Patient outcomes were compared including mortality, length of stay, ventilation times, and adverse events. 69 patients (57%) were neonates, 32 (26%) were infants, 17 (14%) were children, 4 (3%) were adults. TPS class 1 was assigned to 85 (70%) operations, TPS class 2 was assigned to 25 (20%) operations, and TPS class 3 was assigned to 12 (10%) operations. TPS was associated with re-intubation, ICU length of stay, postoperative length of stay, and mortality. TPS did not correlate with unplanned 30-day readmissions, need for reoperation, and inotropic score. Technical performance score was associated with perioperative outcomes and is a useful tool to assess the adequacy of repair for high complexity CHS in a small-to-medium-volume surgical program. TPS should be a part of program review in congenital heart programs of all sizes to identify strategies that may reduce postoperative morbidity and potentially improve long-term outcomes.
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Affiliation(s)
- Entela B Lushaj
- Department of Surgery-Cardiothoracic, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Heather L Bartlett
- Department of Pediatrics-Cardiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Luke J Lamers
- Department of Pediatrics-Cardiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Shannon Arndt
- University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Joshua Hermsen
- Department of Surgery-Cardiothoracic, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - J Carter Ralphe
- Department of Pediatrics-Cardiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Petros V Anagnostopoulos
- Department of Pediatrics-Cardiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA. .,Division of Cardiothoracic Surgery, School of Medicine and Public Health, University of Wisconsin, 600 Highland Avenue, Madison, WI, 53792, USA.
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13
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Corno AF. Valve-sparing in tetralogy of Fallot: how to open the pulmonary valve. Asian Cardiovasc Thorac Ann 2019; 27:710-712. [PMID: 31500442 DOI: 10.1177/0218492319876189] [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
Pulmonary valve stenosis is characterized by high attachment of the commissures to the pulmonary arterial wall. Thus, the tethering of the fused leaflets should be separated from their anomalous insertion, with increased leaflet mobilization in each commissure, and the fusion between the leaflets should be incised until reaching the pulmonary annulus, providing complete opening of the pulmonary valve. This extended opening of pulmonary valve tethering can provide an additional increase of a few millimeters in the diameter of the pulmonary annulus, enough to completely relieve right ventricular outflow tract obstruction without creating pulmonary valve regurgitation.
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Affiliation(s)
- Antonio F Corno
- East Midlands Congenital Heart Center, Glenfield Hospital, Leicester, UK
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14
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Bellsham-Revell HR, Deri A, Caroli S, Durward A, Miller OI, Mathur S, Saundankar J, Anderson DR, Austin BC, Salih C, Pushparajah K, Simpson JM. Application of the Boston Technical Performance Score to intraoperative echocardiography. Echo Res Pract 2019; 6:63-70. [PMID: 31413860 PMCID: PMC6689121 DOI: 10.1530/erp-19-0032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 07/09/2019] [Indexed: 11/11/2022] Open
Abstract
Background The Technical Performance Score (TPS) developed by Boston Children’s Hospital showed surgical outcomes correlate with adequacy of technical repair when implemented on pre-discharge echocardiograms. We applied this scoring system to intraoperative imaging in a tertiary UK congenital heart surgical centre. Methods After a period of training, intraoperative TPS (epicardial and/or transesophageal echocardiography) was instituted. TPS was used to inform intraoperative discussions and recorded on a custom-made database using the previously published scoring system. After a year, we reviewed the feasibility, results and relationship between the TPS and mortality, extubation time and length of stay. Results From 01 September 2015 to 04 July 2016, there were 272 TPS procedures in 251 operations with 208 TPS recorded. Seven patients had surgery with no documented TPS, three had operations with no current TPS score template available. Patients left the operating theatre with TPS optimal in 156 (75%), adequate 34 (16%) and inadequate 18 (9%). Of those with an optimal score on leaving theatre, ten had more than one period of cardiopulmonary bypass. All four deaths <30 days after surgery (1.9%) had optimal TPS. There was a statistically significant difference in extubation times in the RACHS category 4 patients (3 days vs 5 days, P < 0.05) and in PICU and total length of stay in the RACHS category three patients (2 and 8 days vs 12.5 and 21.5 days respectively) if leaving theatre with an inadequate result. Conclusions Application of intraoperative TPS is feasible and provides a way of objectively recording intraoperative imaging assessment of surgery. An ‘inadequate’ TPS did not predict mortality but correlated with a longer ventilation time and longer length of stay compared to those with optimal or adequate scores.
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Affiliation(s)
| | - Antigoni Deri
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - Silvia Caroli
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - Andrew Durward
- Paediatric Airway Service, Evelina London Children's Hospital, London, UK
| | - Owen I Miller
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - Sujeev Mathur
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - Jelena Saundankar
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - David R Anderson
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - B Conal Austin
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - Caner Salih
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - Kuberan Pushparajah
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK.,Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - John M Simpson
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK.,Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
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15
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A Long-Term Survivor with Tetralogy of Fallot Treated Only with the Classical Blalock-Taussig Shunt. Case Rep Cardiol 2018; 2018:5262745. [PMID: 30210878 PMCID: PMC6120336 DOI: 10.1155/2018/5262745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 07/21/2018] [Accepted: 08/01/2018] [Indexed: 11/26/2022] Open
Abstract
The prognosis of tetralogy of Fallot (TOF) treated only with Blalock-Taussig shunt (BTS) operation is unclear. A woman with TOF underwent classic BTS operation at 10 years of age. Despite no medication, she delivered two children and worked without apparent heart failure. At 72 years of age, she complained of dyspnea on exertion and leg edema. The cardiac angiogram revealed a well-patent BTS and severely stenotic right ventricular outflow tract. Right heart catheterization showed adequately maintained pulmonary blood flow with slight pulmonary arterial hypertension. Her unexpected yet favorable outcome reaffirms the importance of structural and functional self-adaptation even with cyanosis. If she had undergone a valve-sparing corrective surgery in adolescence, much better quality of life and outcome could have been expected.
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16
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Valve-sparing repair with intraoperative balloon dilation in tetralogy of Fallot: Midterm results and therapeutic implications. J Thorac Cardiovasc Surg 2018; 155:1163-1173.e4. [DOI: 10.1016/j.jtcvs.2017.08.147] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 07/23/2017] [Accepted: 08/28/2017] [Indexed: 11/18/2022]
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17
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I am at my best when I slow down and that is what I will teach my trainees! J Thorac Cardiovasc Surg 2017; 154:596-597. [PMID: 28412119 DOI: 10.1016/j.jtcvs.2017.03.009] [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: 03/01/2017] [Accepted: 03/02/2017] [Indexed: 11/21/2022]
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18
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Lodin D, Mavrothalassitis O, Haberer K, Sunderji S, Quek RGW, Peyvandi S, Moon-Grady A, Karamlou T. Revisiting the utility of technical performance scores following tetralogy of Fallot repair. J Thorac Cardiovasc Surg 2017; 154:585-595.e3. [PMID: 28461051 DOI: 10.1016/j.jtcvs.2017.02.066] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 01/18/2017] [Accepted: 02/08/2017] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Daud Lodin
- San Juan Bautista School of Medicine, Caguas, Puerto Rico
| | | | - Kim Haberer
- Division of Pediatric Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, Calif
| | - Sherzana Sunderji
- Division of Pediatric Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, Calif
| | - Ruben G W Quek
- Global Health Economics, Amgen Inc, Thousand Oaks, Calif
| | - Shabnam Peyvandi
- Division of Pediatric Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, Calif
| | - Anita Moon-Grady
- Division of Pediatric Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, Calif
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery, Phoenix Children's Hospital, Phoenix, Ariz.
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19
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Rutz T, Ghandour F, Meierhofer C, Naumann S, Martinoff S, Lange R, Ewert P, Stern HC, Fratz S. Evolution of right ventricular size over time after tetralogy of Fallot repair: a longitudinal cardiac magnetic resonance study. Eur Heart J Cardiovasc Imaging 2016; 18:364-370. [DOI: 10.1093/ehjci/jew273] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 09/23/2016] [Indexed: 11/12/2022] Open
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20
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Cunningham MEA, Donofrio MT, Peer SM, Zurakowski D, Jonas RA, Sinha P. Optimal Timing for Elective Early Primary Repair of Tetralogy of Fallot: Analysis of Intermediate Term Outcomes. Ann Thorac Surg 2016; 103:845-852. [PMID: 27692918 DOI: 10.1016/j.athoracsur.2016.07.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 06/14/2016] [Accepted: 07/05/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND We have previously demonstrated that early primary repair of tetralogy of Fallot with pulmonary stenosis (TOF) can be safely performed without increase in hospital resource utilization or compromise to surgical technical performance scores (TPS). We sought to identify the optimal timing for elective early primary repair of TOF with respect to intermediate-term reintervention. METHODS Retrospective review of all patients with TOF undergoing elective primary repair between September 2004 and December 2013 was performed. Patients were stratified into reintervention group or no reintervention group. Multivariable Cox regression analysis identified independent predictors of reintervention. Youden's J-index in receiver operating characteristic analysis identified optimal age cutoff predictive of reintervention. Kaplan-Meier analysis with the log-rank test compared reintervention rates stratified by age and TPS. RESULTS A total of 129 patients with median (interquartile range) age and weight of 78 days (56 to 111) and 5 kg (4.1 to 5.7), respectively, underwent primary repair. After a median (interquartile range) follow-up of 2.3 years (0.1 to 4.6), 18 patients (14%) required a total of 22 reinterventions. Youden's J-index revealed significantly lower risk of intermediate-term reintervention when repaired after 55 days of age (8% for >55 days old versus 31% for ≤55 days of age). Multivariable Cox regression identified age 55 days and younger (hazard ratio [HR] 4.5, 95% confidence interval [CI] 1.6 to 12.8, p = 0.004), valve sparing repair (HR 15.3, 95% CI 1.8 to 128.5, p < 0.001), residual right ventricular outflow tract (RVOT) gradient (HR 1.11, 95% CI 1.1 to 1.2, p < 0.001), and inadequate TPS (HR 21.5, 95% CI 7.4 to 63, p < 0.001) as independent predictors of overall intermediate-term reintervention. CONCLUSIONS Elective repair in patients greater than 55 days of age, irrespective of size of the patient, can be safely performed without any increase in reintervention rates. Both residual peak RVOT gradient and TPS are effective in identifying patients at increased risk of reintervention.
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Affiliation(s)
- Michael E A Cunningham
- Department of Cardiology, Children's National Health System, Washington, District of Columbia
| | - Mary T Donofrio
- Department of Cardiology, Children's National Health System, Washington, District of Columbia
| | - Syed Murfad Peer
- Department of Cardiovascular Surgery, Children's National Health System, Washington, District of Columbia
| | - David Zurakowski
- Departments of Anesthesia and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Richard A Jonas
- Department of Cardiovascular Surgery, Children's National Health System, Washington, District of Columbia
| | - Pranava Sinha
- Department of Cardiovascular Surgery, Children's National Health System, Washington, District of Columbia.
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21
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Cunningham MEA, Donofrio MT, Peer SM, Zurakowski D, Jonas R, Sinha P. Influence of Age and Weight on Technical Repair of Tetralogy of Fallot. Ann Thorac Surg 2016; 102:864-869. [PMID: 27154147 DOI: 10.1016/j.athoracsur.2016.02.087] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 02/21/2016] [Accepted: 02/25/2016] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
| | - Mary T Donofrio
- Department of Cardiology, Children's National Health System, Washington, DC
| | - Syed Murfad Peer
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC
| | - David Zurakowski
- Departments of Anesthesia and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Richard Jonas
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC
| | - Pranava Sinha
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC.
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