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Chiu P, El Azfi A, Kwon B, Emani SM, Marx G, del Nido PJ. Experience Curve With the Cone Procedure for Ebstein's Anomaly: Effect on Cost and Resource Utilization. JACC. ADVANCES 2024; 3:101104. [PMID: 39105113 PMCID: PMC11299563 DOI: 10.1016/j.jacadv.2024.101104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 06/09/2024] [Indexed: 08/07/2024]
Abstract
Background The volume-outcome relationship is well-known in health care. The Experience Curve, initially developed by the Boston Consulting Group for manufacturing, offers insight on this relationship and has never before been applied to health care. Objectives The purpose of this study was to determine the effect of experience on cost and resource utilization for the Cone procedure. Methods We performed a retrospective review of patients who underwent Cone reconstruction for Ebstein's anomaly at Boston Children's Hospital between October 2010 and October 2021. Cardiopulmonary bypass time and aortic cross clamp time over time were evaluated using exponential regression to assess the surgeon-level learning curve. At the hospital level, length of stay and cost over time were assessed using exponential regression. Results There were 115 patients included in the study. Median hospital length of stay was 7.9 days (IQR: 6.4-10.2 days) with a decline of 3.3% per year. Median intensive care unit [ICU] length of stay was 3.2 days (IQR: 2-5.7 days) with a decline of 10.5% per year. Adjusted direct costs indexed to 2020 prices fell by 4% per year. There was no statistically significant change in cardiopulmonary bypass or aortic cross clamp time. In mediation analysis, the reduction in cost was completely accounted for in the decline in ICU length of stay. ICU length of stay was correlated with duration of intubation. Conclusions Increasing familiarity with Ebstein's anomaly and Cone reconstruction led to a reduction in resource utilization.
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Affiliation(s)
- Peter Chiu
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Abdelilah El Azfi
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Brandon Kwon
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Sitaram M. Emani
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Gerald Marx
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Pedro J. del Nido
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
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Park I, Jun TG, Yang JH, Kang IS, Huh J, Song J, Lee OJ. Long-Term Outcomes of Modified Cone Reconstruction for Ebstein's Anomaly in Pediatric Patients in a Single Center. Korean Circ J 2024; 54:78-90. [PMID: 38196117 PMCID: PMC10864249 DOI: 10.4070/kcj.2023.0200] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/23/2023] [Accepted: 11/24/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND AND OBJECTIVE We aimed to investigate long-term clinical and echocardiographic outcomes, including tricuspid valve durability, annular growth, and left ventricular reverse remodeling, after modified cone reconstruction in patients with Ebstein's anomaly. METHODS This was a retrospective analysis of all pediatric patients who underwent modified cone reconstruction for Ebstein's anomaly at a single tertiary center between January 2005 and June 2021. RESULTS A total of 14 pediatric patients underwent modified cone reconstruction for Ebstein's anomaly; the median age was 5.8 years (range, 0.01-16.6). There were three patients (21.4%) with Carpentier type B, ten patients with Carpentier type C (71.4%), and one patient with Carpentier type D (7.1%). There was no early or late mortality, arrhythmia, or readmission for heart failure at a 10-year follow-up. There were no cases of more than mild tricuspid stenosis or more than moderate tricuspid regurgitation during the study period, except for one patient with severe tricuspid regurgitation who underwent reoperation. The z value for tricuspid valve annular size significantly decreased immediately after the operation (2.46 vs. -1.15, p<0.001). However, from 1 year to 7 years after surgery, the z values were maintained between -1 and +1. Left ventricular end-systolic volume, end-diastolic volume, and stroke volume increased after surgery and remained elevated until seven years postoperatively. CONCLUSIONS Ebstein's anomaly in children can be repaired by modified cone reconstruction with low mortality and morbidity, good tricuspid valve durability, and annular growth relative to somatic growth.
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Affiliation(s)
- Ilkun Park
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae-Gook Jun
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Ji-Hyuk Yang
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - I-Seok Kang
- Department of Pediatrics, Cardiovascular Imaging Center, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - June Huh
- Department of Pediatrics, Cardiovascular Imaging Center, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jinyoung Song
- Department of Pediatrics, Cardiovascular Imaging Center, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ok Jeong Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Park HK. Cone Reconstruction for Ebstein's Anomaly: Is It Durable in Pediatric Patients? Korean Circ J 2024; 54:91-92. [PMID: 38346696 PMCID: PMC10864250 DOI: 10.4070/kcj.2024.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/11/2024] [Indexed: 02/16/2024] Open
Affiliation(s)
- Han Ki Park
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Boyd R, Kalfa D, Nguyen S, Setton M, Shah A, Karamichalis J, Lewis M, Wassercug NZ, Rosenbaum M, Bacha E. Comparative outcomes and risk analysis after cone repair or tricuspid valve replacement for Ebstein's anomaly. JTCVS OPEN 2023; 14:372-384. [PMID: 37425446 PMCID: PMC10328840 DOI: 10.1016/j.xjon.2023.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 02/26/2023] [Accepted: 03/02/2023] [Indexed: 07/11/2023]
Abstract
Objective Ebstein's anomaly is a rare congenital heart malformation for which surgical and medical management are still controversial. The cone repair has transformed surgical outcomes in many of these patients. We aimed to present our results on the outcomes of patients with Ebstein's anomaly who underwent a cone repair or tricuspid valve replacement. Methods A total of 85 patients who underwent a cone repair (mean age, 16.5 years) or tricuspid valve replacement (mean age, 40.8 years) between 2006 and 2021 were included. Univariate, multivariate, and Kaplan-Meier analyses were used to evaluate operative and long-term outcomes. Results Residual/recurrent greater than mild-to-moderate tricuspid regurgitation at discharge was higher after cone repair compared with tricuspid valve replacement (36% vs 5%; P = .010). However, at last follow-up, the risk of greater than mild-to-moderate tricuspid regurgitation was not different between groups (35% in the cone group vs 37% in the tricuspid valve replacement group; P = .786). The tricuspid valve replacement group had a higher risk of tricuspid valve reoperation (37% vs 9%; P = .005) and tricuspid stenosis (21% vs 0%; P = .002) compared with the cone repair group. Kaplan-Meier freedom from reintervention was 97%, 91%, and 91% at 2, 4, and 6 years after cone repair, respectively, and 84%, 74%, and 68% at 2, 4, and 6 years after tricuspid valve replacement, respectively (P = .0191). At last follow-up, right ventricular function was significantly worse from baseline in the tricuspid valve replacement group (P = .0294). There were no statistical differences between age-stratified cohorts or surgeon volume in the cone repair group. Conclusions The cone procedure offers excellent results, with stable tricuspid valve function and low reintervention and death rates at last follow-up. The rate of greater than mild-to-moderate residual tricuspid regurgitation at discharge was higher after cone repair compared with tricuspid valve replacement, but this did not expose the patient to a higher risk of reoperation or death at last follow-up. Tricuspid valve replacement was associated with a significantly higher risk of tricuspid valve reoperation and tricuspid valve stenosis, and worse right ventricular function at last follow-up.
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Affiliation(s)
- Rebekah Boyd
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children Hospital New York-Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - David Kalfa
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children Hospital New York-Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Stephanie Nguyen
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children Hospital New York-Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Matan Setton
- Division of Pediatric Cardiology, Morgan Stanley Children Hospital New York-Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Amee Shah
- Division of Pediatric Cardiology, Morgan Stanley Children Hospital New York-Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - John Karamichalis
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children Hospital New York-Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Matthew Lewis
- Division of Cardiology, New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Noa Zemer Wassercug
- Division of Cardiology, New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Marlon Rosenbaum
- Division of Cardiology, New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Emile Bacha
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children Hospital New York-Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
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Ebstein's Anomaly: From Fetus to Adult-Literature Review and Pathway for Patient Care. Pediatr Cardiol 2022; 43:1409-1428. [PMID: 35460366 DOI: 10.1007/s00246-022-02908-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 04/04/2022] [Indexed: 10/18/2022]
Abstract
Ebstein's anomaly, first described in 1866 by Dr William Ebstein, accounts for 0.3-0.5% of congenital heart defects and represents 40% of congenital tricuspid valve abnormalities. Ebstein's anomaly affects the development of the tricuspid valve with widely varying morphology and, therefore, clinical presentation. Associated congenital cardiac lesions tend to be found more often in younger patients and may even be the reason for presentation. Presentation can vary from the most extreme form in fetal life, to asymptomatic diagnosis late in adult life. The most symptomatic patients need intensive care support in the neonatal period. This article summarizes and analyzes the literature on Ebstein's anomaly and provides a framework for the investigation, management, and follow-up of these patients, whether they present via fetal detection or late in adult life. For each age group, the clinical presentation, required diagnostic investigations, natural history, and management are described. The surgical options available for patients with Ebstein's anomaly are detailed and analyzed, starting from the initial mono-leaflet repairs to the most recent cone repair and its modifications. The review also assesses the effects of pregnancy on the Ebstein's circulation, and vice versa, the effects of Ebstein's on pregnancy outcomes. Finally, two attached appendices are provided for a structured echocardiogram protocol and key information useful for comprehensive Multi-Disciplinary Team discussion.
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Stephens EH, Dearani JA. Commentary: Ebstein Anomaly - Still So Many Unanswered Questions. Semin Thorac Cardiovasc Surg 2021; 34:213-214. [PMID: 34000429 DOI: 10.1053/j.semtcvs.2021.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/28/2021] [Indexed: 11/11/2022]
Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
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