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Kimura S, Shimizu K, Izumi K, Kanazawa T, Mizuno K, Iwasaki T, Morimatsu H. Regional Cerebral Oxygen Saturation and Estimated Oxygen Extraction Ratio as Predictive Markers of Major Adverse Events in Infants with Congenital Heart Disease. Pediatr Cardiol 2024; 45:1398-1406. [PMID: 37029812 DOI: 10.1007/s00246-023-03158-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/28/2023] [Indexed: 04/09/2023]
Abstract
Regional cerebral oxygen saturation (ScO2) determined by near-infrared spectroscopy, monitoring both arterial and venous blood oxygenation of the brain, could reflect the balance between oxygen delivery and consumption. The aim of this study was to determine the predictabilities of ScO2 and estimated oxygen extraction ratio (eO2ER) with outcomes in infants with congenital heart disease (CHD). This study was a two-center, retrospective study of patients at 12 months of age or younger with CHD who underwent cardiac surgery. The primary outcome was a composite of one or more major adverse events (MAEs) after surgery: death from any cause, circulatory collapse that needed cardiopulmonary resuscitation, and requirement for extracorporeal membrane oxygenation. Based on the assumptions of arterial to venous blood ratio, eO2ER was calculated. A total of 647 cases were included in this study. MAEs occurred in 16 patients (2.5%). There were significant differences in post-bypass ScO2 [46.61 (40.90, 52.05) vs. 58.52 (51.52, 66.08), p < 0.001] and post-bypass eO2ER [0.66 (0.60, 0.78) vs. 0.52 (0.43, 0.61), p < 0.001] between patients with MAEs and patients without MAEs. Area under the receiver operating curve (AUROC) of post-bypass ScO2 was 0.818 (95% confidence interval: 0.747-0.889), AUROC of post-bypass eO2ER was 0.783 (0.697-0.870) and AUROC of post-bypass maximum serum lactate level was 0.635 (0.525-0.746). Both ScO2 and eO2ER, especially after weaning off bypass, are acceptable predictive markers for predicting MAEs after cardiac surgery in infants.(227 words).
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Affiliation(s)
- Satoshi Kimura
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan.
| | - Kazuyoshi Shimizu
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| | - Kaoru Izumi
- Department of Anesthesia, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha, Higashi-Ku, Fukuoka, 813-0017, Japan
| | - Tomoyuki Kanazawa
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| | - Keiichiro Mizuno
- Department of Anesthesia, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha, Higashi-Ku, Fukuoka, 813-0017, Japan
| | - Tatsuo Iwasaki
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
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Kong F, Stocker S, Choi PS, Ma M, Ennis DB, Marsden AL. SDF4CHD: Generative modeling of cardiac anatomies with congenital heart defects. Med Image Anal 2024; 97:103293. [PMID: 39146700 PMCID: PMC11372630 DOI: 10.1016/j.media.2024.103293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 05/07/2024] [Accepted: 07/30/2024] [Indexed: 08/17/2024]
Abstract
Congenital heart disease (CHD) encompasses a spectrum of cardiovascular structural abnormalities, often requiring customized treatment plans for individual patients. Computational modeling and analysis of these unique cardiac anatomies can improve diagnosis and treatment planning and may ultimately lead to improved outcomes. Deep learning (DL) methods have demonstrated the potential to enable efficient treatment planning by automating cardiac segmentation and mesh construction for patients with normal cardiac anatomies. However, CHDs are often rare, making it challenging to acquire sufficiently large patient cohorts for training such DL models. Generative modeling of cardiac anatomies has the potential to fill this gap via the generation of virtual cohorts; however, prior approaches were largely designed for normal anatomies and cannot readily capture the significant topological variations seen in CHD patients. Therefore, we propose a type- and shape-disentangled generative approach suitable to capture the wide spectrum of cardiac anatomies observed in different CHD types and synthesize differently shaped cardiac anatomies that preserve the unique topology for specific CHD types. Our DL approach represents generic whole heart anatomies with CHD type-specific abnormalities implicitly using signed distance fields (SDF) based on CHD type diagnosis. To capture the shape-specific variations, we then learn invertible deformations to morph the learned CHD type-specific anatomies and reconstruct patient-specific shapes. After training with a dataset containing the cardiac anatomies of 67 patients spanning 6 CHD types and 14 combinations of CHD types, our method successfully captures divergent anatomical variations across different types and the meaningful intermediate CHD states across the spectrum of related CHD diagnoses. Additionally, our method demonstrates superior performance in CHD anatomy generation in terms of CHD-type correctness and shape plausibility. It also exhibits comparable generalization performance when reconstructing unseen cardiac anatomies. Moreover, our approach shows potential in augmenting image-segmentation pairs for rarer CHD types to significantly enhance cardiac segmentation accuracy for CHDs. Furthermore, it enables the generation of CHD cardiac meshes for computational simulation, facilitating a systematic examination of the impact of CHDs on cardiac functions.
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Affiliation(s)
- Fanwei Kong
- Institute for Computational and Mathematical Engineering, Stanford University, Stanford, CA, USA; Department of Pediatrics, Stanford University, Stanford, CA, USA; Cardiovascular Institute, Stanford University, Stanford, CA, USA.
| | - Sascha Stocker
- Department of Radiology, Stanford University, Stanford, CA, USA; Institute for Biomedical Engineering, ETH Zurich and University Zurich, Zurich, Switzerland
| | - Perry S Choi
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Michael Ma
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Daniel B Ennis
- Cardiovascular Institute, Stanford University, Stanford, CA, USA; Department of Radiology, Stanford University, Stanford, CA, USA
| | - Alison L Marsden
- Institute for Computational and Mathematical Engineering, Stanford University, Stanford, CA, USA; Department of Pediatrics, Stanford University, Stanford, CA, USA; Cardiovascular Institute, Stanford University, Stanford, CA, USA; Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA.
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El-Amin A, Koehlmoos T, Yue D, Chen J, Cho NY, Benharash P, Franzini L. The Association of High-Quality Hospital Use on Health Care Outcomes for Pediatric Congenital Heart Defects in a Universal Health Care System. Mil Med 2024; 189:e2163-e2169. [PMID: 38364865 DOI: 10.1093/milmed/usae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/18/2024] [Accepted: 01/29/2024] [Indexed: 02/18/2024] Open
Abstract
INTRODUCTION Congenital heart disease (CHD) has an incidence of 0.8% to 1.2% worldwide, making it the most common birth defect. Researchers have compared high-volume to low-volume hospitals and found significant hospital-level variation in major complications, health resource utilization, and mortality after CHD surgery. In addition, researchers found critical CHD patients at low-volume/non-teaching facilities to be associated with higher odds of inpatient mortality when compared to CHD patients at high-volume/teaching hospitals (odds ratio 1.76). We examined the effects of high-quality hospital (HQH) use on health care outcomes and health care costs in pediatric CHD care using an instrumental variable (IV) approach. MATERIALS AND METHODS Using nationwide representative claim data from the United States Military Health System from 2016 to 2020, TRICARE beneficiaries with a diagnosis of CHD were tabulated based on relevant ICD-10 (International Classification of Diseases, 10th revision) codes. We examined the relationships between annual readmissions, annual emergency room (ER) use, and mortality and HQH use. We applied both the naive linear probability model (LPM), controlling for the observed patient and hospital characteristics, and the two-stage least squares (2SLS) model, accounting for the unobserved confounding factors. The differential distance between the patient and the closest HQH at the index date and the patient and nearest non-HQH was used as the IV. This protocol was approved by the Institutional Review Board at the University of Maryland, College Park (Approval Number: 1576246-2). RESULTS The naive LPM indicated that HQH use was associated with a higher probability of annual readmissions (marginal effect, 18%; 95% CI, 0.12 to 0.23). The naive LPM indicated that HQH use was associated with a higher probability of mortality (marginal effect, 2.2%; 95% CI, 0.01 to 0.03). Using the differential distance of closest HQH and non-HQH, we identified a significant association between HQH use and annual ER use (marginal effect, -14%; 95% CI, -0.24 to -0.03). CONCLUSIONS After controlling for patient-level and facility-level covariates and adjusting for endogeneity, (1) HQH use did not increase the probability of more than one admission post 1-year CHD diagnosis, (2) HQH use lowered the probability of annual ER use post 1-year CHD diagnosis, and (3) HQH use did not increase the probability of mortality post 1-year CHD diagnosis. Patients who may have benefited from utilizing HQH for CHD care did not, alluding to potential barriers to access, such as health insurance restrictions or lack of patient awareness. Although we used hospital quality rating for congenital cardiac surgery as reported by the Society of Thoracic Surgeons, the contributing data span a 4-year period and may not reflect real-time changes in center performance. Since this study focused on inpatient care within the first-year post-initial CHD diagnosis, it may not reflect the full range of health system utilization. It is necessary for clinicians and patient advocacy groups to collaborate with policymakers to promote the development of an overarching HQH designation authority for CHD care. Such establishment will facilitate access to HQH for military beneficiary populations suffering from CHD.
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Affiliation(s)
- Amber El-Amin
- Center for Health Services Research, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
| | - Tracey Koehlmoos
- Center for Health Services Research, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
| | - Dahai Yue
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
| | - Jie Chen
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA 90024, USA
| | - Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA 90024, USA
- Department of Surgery, University of California, Los Angeles, CA 90024, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA 90024, USA
- Department of Surgery, University of California, Los Angeles, CA 90024, USA
| | - Luisa Franzini
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
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du Toit D, Swanson LC, Salie S, Perkins S, Basera W, Lawrenson JB, Aldersley T, Brooks A, Zühlke LJ. Outcomes Following Neonatal Cardiac Surgery in Cape Town, South Africa. World J Pediatr Congenit Heart Surg 2024:21501351241268559. [PMID: 39205439 DOI: 10.1177/21501351241268559] [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: 09/04/2024]
Abstract
BACKGROUND Neonatal Cardiac Surgery has developed significantly since its advent, with improved outcomes, survival, and physiological repair. Limited programs offer neonatal cardiac surgery in emerging economies. We report our experience with neonates undergoing cardiac surgery in our cardiac surgery program. METHODS We performed a secondary data analysis on all neonates aged ≤ 30 days undergoing congenital cardiac surgery from April 1, 2017 to March 31, 2020, including outcomes up to 30-days post-surgery. RESULTS A total of 859 patients underwent cardiac surgery at our center, of these 81 (9.4%) were neonates. The proportion of neonates increased annually (8.7%, 9.6%, and 10.2%). There were 49 (60%) male patients, and 32 (40%) had surgery in the second week of life. Fourteen (17%) were premature, four (5%) had a major chromosomal abnormality, five (6%) a major medical illness, and eight (10%) a major noncardiac structural anomaly. The Risk Adjustment for Congenital Heart Surgery (RACHS) categorization of surgery was predominantly RACHS 3; n = 28 (35%) and 4; n = 23 (29%). Hours in the intensive care unit (ICU) were extensive; median 189 [interquartile range (IQR): 114-286] as were hours of ventilation; median 95 [IQR 45-163]. Almost 60% (n = 48) of procedures were complicated by sepsis, as defined in our database. The in-hospital mortality rate was 16% (n = 13); the 30-day mortality rate was 19.8% (n = 16). CONCLUSION The proportion of neonates in our service increased over the period. Focused strategies to shorten prolonged ICU stay and decrease rates of bacterial sepsis in neonates are needed. A multidisciplinary, collaborative heart-team approach is crucial for best outcomes.
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Affiliation(s)
- Derrik du Toit
- Department of Pediatrics and Child Health, Red Cross War Memorial Children's Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Lenise C Swanson
- Division of Pediatric Cardiology, Department of Pediatrics and Child Health, Red Cross War Memorial Children's Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, South Africa
| | - Shamiel Salie
- Department of Pediatrics and Child Health, Red Cross War Memorial Children's Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Susan Perkins
- Division of Pediatric Cardiology, Department of Pediatrics and Child Health, Red Cross War Memorial Children's Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, South Africa
| | - Wisdom Basera
- School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, South Africa
- Burden of Disease Research Unit, South African Medical Research Council Francie Van Zijl Drive, Cape Town, South Africa
| | - John B Lawrenson
- Division of Pediatric Cardiology, Department of Pediatrics and Child Health, University of Stellenbosch, Cape Town, South Africa
| | - Thomas Aldersley
- Division of Pediatric Cardiology, Department of Pediatrics and Child Health, Red Cross War Memorial Children's Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, South Africa
| | - Andre Brooks
- Chris Barnard Division of Cardiothoracic Surgery, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, South Africa
| | - Liesl J Zühlke
- Division of Pediatric Cardiology, Department of Pediatrics and Child Health, Red Cross War Memorial Children's Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, South Africa
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, South Africa
- South African Medical Research Council Francie Van Zijl Drive, Cape Town, South Africa
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Terol C, Hagen J, Rammeloo L, Kuipers IM, Blom NA, ten Harkel ADJ. Prognostic value of cardiopulmonary exercise test in children with congenital heart defects. Open Heart 2024; 11:e002820. [PMID: 39160087 PMCID: PMC11337671 DOI: 10.1136/openhrt-2024-002820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 07/12/2024] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND Cardiopulmonary exercise testing (CPET) has an important prognostic value in adults with different congenital heart defects (CHDs) and is a useful tool for risk stratification and clinical decision-making. In this retrospective study, we studied the prognostic value of CPET in paediatric patients with CHD. METHODS 411 CPET performed by paediatric patients with different CHDs were evaluated in this retrospective study. Medical records were reviewed to determine the presence of cardiac events. Participants were classified using the 2018 AHA/ACC guideline for the management of adults with CHD that combines anatomical complexity and current physiological stage. RESULTS 411 patients with a median age at test of 12 years, 51 patients with simple CHD, 170 patients with moderate complexity CHD and 190 with high complexity CHD underwent CPET. Overall, CPET parameters were lower than the reference values (%predicted VO2peak=75% and %predicted oxygen uptake efficiency slope (OUES)=79%), showing worst exercise capacity in the most complex types of CHD (Group III: %predicted VO2peak=72% and %predicted OUES=75%). Seventy-one patients presented with cardiac events at a median time from CPET to first event of 28 months. Patients with cardiac events had lower exercise performance as compared with patients without cardiac events as determined by the submaximal variables (%predicted OUES: HR=2.6 (1.5-4.4), p<0.001 and VE/VCO2: HR=2.2 (1.4-3.5), p=0.001). CONCLUSION Reduced exercise capacity at young age is related to a higher probability of future cardiovascular events in paediatric patients with CHD. Submaximal exercise variables can be used instead when maximal exercise cannot be achieved.
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Affiliation(s)
- Covadonga Terol
- Department of Paediatrics, Division of Paediatric Cardiology, LUMC, Leiden, The Netherlands
| | - Juliette Hagen
- Department of Paediatrics, Division of Paediatric Cardiology, LUMC, Leiden, The Netherlands
| | - Lukas Rammeloo
- Department of Paediatrics, Division of Paediatric Cardiology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Irene M Kuipers
- Department of Paediatrics, Division of Paediatric Cardiology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Nicolaas A Blom
- Department of Paediatrics, Division of Paediatric Cardiology, LUMC, Leiden, The Netherlands
- Department of Paediatrics, Division of Paediatric Cardiology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Arend DJ ten Harkel
- Department of Paediatrics, Division of Paediatric Cardiology, LUMC, Leiden, The Netherlands
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Sooy-Mossey M, Matsuura M, Ezekian JE, Williams JL, Lee GS, Wood K, Dizon S, Kaplan SJ, Li JS, Parente V. The Association of Race and Ethnicity with Mortality in Pediatric Patients with Congenital Heart Disease: a Systematic Review. J Racial Ethn Health Disparities 2024; 11:2182-2196. [PMID: 37436684 DOI: 10.1007/s40615-023-01687-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 06/09/2023] [Accepted: 06/18/2023] [Indexed: 07/13/2023]
Abstract
CONTEXT Congenital heart disease (CHD) is a common condition with high morbidity and mortality and is subject to racial and ethnic health disparities. OBJECTIVE To conduct a systematic review of the literature to identify differences in mortality in pediatric patients with CHD based on race and ethnicity. DATA SOURCES Legacy PubMed (MEDLINE), Embase (Elsevier), and Scopus (Elsevier) STUDY SELECTION: English language articles conducted in the USA focused on mortality based on race and ethnicity in pediatric patients with CHD. DATA EXTRACTION Two independent reviewers assessed studies for inclusion and performed data extraction and quality assessment. Data extraction included mortality based on patient race and ethnicity. RESULTS There were 5094 articles identified. After de-duplication, 2971 were screened for title and abstract content, and 45 were selected for full-text assessment. Thirty studies were included for data extraction. An additional 8 articles were identified on reference review and included in data extraction for a total of 38 included studies. Eighteen of 26 studies showed increased risk of mortality in non-Hispanic Black patients. Results were heterogenous in Hispanic patients with eleven studies of 24 showing an increased risk of mortality. Results for other races demonstrated mixed outcomes. LIMITATIONS Study cohorts and definitions of race and ethnicity were heterogenous, and there was some overlap in national datasets used. CONCLUSION Overall, racial and ethnic disparities existed in the mortality of pediatric patients with CHD across a variety of mortality types, CHD lesions, and pediatric age ranges. Children of races and ethnicities other than non-Hispanic White generally had increased risk of mortality, with non-Hispanic Black children most consistently having the highest risk of mortality. Further investigation is needed into the underlying mechanisms of these disparities so interventions to reduce inequities in CHD outcomes can be implemented.
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Affiliation(s)
- Meredith Sooy-Mossey
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University School of Medicine, 2301 Erwin Road, DUMC Box 3127, Durham, NC, 27710, USA.
| | - Mirai Matsuura
- Deparment of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Jordan E Ezekian
- Division of Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jason L Williams
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University School of Medicine, 2301 Erwin Road, DUMC Box 3127, Durham, NC, 27710, USA
| | - Grace S Lee
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Kathleen Wood
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University School of Medicine, 2301 Erwin Road, DUMC Box 3127, Durham, NC, 27710, USA
| | - Samantha Dizon
- Division of Cardiology, Columbia University Department of Medicine, New York, NY, USA
| | - Samantha J Kaplan
- Medical Center Library and Archives, Duke University, Durham, NC, USA
| | - Jennifer S Li
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University School of Medicine, 2301 Erwin Road, DUMC Box 3127, Durham, NC, 27710, USA
| | - Victoria Parente
- Pediatric Hospital Medicine, Duke University School of Medicine, Durham, NC, USA
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Alexander GK, Namachivayam SP, Chiletti R, Butt W. Why do children not survive extracorporeal membrane oxygenation? J Paediatr Child Health 2024; 60:361-368. [PMID: 39034664 DOI: 10.1111/jpc.16614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/14/2024] [Accepted: 06/26/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is used in critically ill children with cardiac and/or respiratory failure. Use is increasing in children with high-risk comorbidities. Reasons children do not survive ECMO are poorly described. AIMS Describe characteristics and cause of death, compare mortality in children with high-risk comorbidities, evaluate mortality trends over a decade. METHOD All children <18 years old who received ECMO at this institution from 1 January 2011 to 31 December 2020 were described and categorised by outcome: died on or <48 h post-ECMO, died ≥48 h post-ECMO, survived to hospital discharge. Children who did not survive ECMO (DNSE) were categorised to: ECMO withdrawal for irrecoverable original condition, withdrawal for poor prognosis neurological condition, brain death, withdrawal for poor prognosis with multiple complex conditions, and unsupportable. Poison regression was used to analyse survival trends. RESULTS Four hundred twenty-eight children received ECMO, 19% DNSE, 14% died ≥48 h post-ECMO and 67% survived. ECMO was electively withdrawn for irrecoverable original condition (39%), poor prognosis for neurological condition (32%) or multiple complex conditions (18%). One hundred twenty-two children had ≥1 high-risk comorbidity. Children with genetic syndromes (58%), risk-adjusted congenital heart surgery score-1 ≥4 (53%), primary immunodeficiency (50%) had lower hospital survival. No children with malignancy/bone marrow transplant survived to hospital discharge. Overall hospital survival was 67%, with no significant change during the study period (P-trend = 0.99). CONCLUSION Children who DNSE have therapy electively withdrawn for irrecoverable disease or poor prognosis. Children with high-risk comorbidities have a reasonable chance of survival. This study informs clinicians ECMO may be a therapeutic option.
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Affiliation(s)
- Georgina K Alexander
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Siva P Namachivayam
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Roberto Chiletti
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Warwick Butt
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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Florquin R, Florquin R, Schmartz D, Dony P, Briganti G. Pediatric cardiac surgery: machine learning models for postoperative complication prediction. J Anesth 2024:10.1007/s00540-024-03377-7. [PMID: 39028323 DOI: 10.1007/s00540-024-03377-7] [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: 12/08/2023] [Accepted: 07/04/2024] [Indexed: 07/20/2024]
Abstract
PURPOSE Managing children undergoing cardiac surgery with cardiopulmonary bypass (CPB) presents a significant challenge for anesthesiologists. Machine Learning (ML)-assisted tools have the potential to enhance the recognition of patients at risk of complications and predict potential issues, ultimately improving outcomes. METHODS We evaluated the prediction capacity of six models, ranging from logistic regression to support vector machine, using a dataset comprising 33 variables and 1364 subjects. The Area Under the Curve (AUC) and the F1 score served as the primary evaluation metrics. Our primary objectives were twofold: first, to develop an effective prediction model, and second, to create a user-friendly comprehensive model for identifying high-risk patients. RESULTS The logistic regression model demonstrated the highest effectiveness, achieving an AUC of 83.65%, and an F1 score of 0.7296, with balanced sensitivity and specificity of 77.94% and 76.47%, respectively. In comparison, the comprehensive three-layer decision tree model achieved an AUC of 72.84%, with sensitivity (79.41%) comparable to more complex models. CONCLUSION Our machine learning-assisted tools provide an additional perspective and enhance the predictive capabilities of traditional scoring methods. These tools can assist anesthesiologists in making well-informed decisions. Furthermore, we have successfully demonstrated the feasibility of creating a practical white-box model. The next steps involve conducting clinical validation and multicenter cross-validation. TRIAL REGISTRATION NCT05537168.
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Affiliation(s)
- Rémi Florquin
- Department of Anesthesiology, CHU Charleroi, Chaussée de Bruxelles 140, 6042, Lodelinsart, Belgium.
- Chair of Artificial Intelligence and Digital Medicine, Mons University, 7000, Mons, Belgium.
| | | | - Denis Schmartz
- Department of Anesthesiology, Hôpital Universitaire de Bruxelles (H.U.B), Université Libre de Bruxelles, 1070, Brussels, Belgium
| | - Philippe Dony
- Department of Anesthesiology, CHU Charleroi, Chaussée de Bruxelles 140, 6042, Lodelinsart, Belgium
| | - Giovanni Briganti
- Chair of Artificial Intelligence and Digital Medicine, Mons University, 7000, Mons, Belgium
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El-Amin A, Koehlmoos T, Yue D, Chen J, Cho NY, Benharash P, Franzini L. High-Quality Hospital Status on Health Care Costs for Pediatric Congenital Heart Disease Care for U.S. Military Beneficiaries. Mil Med 2024:usae350. [PMID: 38970436 DOI: 10.1093/milmed/usae350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 06/05/2024] [Accepted: 06/25/2024] [Indexed: 07/08/2024] Open
Abstract
INTRODUCTION Congenital heart disease (CHD) is the most common and resource demanding birth defect managed in the United States, with approximately 40,000 children undergoing CHD surgery year. Researchers have compared high-volume to low-volume hospitals and found significant hospital-level variation in major complications, health resource utilization, and health care costs after CHD surgery. MATERIALS AND METHODS Using nationwide representative claim data from the United States Military Health System from 2016 to 2020, TRICARE beneficiaries diagnosed with CHD were tabulated based on ICD-10 codes (International Classification of Diseases, 10th revision). We examined the relationships between total costs and total hospitalizations costs post 1-year CHD diagnosis and presence or absence of High-Quality Hospital (HQH) designation. We applied both the naive generalized linear model (GLM) to control for the observed patient and hospital characteristics and the 2-stage least squares (2SLS) model to account for the unobserved confounding factors. This study was approved by University of Maryland, College Park Institutional Review Board (IRB) (Approval Number: 1576246-2). RESULTS A relationship between HQH designation and total CHD related costs was not seen across 2SLS model specifications (marginal effect; -$41,579; 95% CI, -$83,429 to $271). For patients diagnosed with a moderate-complex or single ventricle CHD, the association of HQH status was a statistically significant reduction in total costs (marginal effect; -$84,395; 95% CI, -$140,560 to -$28,229) and hospitalization costs (marginal effect; -$73,958; 95% CI, -$121,878 to -$26,039). CONCLUSIONS It is very imperative for clinicians and patient support advocates to urge policymakers to deliberate the establishment of a quality designation authority for CHD management. These efforts will not only help to identify and standardize quality care metrics but to improve long-term health, effectiveness, and equity in the management of CHD. Furthermore, these efforts can be used to navigate patients to proven HQH, thereby improving care and reducing associated treatment costs for CHD patients.
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Affiliation(s)
- Amber El-Amin
- Center for Health Services Research, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
| | - Tracey Koehlmoos
- Center for Health Services Research, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
| | - Dahai Yue
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
| | - Jie Chen
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA 90024, USA
| | - Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA 90024, USA
- Department of Surgery, University of California, Los Angeles, CA 90024, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA 90024, USA
- Department of Surgery, University of California, Los Angeles, CA 90024, USA
| | - Luisa Franzini
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, USA
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10
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Niiyama S, Nakashima T, Ueno K, Hirahara D, Nakajo M, Madokoro Y, Sato M, Shimono K, Futatsuki T, Kakihana Y. Machine Learning Analysis of Predictors for Inhaled Nitric Oxide Therapy Administration Time Post Congenital Heart Disease Surgery: A Single-Center Observational Study. Cureus 2024; 16:e65783. [PMID: 39082048 PMCID: PMC11288644 DOI: 10.7759/cureus.65783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2024] [Indexed: 08/02/2024] Open
Abstract
Background Congenital heart disease (CHD) is a structural deformity of the heart present at birth. Pulmonary hypertension (PH) may arise from increased blood flow to the lungs, persistent pulmonary arterial pressure elevation, or the use of cardiopulmonary bypass (CPB) during surgical repair. Inhaled nitric oxide (iNO) selectively reduces high blood pressure in the pulmonary vessels without lowering systemic blood pressure, making it useful for treating children with postoperative PH due to heart disease. However, reducing or stopping iNO can exacerbate postoperative PH and hypoxemia, necessitating long-term administration and careful tapering. This study aimed to evaluate, using machine learning (ML), factors that predict the need for long-term iNO administration after open heart surgery in CHD patients in the postoperative ICU, primarily for PH management. Methods We used an ML approach to establish an algorithm to predict 'patients with long-term use of iNO' and validate its accuracy in 34 pediatric postoperative open heart surgery patients who survived and were discharged from the ICU at Kagoshima University Hospital between April 2016 and March 2019. All patients were started on iNO therapy upon ICU admission. Overall, 16 features reflecting patient and surgical characteristics were utilized to predict the patients who needed iNO for over 168 hours using ML analysis with AutoGluon. The dataset was randomly classified into training and test cohorts, comprising 80% and 20% of the data, respectively. In the training cohort, the ML model was constructed using the important features selected by the decrease in Gini impurity and a synthetic oversampling technique. In the testing cohort, the prediction performance of the ML model was evaluated by calculating the area under the receiver operating characteristics curve (AUC) and accuracy. Results Among 28 patients in the training cohort, five needed iNO for over 168 hours; among six patients in the testing cohort, one needed iNO for over 168 hours. CPB, aortic clamp time, in-out balance, and lactate were the four most important features for predicting the need for iNO for over 168 hours. In the training cohorts, the ML model achieved perfect classification with an AUC of 1.00. In the testing cohort, the ML model also achieved perfect classification with an AUC of 1.00 and an accuracy of 1.00. Conclusion The ML approach identified that four factors (CPB, in-out balance, aortic cross-clamp time, and lactate) are strongly associated with the need for long-term iNO administration after open heart surgery in CHD patients. By understanding the outcomes of this study, we can more effectively manage iNO administration in postoperative open heart surgery in CHD patients with PH, potentially preventing the recurrence of postoperative PH and hypoxemia, thereby contributing to safer patient management.
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Affiliation(s)
- Shuhei Niiyama
- Department of Emergency and Intensive Care Medicine, Kagoshima University Hospital, Kagoshima, JPN
| | - Takahiro Nakashima
- Department of Clinical Engineering, Kagoshima University Hospital, Kagoshima, JPN
| | - Kentaro Ueno
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, JPN
| | - Daisuke Hirahara
- Department of Management Planning Division, Harada Academy, Kagoshima, JPN
| | - Masatoyo Nakajo
- Department of Radiology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, JPN
| | - Yutaro Madokoro
- Department of Emergency and Intensive Care Medicine, Kagoshima University Hospital, Kagoshima, JPN
| | - Mitsuhito Sato
- Department of Emergency and Intensive Care Medicine, Kagoshima University Hospital, Kagoshima, JPN
| | - Kenshin Shimono
- Department of Emergency and Intensive Care Medicine, Kagoshima University Hospital, Kagoshima, JPN
| | - Takahiro Futatsuki
- Department of Emergency and Intensive Care Medicine, Kagoshima University Hospital, Kagoshima, JPN
| | - Yasuyuki Kakihana
- Department of Emergency and Intensive Care Medicine, Kagoshima University Hospital, Kagoshima, JPN
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11
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Das D, Dutta N, Das S, Sharma MK, Chattopadhyay A, Ghosh S, Das JN. Public-Private Partnership for Treatment of Congenital Heart Diseases: Experiences From an Indian State. World J Pediatr Congenit Heart Surg 2024; 15:439-445. [PMID: 38263667 DOI: 10.1177/21501351231215257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
Background: Treatment of congenital heart disease (CHD), being the most common congenital anomaly, puts immense financial burden in low- and middle-income countries (LMICs) and contributes significantly to infant mortality. We report experiences of treatment of CHD in the Indian state of West Bengal by a public-private partnership (PPP) model. Methods: Under the Rashtriya Bal Swasthya Karyakram, the government of the state of West Bengal in India launched a program called the "Sishu Sathi Scheme" to provide free treatment to children who need heart surgeries, irrespective of economic status. Treatment was provided in selected private hospitals and some public hospitals in a reimbursement model where government compensated the hospitals. Data were collected on such procedures from 2013 to 2022 and analyzed. Results: A total of 27,844 patients with CHD received treatment under the Sishu Sathi Scheme from August 2013 to December 2022. The average number of patients per year was 3,093. Detailed data of procedures from January 2016 to December 2022 showed a total of 22,572 procedures (6,249 device interventions, 4,840 cardiac catheterizations, and 11,483 surgical interventions). The in-hospital mortality of surgical procedures and catheterization lab procedures were 5.2% and 0.9%, respectively. Conclusions: A large number of patients with CHD were successfully treated under a PPP in the state of West Bengal in India. In spite of its inherent challenges, this model is of special relevance in LMICs where access and affordability for treatment of CHD always remain a challenge.
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Affiliation(s)
- Debasis Das
- Departments of Cardiac Surgery, Narayana Superspeciality Hospital, Howrah, India
| | - Nilanjan Dutta
- Departments of Cardiac Surgery, Narayana Superspeciality Hospital, Howrah, India
| | - Shubhadeep Das
- Pediatric Cardiac Intensive Care, Narayana Superspeciality Hospital, Howrah, India
| | | | | | - Sanjiban Ghosh
- Pediatric Cardiology, Narayana Superspeciality Hospital, Howrah, India
| | - Jayita Nandy Das
- Pediatric Cardiology, Narayana Superspeciality Hospital, Howrah, India
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12
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Rowe S, Best KM. Individualized Numeric Rating Scale to Assess Pain in Critically Ill Children With Neurodevelopmental Disabilities. Am J Crit Care 2024; 33:280-288. [PMID: 38945815 DOI: 10.4037/ajcc2024343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
BACKGROUND Pain is a significant burden for children with neurodevelopmental disabilities but is difficult for clinicians to identify. No pain assessment tools for children with neurodevelopmental disabilities have been validated for use in pediatric intensive care units. The Individualized Numeric Rating Scale (INRS) is an adapted 0-to-10 rating that includes parents' input on their child's pain indicators. OBJECTIVES To evaluate the reliability, validity, and feasibility and acceptability of use of the INRS for assessing pain in critically ill children with neurodevelopmental disabilities. METHODS This observational study enrolled critically ill patients with neurodevelopmental disabilities aged 3 to 17 years in 2 pediatric intensive care units at a children's hospital using a prospective repeated-measures cohort design. Structured parent interviews were used to populate each patient's INRS. Bedside nurses assessed pain using the INRS throughout the study. The research team completed independent INRS ratings using video clips. Participating parents and nurses completed feasibility and acceptability surveys. Psychometric properties of the INRS and survey responses were evaluated with appropriate statistical methods. RESULTS For 481 paired INRS pain ratings in 34 patients, interrater reliability between nurse and research team ratings was moderate (weighted κ = 0.56). Parents said that creating the INRS was easy, made them feel more involved in care, and helped them communicate with nurses. CONCLUSIONS The INRS has adequate measurement properties for assessing pain in critically ill children with neurodevelopmental disabilities. It furthers goals of patient- and family-centered care but may have implementation barriers.
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Affiliation(s)
- Shaneel Rowe
- Shaneel Rowe is a study coordinator, Clinical Research Support Office, Children's Hospital of Philadelphia, Penn-sylvania
| | - Kaitlin M Best
- Kaitlin M. Best is a nurse practitioner, Cardiac Critical Care Unit, the Hospital for Sick Children, Toronto, Ontario, Canada
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13
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Saha P, Tjoeng YL, Algaze C, Kameny R, Pinto N, Chan T. Racial and Ethnic Disparities in Cardiac Reintervention After Pediatric Cardiac Surgical Procedures. Ann Thorac Surg 2024; 117:1195-1202. [PMID: 37923240 DOI: 10.1016/j.athoracsur.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 09/17/2023] [Accepted: 10/20/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Children undergoing cardiac surgical procedures may require postoperative surgical or catheter-based reintervention before discharge. We examined racial/ethnic variations in reintervention and associated in-hospital death. METHODS Children undergoing cardiac surgical procedures from 2004 to 2015 were identified in the Pediatric Health Information Systems (PHIS) database. Regression analysis measured associations between race/ethnicity, in-hospital death, and postoperative cardiac surgical or catheter-based reintervention (surgical/catheter reintervention). RESULTS Of 124,263 patients, 8265 (6.7%) had a surgical/catheter reintervention. Black patients had fewer reinterventions (5.9% vs 6.7%) and higher in-hospital mortality (3.9% vs 2.7%, P < .01) than White patients. After adjusting for sociodemographic and illness severity indicators, Black patients remained less likely to receive surgical/catheter reintervention (adjusted hazard ratio [aHR], 0.89; 95% CI, 0.82-0.98) despite having similar risk of death after reintervention (adjusted odds ratio, 1.17; 95% CI, 0.98-1.41) compared with White patients. The risk of death without surgical/catheter reintervention was also higher for Black (aHR, 1.26; 95% CI, 1.08-1.47) and other race/ethnicity (aHR, 1.33; 95% CI, 1.13-1.57) patients than for White patients. Similar trends were demonstrated when mechanical circulatory support and cardiac transplantation were included as reinterventions. CONCLUSIONS Patients of Black and other race/ethnicity undergoing pediatric cardiac surgical procedures are more likely to die without postoperative cardiac reintervention than White patients. Black patients are also less likely to receive reintervention despite no significant difference in mortality with reintervention. Further studies should evaluate etiologies and methods of addressing these disparities.
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Affiliation(s)
- Priyanka Saha
- The Heart Center, Seattle Children's Hospital, University of Washington, Seattle, Washington; Division of Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.
| | - Yuen Lie Tjoeng
- The Heart Center, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Claudia Algaze
- Division of Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Rebecca Kameny
- Division of Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Nelangi Pinto
- Division of Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Titus Chan
- The Heart Center, Seattle Children's Hospital, University of Washington, Seattle, Washington
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14
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Opotowsky AR, Khairy P, Diller G, Kasparian NA, Brophy J, Jenkins K, Lopez KN, McCoy A, Moons P, Ollberding NJ, Rathod RH, Rychik J, Thanassoulis G, Vasan RS, Marelli A. Clinical Risk Assessment and Prediction in Congenital Heart Disease Across the Lifespan: JACC Scientific Statement. J Am Coll Cardiol 2024; 83:2092-2111. [PMID: 38777512 DOI: 10.1016/j.jacc.2024.02.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/12/2024] [Accepted: 02/22/2024] [Indexed: 05/25/2024]
Abstract
Congenital heart disease (CHD) comprises a range of structural anomalies, each with a unique natural history, evolving treatment strategies, and distinct long-term consequences. Current prediction models are challenged by generalizability, limited validation, and questionable application to extended follow-up periods. In this JACC Scientific Statement, we tackle the difficulty of risk measurement across the lifespan. We appraise current and future risk measurement frameworks and describe domains of risk specific to CHD. Risk of adverse outcomes varies with age, sex, genetics, era, socioeconomic status, behavior, and comorbidities as they evolve through the lifespan and across care settings. Emerging technologies and approaches promise to improve risk assessment, but there is also need for large, longitudinal, representative, prospective CHD cohorts with multidimensional data and consensus-driven methodologies to provide insight into time-varying risk. Communication of risk, particularly with patients and their families, poses a separate and equally important challenge, and best practices are reviewed.
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Affiliation(s)
- Alexander R Opotowsky
- Adult Congenital Heart Disease Program, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
| | - Paul Khairy
- Adult Congenital Heart Centre, Montreal Heart Institute, Montréal, Quebec, Canada
| | - Gerhard Diller
- Department of Cardiology III, University Hospital Münster, Münster, Germany
| | - Nadine A Kasparian
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Heart and Mind Wellbeing Center, Cincinnati, Ohio, USA; Heart Institute and Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - James Brophy
- Department of Medicine, Faculty of Medicine and Health Sciences, McGill University, Montréal, Quebec, Canada
| | - Kathy Jenkins
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Keila N Lopez
- Department of Pediatrics, Section of Cardiology, Texas Children's Hospital & Baylor College of Medicine, Houston, Texas, USA
| | - Alison McCoy
- Vanderbilt Clinical Informatics Core, Department of Biomedical Informatics, Vanderbilt University Medical Center and Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Philip Moons
- KU Leuven Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium; Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden; Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Nicholas J Ollberding
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rahul H Rathod
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jack Rychik
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - George Thanassoulis
- Department of Medicine, Faculty of Medicine and Health Sciences, McGill University, Montréal, Quebec, Canada
| | - Ramachandran S Vasan
- School of Public Health, University of Texas, San Antonio, Texas, USA; Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Ariane Marelli
- McGill Adult Unit for Congenital Heart Disease Excellence, McGill University, Montreal, Quebec, Canada.
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15
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St Louis JD, Bhat A, Carey JC, Lin AE, Mann PC, Smith LM, Wilfond BS, Kosiv KA, Sorabella RA, Alsoufi B. The American Association for Thoracic Surgery (AATS) 2023 Expert Consensus Document: Recommendation for the care of children with trisomy 13 or trisomy 18 and a congenital heart defect. J Thorac Cardiovasc Surg 2024; 167:1519-1532. [PMID: 38284966 DOI: 10.1016/j.jtcvs.2023.11.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/27/2023] [Accepted: 11/30/2023] [Indexed: 01/30/2024]
Abstract
OBJECTIVES Recommendations for surgical repair of a congenital heart defect in children with trisomy 13 or trisomy 18 remain controversial, are subject to biases, and are largely unsupported with limited empirical data. This has created significant distrust and uncertainty among parents and could potentially lead to suboptimal care for patients. A working group, representing several clinical specialties involved with the care of these children, developed recommendations to assist in the decision-making process for congenital heart defect care in this population. The goal of these recommendations is to provide families and their health care teams with a framework for clinical decision making based on the literature and expert opinions. METHODS This project was performed under the auspices of the AATS Congenital Heart Surgery Evidence-Based Medicine Taskforce. A Patient/Population, Intervention, Comparison/Control, Outcome process was used to generate preliminary statements and recommendations to address various aspects related to cardiac surgery in children with trisomy 13 or trisomy 18. Delphi methodology was then used iteratively to generate consensus among the group using a structured communication process. RESULTS Nine recommendations were developed from a set of initial statements that arose from the Patient/Population, Intervention, Comparison/Control, Outcome process methodology following the groups' review of more than 500 articles. These recommendations were adjudicated by this group of experts using a modified Delphi process in a reproducible fashion and make up the current publication. The Class (strength) of recommendations was usually Class IIa (moderate benefit), and the overall level (quality) of evidence was level C-limited data. CONCLUSIONS This is the first set of recommendations collated by an expert multidisciplinary group to address specific issues around indications for surgical intervention in children with trisomy 13 or trisomy 18 with congenital heart defect. Based on our analysis of recent data, we recommend that decisions should not be based solely on the presence of trisomy but, instead, should be made on a case-by-case basis, considering both the severity of the baby's heart disease as well as the presence of other anomalies. These recommendations offer a framework to assist parents and clinicians in surgical decision making for children who have trisomy 13 or trisomy 18 with congenital heart defect.
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Affiliation(s)
- James D St Louis
- Department of Surgery, Children's Hospital of Georgia, Augusta University, Augusta, Ga.
| | - Aarti Bhat
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Wash
| | - John C Carey
- Department of Pediatrics, University of Utah Health and Primary Children's Hospital, Salt Lake City, Utah
| | - Angela E Lin
- Department of Pediatrics, Mass General Hospital for Children, Boston, Mass
| | - Paul C Mann
- Department of Surgery, Children's Hospital of Georgia, Augusta University, Augusta, Ga
| | - Laura Miller Smith
- Department of Pediatrics, Oregon Health and Science University, Portland, Ore
| | - Benjamin S Wilfond
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Wash
| | - Katherine A Kosiv
- Department of Pediatrics, Yale University School of Medicine, New Haven, Conn
| | - Robert A Sorabella
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | - Bahaaldin Alsoufi
- Department of Surgery, University of Louisville and Norton Children's Hospital, Louisville, Ky
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Viswanathan S, F Ong KJ, Kakavand B. Prevalence and Risk Factors for Tube-Feeding at Discharge in Infants following Early Congenital Heart Disease Surgery: A Single-Center Cohort Study. Am J Perinatol 2024; 41:e2832-e2841. [PMID: 37848045 DOI: 10.1055/s-0043-1775976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE Oral feeding difficulty is common in infants after congenital heart disease (CHD) surgical repair and is associated with prolonged hospital stay and increased risk for tube-feeding at discharge (TF). The current understanding of the enteropathogenesis of oral feeding difficulty in infants requiring CHD surgery is limited. To determine the prevalence and risk factors for TF following CHD surgery in early infancy. STUDY DESIGN This was a 6-year single-center retrospective cohort study (2016-2021) of infants under 6 months who had CHD surgery. Infants required TF were compared with infants who reached independent oral feeding (IOF). RESULTS Of the final sample of 128 infants, 24 (18.8%) infants required TF at discharge. The risk factors for TF in univariate analysis include low birth weight, low 5-minute Apgar score, admitted at birth, risk adjustment in congenital heart surgery categories IV to VI, presence of genetic diagnosis, use of Prostin, higher pre- and postsurgery respiratory support, lower weight at surgery, lower presurgery oral feeding, higher presurgery milk calory, delayed postsurgery enteral and oral feeding, higher pre- and postsurgery gastroesophageal reflux disease (GERD), need for swallow study, abnormal brain magnetic resonance imaging (p < 0.05). In the multivariate analysis, only admitted at birth, higher presurgery milk calories, and GERD were significant risk factors for TF. TF had significantly longer hospital stay (72 vs. 17 days) and lower weight gain at discharge (z-score: -3.59 vs. -1.94) compared with IOF (p < 0.05). CONCLUSION The prevalence of TF at discharge in our study is comparable to previous studies. Infants with CHD admitted at birth, received higher presurgery milk calories, and clinical GERD are significant risk factors for TF. Mitigating the effects of identified risk factors for TF will have significant impact on the quality of life for these infants and their families and may reduce health care cost. KEY POINTS · Oral feeding difficulty in infants after congenital heart disease surgical repair is common.. · Such infants require prolonged hospital stay and higher risk for tube-feeding at discharge.. · Identifying modifiable risk factors associated with tube-feeding can enhance clinical outcomes..
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Affiliation(s)
- Sreekanth Viswanathan
- Division of Neonatology, Department of Pediatrics, Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando, Florida
| | - Kaitlyn Jade F Ong
- Division of Neonatology, Department of Pediatrics, Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando, Florida
| | - Bahram Kakavand
- Department of Pediatrics, Division of Pediatric Cardiology, Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando, Florida
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Kristensen R, Omann C, Ekelund CK, Gaynor JW, Hjortdal VE. Impact of an Impaired Maternal-Fetal Environment on Death in Children With Congenital Heart Defects Undergoing Surgery in Denmark From 1994 to 2018. J Am Heart Assoc 2024; 13:e031575. [PMID: 38533951 PMCID: PMC11179785 DOI: 10.1161/jaha.123.031575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 02/28/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Studies show that an impaired maternal-fetal environment (iMFE) increases the mortality risk in children with single-ventricle congenital heart defects (CHDs). We investigated the impact of an iMFE on death in children with various surgically corrected CHDs. METHODS AND RESULTS In this nationwide register-based study, we examined the association between an iMFE (including preeclampsia, gestational hypertension, gestational diabetes, maternal smoking during pregnancy) and death in a large cohort of children with surgically corrected CHDs in Denmark (1994-2018). Survival analysis was done using Cox regression, adjusted for confounding and mediating covariates. The cohort included 3304 children: 1662 (50.3%) with minor CHD and 1642 (49.7%) with major CHD. Among them, 792 (24%) children were exposed to an iMFE. During the study, there were 290 deaths: 71 (9.3%) in children exposed to an iMFE and 219 (8.7%) in those unexposed. There were no differences in mortality risk between children with CHD exposed to an iMFE and those unexposed (hazard ratio [HR], 1.12 [95% CI, 0.86-1.47]; P=0.4). This was consistent across subgroups, including minor CHD (HR, 0.76 [95% CI, 0.39-1.47]; P=0.4), major CHD (HR, 1.23 [95% CI, 0.92-1.64]; P=0.2), and hypoplastic left heart syndrome/univentricular heart (HR, 1.08 [95% CI, 0.64-1.85]; P=0.8). CONCLUSIONS Impairment of the maternal-fetal environment did not impact the mortality rate in children with CHD undergoing operation in Denmark from 1994 to 2018. We believe the cause of these discrepant findings to previous studies may be due to differences in the composition of CHD and prenatal maternal health care and health status of the population.
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Affiliation(s)
- Rasmus Kristensen
- Department of Cardiothoracic SurgeryCopenhagen University Hospital – RigshospitaletDenmark
- Faculty of Health SciencesCopenhagen UniversityDenmark
| | - Camilla Omann
- Department of Clinical MedicineAarhus UniversityDenmark
- Department of Cardiothoracic & Vascular SurgeryAarhus University HospitalDenmark
| | - Charlotte K. Ekelund
- Faculty of Health SciencesCopenhagen UniversityDenmark
- Department of Obstetrics, Center for Fetal MedicineCopenhagen University Hospital – RigshospitaletCopenhagenDenmark
| | - J. William Gaynor
- Division of Cardiothoracic SurgeryChildren’s Hospital of PhiladelphiaPAUSA
| | - Vibeke E. Hjortdal
- Department of Cardiothoracic SurgeryCopenhagen University Hospital – RigshospitaletDenmark
- Faculty of Health SciencesCopenhagen UniversityDenmark
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Erek E, Başgöze S, Yıldız O, Sarıosmanoğlu NO, Yalçınbaş YK, Turköz R, Kutsal A, Seçici S, Ergün S, Chadikovski V, Arnaz A, Koç M, Korun O, Şenkaya I, Özdemir F, Biçer M, Sarıtaş B, Atay Y, Haydın S, Bilen Ç, Onan İS, Tuncer ON, Citoglu G, Dogan A, Temur B, Özkan M, Sarioglu CT. Second harvest of Congenital Heart Surgery Database in Türkiye: Current outcomes. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2024; 32:162-178. [PMID: 38933312 PMCID: PMC11197406 DOI: 10.5606/tgkdc.dergisi.2024.25758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 04/03/2024] [Indexed: 06/28/2024]
Abstract
Background This second harvest of the Congenital Heart Surgery Database intended to compare current results with international databases. Methods This retrospective study examined a total of 4007 congenital heart surgery procedures from 15 centers in the Congenital Heart Surgery Database between January 2018 and January 2023. International diagnostic and procedural codes were used for data entry. STAT (Society of Thoracic Surgeons and European Association for Cardiothoracic Surgery) mortality scores and categories were used for comparison of the data. Surgical priority status was modified from American Society of Anesthesiologist guidelines. Centers that sent more than 5 cases to the database were included to the study. Results Cardiopulmonary bypass and cardioplegic arrest were performed in 2,983 (74.4%) procedures. General risk factors were present in 22.6% of the patients, such as genetic anomaly, syndrome, or prematurity. Overall, 18.9% of the patients had preoperative risk factors (e.g., mechanical ventilation, renal failure, and sepsis). Of the procedures, 610 (15.2%) were performed on neonates, 1,450 (36.2%) on infants, 1,803 (45%) on children, and 144 (3.6%) on adults. The operative timing was elective in 56.5% of the patients, 34.4% were urgent, 8% were emergent, and 1.1% were rescue procedures. Extracorporeal membrane oxygenation support was used in 163 (4%) patients, with a 34.3% survival rate. Overall mortality in this series was 6.7% (n=271). Risk for mortality was higher in patients with general risk factors, such as prematurity, low birth weight neonates, and heterotaxy syndrome. Mortality for patients with preoperative mechanical ventilation was 17.5%. Pulmonary hypertension and preoperative circulatory shock had 11.6% and 10% mortality rates, respectively. Mortality for patients who had no preoperative risk factor was 3.9%. Neonates had the highest mortality rate (20.5%). Intensive care unit and hospital stay time for neonates (median of 17.8 days and 24.8 days, respectively) were also higher than the other age groups. Infants had 6.2% mortality. Hospital mortality was 2.8% for children and 3.5% for adults. Mortality rate was 2.8% for elective cases. Observed mortality rates were higher than expected in the fourth and fifth categories of the STAT system (observed, 14.8% and 51.9%; expected, 9.9% and 23.1%; respectively). Conclusion For the first time, outcomes of congenital heart surgery in Türkiye could be compared to the current world experience with this multicenter database study. Increased mortality rate of neonatal and complex heart operations could be delineated as areas that need improvement. The Congenital Heart Surgery Database has great potential for quality improvement of congenital heart surgery in Türkiye. In the long term, participation of more centers in the database may allow more accurate risk adjustment.
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Affiliation(s)
- Ersin Erek
- Department of Pediatric Cardiovascular Surgery, Acıbadem Mehmet Ali Aydınlar University Faculty of Medicine, Acıbadem Atakent Hospital, İstanbul, Türkiye
- Children’s Heart Foundation, Board of Directors, İstanbul, Türkiye
| | - Serdar Başgöze
- Department of Pediatric Cardiovascular Surgery, Acıbadem Mehmet Ali Aydınlar University Faculty of Medicine, Acıbadem Atakent Hospital, İstanbul, Türkiye
| | - Okan Yıldız
- Department of Pediatric Cardiovascular Surgery, İstanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Türkiye
| | - Nejat Osman Sarıosmanoğlu
- Department of Pediatric Cardiovascular Surgery, Dokuz Eylül University Faculty of Medicine, İzmir, Türkiye
| | - Yusuf Kenan Yalçınbaş
- Department of Pediatric Cardiovascular Surgery, Acıbadem Bakırköy Hospital, İstanbul, Türkiye
- Children’s Heart Foundation, Board of Directors, İstanbul, Türkiye
| | - Rıza Turköz
- Department of Pediatric Cardiovascular Surgery, Acıbadem Bakırköy Hospital, İstanbul, Türkiye
| | - Ali Kutsal
- Department of Pediatric Cardiovascular Surgery, Sami Ulus Gynecology and Pediatrics Training and Research Hospital, Ankara, Türkiye
| | - Serkan Seçici
- Department of Pediatric Cardiovascular Surgery, Medicana Hospital, Bursa, Türkiye
| | - Servet Ergün
- Department of Pediatric Cardiovascular Surgery, Erzurum Training and Research Hospital, Erzurum, Türkiye
| | - Vladimir Chadikovski
- Department of Pediatric Cardiovascular Surgery, Acıbadem Sistina Hospital, Skopje, North Macedonia
| | - Ahmet Arnaz
- Department of Pediatric Cardiovascular Surgery, Acıbadem Bakırköy Hospital, İstanbul, Türkiye
| | - Murat Koç
- Department of Pediatric Cardiovascular Surgery, Sami Ulus Gynecology and Pediatrics Training and Research Hospital, Ankara, Türkiye
| | - Oktay Korun
- Department of Pediatric Cardiovascular Surgery, Cerrahpaşa University Faculty of Medicine, İstanbul, Türkiye
| | - Işık Şenkaya
- Department of Pediatric Cardiovascular Surgery, Uludağ University Faculty of Medicine, Bursa, Türkiye
| | - Fatih Özdemir
- Department of Pediatric Cardiovascular Surgery, Gazi Yaşargil Training and Research Hospital, Diyarbakır, Türkiye
| | - Mehmet Biçer
- Department of Pediatric Cardiovascular Surgery, Koç University Faculty of Medicine, İstanbul, Türkiye
| | - Bülent Sarıtaş
- Department of Pediatric Cardiovascular Surgery, İstanbul Aydin University, İstanbul, Türkiye
| | - Yüksel Atay
- Department of Pediatric Cardiovascular Surgery, Ege University Faculty of Medicine, İzmir, Türkiye
| | - Sertaç Haydın
- Department of Pediatric Cardiovascular Surgery, İstanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Türkiye
| | - Çağatay Bilen
- Department of Pediatric Cardiovascular Surgery, Dokuz Eylül University Faculty of Medicine, İzmir, Türkiye
| | - İsmihan S. Onan
- Department of Pediatric Cardiovascular Surgery, İstanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Türkiye
| | - Osman N. Tuncer
- Department of Pediatric Cardiovascular Surgery, Ege University Faculty of Medicine, İzmir, Türkiye
| | - Görkem Citoglu
- Department of Pediatric Cardiovascular Surgery, Uludağ University Faculty of Medicine, Bursa, Türkiye
| | - Abdullah Dogan
- Department of Pediatric Cardiovascular Surgery, Acıbadem Bakırköy Hospital, İstanbul, Türkiye
| | - Bahar Temur
- Department of Pediatric Cardiovascular Surgery, Acıbadem Mehmet Ali Aydınlar University Faculty of Medicine, Acıbadem Atakent Hospital, İstanbul, Türkiye
| | - Murat Özkan
- Department of Pediatric Cardiovascular Surgery, Başkent University Faculty of Medicine, Ankara, Türkiye
| | - C. Tayyar Sarioglu
- Department of Pediatric Cardiovascular Surgery, Acıbadem Mehmet Ali Aydınlar University Faculty of Medicine, Acıbadem Atakent Hospital, İstanbul, Türkiye
- Department of Pediatric Cardiovascular Surgery, Acıbadem Bakırköy Hospital, İstanbul, Türkiye
- Children’s Heart Foundation, Board of Directors, İstanbul, Türkiye
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Teng C, Shu D, Faerber JA, Goldenring J, Butto A, Tam V, Olsen R, Glatz AC, Cohen MS. Factors Associated with Growth in a Cohort of Children with Complex Biventricular Congenital Heart Disease. J Pediatr 2024; 267:113901. [PMID: 38181978 DOI: 10.1016/j.jpeds.2024.113901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 12/30/2023] [Accepted: 01/01/2024] [Indexed: 01/07/2024]
Abstract
OBJECTIVES To evaluate patterns and determinants of longitudinal growth among children requiring complex biventricular repair for congenital heart disease, as well as to assess for associations of growth with early feeding modality, comorbidities, postoperative complications, and socioeconomic characteristics. STUDY DESIGN A single-institution retrospective cohort study was performed in children born February 1999 to March 2009 with complex congenital heart disease who underwent biventricular repair before age 4 years, defined by Risk Adjustment in Congenital Heart Surgery-1 category 3-5. Clinical characteristics, height, weight, and body mass index (BMI) from ages 2-12 years were collected by chart review. Neighborhood-level socioeconomic data were identified using a geographic information system approach. The adjusted association of covariates with growth outcomes was estimated using multivariable linear regression models using generalized estimating equations. RESULTS Compared with population growth curves, the cohort (n = 150) trended toward early decrease in age-adjusted weight and height. Early tube feeding was significantly associated with decreased BMI before adolescence (-0.539; 95% CI -1.02, -0.054; P = .029). In addition, other clinical and perioperative characteristics had significant associations with growth, including low birth weight, preoperative tube feeds, need for multiple bypass runs, and diagnosis of feeding disorder. CONCLUSIONS Early childhood growth in children with complex biventricular repair may be impaired. Early tube feeding was associated with decreased BMI over the course of early childhood, which may indicate a need for continued close nutrition follow-up and support even beyond the duration of tube feeds.
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Affiliation(s)
- Christopher Teng
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Di Shu
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA; Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jennifer A Faerber
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jacob Goldenring
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Arene Butto
- Sibley Heart Center, Children's Healthcare of Atlanta, Atlanta, GA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Vicky Tam
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Robert Olsen
- Center for Healthcare and Quality Analytics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Andrew C Glatz
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Meryl S Cohen
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Saengsin K, Sittiwangkul R, Borisuthipandit T, Wongyikul P, Tanasombatkul K, Phanacharoensawad T, Moonsawat G, Trongtrakul K, Phinyo P. Development of a clinical prediction tool for extubation failure in pediatric cardiac intensive care unit. Front Pediatr 2024; 12:1346198. [PMID: 38504995 PMCID: PMC10948403 DOI: 10.3389/fped.2024.1346198] [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: 11/30/2023] [Accepted: 02/22/2024] [Indexed: 03/21/2024] Open
Abstract
Introduction/objective Extubation failure in pediatric patients with congenital or acquired heart diseases increases morbidity and mortality. This study aimed to develop a clinical risk score for predicting extubation failure to guide proper clinical decision-making and management. Methods We conducted a retrospective study. This clinical prediction score was developed using data from the Pediatric Cardiac Intensive Care Unit (PCICU) of the Faculty of Medicine, Chiang Mai University, Thailand, from July 2016 to May 2022. Extubation failure was defined as the requirement for re-intubation within 48 h after extubation. Multivariable logistic regression was used for modeling. The score was evaluated in terms of discrimination and calibration. Results A total of 352 extubation events from 270 patients were documented. Among these, 40 events (11.36%) were extubation failure. Factors associated with extubation failure included history of pneumonia (OR: 4.14, 95% CI: 1.83-9.37, p = 0.001), history of re-intubation (OR: 5.99, 95% CI: 2.12-16.98, p = 0.001), and high saturation in physiologic cyanosis (OR: 5.94, 95% CI: 1.87-18.84, p = 0.003). These three factors were utilized to develop the risk score. The score showed acceptable discrimination with an area under the curve (AUC) of 0.77 (95% CI: 0.69-0.86), and good calibration. Conclusion The derived Pediatric CMU Extubation Failure Prediction Score (Ped-CMU ExFPS) could satisfactorily predict extubation failure in pediatric cardiac patients. Employing this score could promote proper personalized care. We suggest conducting further external validation studies before considering implementation in practice.
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Affiliation(s)
- Kwannapas Saengsin
- Division of Cardiology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Rekwan Sittiwangkul
- Division of Cardiology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Thirasak Borisuthipandit
- Division of Pulmonology and Critical Care, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pakpoom Wongyikul
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Krittai Tanasombatkul
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | | | - Konlawij Trongtrakul
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Division of Pulmonary, Critical Care Medicine, and Allergy, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Phichayut Phinyo
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Ihle E, Thompson J, Butt W, Namachivayam SP. High risk of necrotising enterocolitis in term-born neonates with CHD delivered by caesarean section: a case-control study. Cardiol Young 2024; 34:576-580. [PMID: 37608758 DOI: 10.1017/s1047951123003128] [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: 08/24/2023]
Abstract
OBJECTIVE Necrotising enterocolitis is linked with altered intestinal microbiota, and caesarean birth is associated with imbalance of newborn intestinal microbiome. We aimed to investigate the role of delivery mode (vaginal or caesarean) and gestational age in the development of necrotising enterocolitis among term-born neonates (≥ 37 weeks) with CHD. METHODS Case-control study. We studied all newborns with CHD who underwent cardiac surgery during the neonatal (≤ 28 days of age) period, between 2007 and 2017. Totally, 60 cases of necrotising enterocolitis were matched (by year of birth and type of congenital heart lesion) with 180 controls (1:3 ratio). Multivariable conditional logistic regression was used to assess the study question. RESULTS The overall prevalence of necrotising enterocolitis was 6.3% in term-born newborns with CHD. Neonates with a left-ventricular outflow tract lesion or single ventricle lesion accounted for 55% (n = 33) of cases. 62% (n = 37) cases were in the modified Bell's stage 2 or more for necrotising enterocolitis classification. In multivariable modelling, gestational age at birth was not associated with the development of necrotising enterocolitis [adjusted odds ratio per week increase, 95% confidence interval: 1.20 (0.90-1.60)]. Birth by caesarean delivery (compared to vaginal) was strongly associated with development of necrotising enterocolitis [adjusted odds ratio (95% confidence interval): 2.64 (1.31-5.29)]. We failed to identify an association between preoperative enteral nutrition and necrotising enterocolitis. CONCLUSION This study showed a high risk of necrotising enterocolitis in newborns with critical CHD born via caesarean. This information is important given the high prevalence of planned birth by caesarean in newborns with CHD.
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Affiliation(s)
- Eloise Ihle
- Cardiac Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
| | - Jenny Thompson
- Cardiac Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
| | - Warwick Butt
- Cardiac Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Siva P Namachivayam
- Cardiac Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
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22
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Wang Z, Ma K, Zhu Y, Li Z, Li S. Predictive Value of Myocardial Markers for Early Postoperative Mortality in Children with Congenital Heart Disease. Pediatr Cardiol 2024:10.1007/s00246-024-03404-0. [PMID: 38363311 DOI: 10.1007/s00246-024-03404-0] [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: 11/25/2023] [Accepted: 01/04/2024] [Indexed: 02/17/2024]
Abstract
To investigate the influencing factors of postoperative creatine kinase-MB (CK-MB) elevation in children with congenital heart disease and its peak value in predicting early postoperative mortality. The clinical data of 521 children with congenital heart disease under the age of 14 who underwent elective surgery in Beijing Children's Hospital from December 2018 to December 2020 were retrospectively analyzed. Stepwise multiple linear regression was used to analyze independent risk factors for postoperative CK-MB elevation, receiver operating characteristic (ROC) curve was used to determine the predictive value of postoperative CK-MB peak, CK peak, and LDH peak on mortality, and linear correlation and regression analysis were used to analyze the interdependence among postoperative CK-MB peak, CK peak, and LDH peak, and multivariate Logistic regression was used to identify independent risk factors for early postoperative mortality. Preterm birth (P = 0.004), ventriculotomy (P = 0.009), the re-establish of bypass (P = 0.007), cardiopulmonary bypass time (P = 0.024), deep hypothermic circulatory arrest time (P = 0.000), assisted ventilation time (P = 0.049), CK peak (P = 0.000), and LDH peak (P = 0.000) were independently associated with increased postoperative CK-MB elevation. The ROC curve showed that CK-MB peak had the strongest predictive value for death (AUC = 0.924), followed by LDH peak (AUC = 0.864) and CK peak (AUC = 0.758). The cut-off value of the postoperative CK-MB peak was 144.5 IU/L, with a sensitivity of 87% and a specificity of 97%. CK-MB peak was moderately correlated with CK peak (Pearson Correlation coefficient r = 0.514, P = 0.000) and strongly correlated with LDH peak (Pearson Correlation coefficient r = 0.601, P = 0.000). Multivariate analysis showed that delayed chest closure (OR = 4.865, P = 0.004) and postoperative CK-MB peak (OR = 1.031, P = 0.000) were independent risk factors for postoperative mortality. The postoperative CK-MB peak has a certain predictive value for the early postoperative mortality of children with congenital heart disease. It is affected by many factors, and the risk of mortality is significantly increased in children with severely elevated postoperative CK-MB.
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Affiliation(s)
- Zhangwei Wang
- Department of Cardiovascular Surgery, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing, China
| | - Kai Ma
- Department of Cardiovascular Surgery, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing, China
| | - Yaobin Zhu
- Department of Cardiac Surgery, Beijing Children's Hospital, Capital Medical University, National Children's Medical Center, Beijing, China
| | - Zhiqiang Li
- Department of Cardiac Surgery, Beijing Children's Hospital, Capital Medical University, National Children's Medical Center, Beijing, China
| | - Shoujun Li
- Department of Cardiovascular Surgery, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing, China.
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23
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Sengupta A, Gauvreau K, Kohlsaat K, Lee JM, Mayer JE, Del Nido PJ, Nathan M. Prognostic utility of a novel risk prediction model of 1-year mortality in patients surviving to discharge after surgery for congenital or acquired heart disease. J Thorac Cardiovasc Surg 2024; 167:454-463.e6. [PMID: 37160220 DOI: 10.1016/j.jtcvs.2023.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/09/2023] [Accepted: 04/22/2023] [Indexed: 05/11/2023]
Abstract
OBJECTIVE We sought to develop a novel risk prediction model of 1-year mortality after congenital heart surgery that accounts for clinical, anatomic, echocardiographic, and socioeconomic factors. METHODS This was a single-center, retrospective review of consecutive index operations for congenital or acquired heart disease, from January 2011 to January 2021, among patients with known survival status at 1 year after discharge from the index hospitalization. The primary outcome was postdischarge mortality at 1 year. Variables of interest included age, prematurity, noncardiac anomalies or syndromes, the Childhood Opportunity Index, primary procedure, major adverse postoperative complications, and the Residual Lesion Score. Logistic regression was used to develop a weighted risk score for the primary outcome. Internal validation using a bootstrap-resampling approach was performed. RESULTS Of 10,412 consecutive operations for congenital or acquired heart disease, 8808 (84.6%) cases met entry criteria, including survival to discharge. There were 190 (2.2%) deaths at 1 year postdischarge. A weighted risk score was formulated on the basis of the variables in the final risk prediction model, which included all aforementioned risk factors of interest. This model had a C-statistic of 0.82 (95% confidence interval, 0.80-0.85). The median risk score was 6 (interquartile range, 4-8) points. Patients were categorized as low (score 0-5), medium (score 6-10), high (score 11-15), or very high (score 16-20) risk. The expected probability of mortality was 0.4% ± 0.2%, 2.0% ± 1.1%, 10.1% ± 5.0%, and 36.6% ± 9.6% for low-risk, medium-risk, high-risk, and very high-risk patients, respectively. CONCLUSIONS A risk prediction model of 1-year mortality may guide prognostication and follow-up of patients after discharge after surgery for congenital or acquired heart disease.
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Affiliation(s)
- Aditya Sengupta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Biostatistics, Harvard School of Public Health, Boston, Mass
| | | | - Ji M Lee
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass.
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24
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Lücht J, Seiler R, Herre AL, Brankova L, Fritsche-Guenther R, Kirwan J, Huscher D, Münzfeld H, Berger F, Photiadis J, Tong G, Schmitt KRL. Promising results of a clinical feasibility study: CIRBP as a potential biomarker in pediatric cardiac surgery. Front Cardiovasc Med 2024; 11:1247472. [PMID: 38361581 PMCID: PMC10867162 DOI: 10.3389/fcvm.2024.1247472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 01/19/2024] [Indexed: 02/17/2024] Open
Abstract
Objective Cold-inducible RNA binding Protein (CIRBP) has been shown to be a potent inflammatory mediator and could serve as a novel biomarker for inflammation. Systemic inflammatory response syndrome (SIRS) and capillary leak syndrome (CLS) are frequent complications after pediatric cardiac surgery increasing morbidity, therefore early diagnosis and therapy is crucial. As CIRBP serum levels have not been analyzed in a pediatric population, we conducted a clinical feasibility establishing a customized magnetic bead panel analyzing CIRBP in pediatric patients undergoing cardiac surgery. Methods A prospective hypothesis generating observational clinical study was conducted at the German Heart Center Berlin during a period of 9 months starting in May 2020 (DRKS00020885, https://drks.de/search/de/trial/DRKS00020885). Serum samples were obtained before the cardiac operation, upon arrival at the pediatric intensive care unit, 6 and 24 h after the operation in patients up to 18 years of age with congenital heart disease (CHD). Customized multiplex magnetic bead-based immunoassay panels were developed to analyze CIRBP, Interleukin-1β (IL-1β), Interleukin-6 (IL-6), Interleukin-8 (IL-8), Interleukin-10 (IL-10), Monocyte chemotactic protein 1 (MCP-1), Syndecan-1 (SDC-1), Thrombomodulin (TM), Vascular endothelial growth factor (VEGF-A), Angiopoietin-2 (Ang-2), and Fibroblast growth factor 23 (FGF-23) in 25 µl serum using the Luminex MagPix® system. Results 19 patients representing a broad range of CHD (10 male patients, median age 2 years, 9 female patients, median age 3 years) were included in the feasibility study. CIRBP was detectable in the whole patient cohort. Relative to individual baseline values, CIRBP concentrations increased 6 h after operation and returned to baseline levels over time. IL-6, IL-8, IL-10, and MCP-1 concentrations were significantly increased after operation and except for MCP-1 concentrations stayed upregulated over time. SDC-1, TM, Ang-2, as well as FGF-23 concentrations were also significantly increased, whereas VEGF-A concentration was significantly decreased after surgery. Discussion Using customized magnetic bead panels, we were able to detect CIRBP in a minimal serum volume (25 µl) in all enrolled patients. To our knowledge this is the first clinical study to assess CIRBP serum concentrations in a pediatric population.
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Affiliation(s)
- Jana Lücht
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Raphael Seiler
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Berlin, Germany
| | - Alexa Leona Herre
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Berlin, Germany
| | - Liliya Brankova
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Berlin, Germany
| | - Raphaela Fritsche-Guenther
- Metabolomics Platform, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Jennifer Kirwan
- Metabolomics Platform, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Dörte Huscher
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Hanna Münzfeld
- Department of Radiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Berlin, Germany
| | - Joachim Photiadis
- Department of Congenital Heart Surgery and Pediatric Heart Surgery, Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Berlin, Germany
| | - Giang Tong
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Berlin, Germany
| | - Katharina R. L. Schmitt
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Berlin, Germany
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Li H, Zhou M, Sun Y, Yang J, Zeng X, Qiu Y, Xia Y, Zheng Z, Yu J, Feng Y, Shi Z, Huang T, Tan L, Lin R, Li J, Fan X, Ye J, Duan H, Shi S, Shu Q. A Patient Similarity Network (CHDmap) to Predict Outcomes After Congenital Heart Surgery: Development and Validation Study. JMIR Med Inform 2024; 12:e49138. [PMID: 38297829 PMCID: PMC10850852 DOI: 10.2196/49138] [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: 05/24/2023] [Revised: 08/21/2023] [Accepted: 11/16/2023] [Indexed: 02/02/2024] Open
Abstract
Background Although evidence-based medicine proposes personalized care that considers the best evidence, it still fails to address personal treatment in many real clinical scenarios where the complexity of the situation makes none of the available evidence applicable. "Medicine-based evidence" (MBE), in which big data and machine learning techniques are embraced to derive treatment responses from appropriately matched patients in real-world clinical practice, was proposed. However, many challenges remain in translating this conceptual framework into practice. Objective This study aimed to technically translate the MBE conceptual framework into practice and evaluate its performance in providing general decision support services for outcomes after congenital heart disease (CHD) surgery. Methods Data from 4774 CHD surgeries were collected. A total of 66 indicators and all diagnoses were extracted from each echocardiographic report using natural language processing technology. Combined with some basic clinical and surgical information, the distances between each patient were measured by a series of calculation formulas. Inspired by structure-mapping theory, the fusion of distances between different dimensions can be modulated by clinical experts. In addition to supporting direct analogical reasoning, a machine learning model can be constructed based on similar patients to provide personalized prediction. A user-operable patient similarity network (PSN) of CHD called CHDmap was proposed and developed to provide general decision support services based on the MBE approach. Results Using 256 CHD cases, CHDmap was evaluated on 2 different types of postoperative prognostic prediction tasks: a binary classification task to predict postoperative complications and a multiple classification task to predict mechanical ventilation duration. A simple poll of the k-most similar patients provided by the PSN can achieve better prediction results than the average performance of 3 clinicians. Constructing logistic regression models for prediction using similar patients obtained from the PSN can further improve the performance of the 2 tasks (best area under the receiver operating characteristic curve=0.810 and 0.926, respectively). With the support of CHDmap, clinicians substantially improved their predictive capabilities. Conclusions Without individual optimization, CHDmap demonstrates competitive performance compared to clinical experts. In addition, CHDmap has the advantage of enabling clinicians to use their superior cognitive abilities in conjunction with it to make decisions that are sometimes even superior to those made using artificial intelligence models. The MBE approach can be embraced in clinical practice, and its full potential can be realized.
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Affiliation(s)
- Haomin Li
- Clinical Data Center, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Mengying Zhou
- Clinical Data Center, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- The College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Yuhan Sun
- Clinical Data Center, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- The College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Jian Yang
- Clinical Data Center, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- The College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Xian Zeng
- Clinical Data Center, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- The College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Yunxiang Qiu
- Cardiac Intensive Care Unit, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Yuanyuan Xia
- Cardiac Intensive Care Unit, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Zhijie Zheng
- Cardiac Intensive Care Unit, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jin Yu
- Ultrasonography Department, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Yuqing Feng
- Clinical Data Center, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Zhuo Shi
- Cardiac Surgery, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Ting Huang
- Cardiac Surgery, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Linhua Tan
- Cardiac Intensive Care Unit, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Ru Lin
- Cardiac Surgery, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jianhua Li
- Cardiac Surgery, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Xiangming Fan
- Cardiac Surgery, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jingjing Ye
- Ultrasonography Department, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Huilong Duan
- The College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Shanshan Shi
- Cardiac Intensive Care Unit, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Qiang Shu
- Cardiac Surgery, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
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Law YM, Hsu C, Hingorani SR, Richards M, McMullan DM, Jefferies H, Himmelfarb J, Katz R. Randomized controlled trial of remote ischemic preconditioning in children having cardiac surgery. J Cardiothorac Surg 2024; 19:5. [PMID: 38172875 PMCID: PMC10765905 DOI: 10.1186/s13019-023-02450-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 11/04/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Children undergoing cardiac surgery are at risk for acute kidney injury (AKI) and cardiac dysfunction. Opportunity exists in protecting end organ function with remote ischemic preconditioning. We hypothesize this intervention lessens kidney and myocardial injury. METHODS We conducted a randomized, double blind, placebo controlled trial of remote ischemic preconditioning in children undergoing cardiac surgery. Pre-specified end points are change in creatinine, estimated glomerular filtration rate, development of AKI, B-type natriuretic peptide and troponin I at 6, 12, 24, 48, 72 h post separation from bypass. RESULTS There were 45 in the treatment and 39 patients in the control group, median age of 3.5 and 3.8 years, respectively. There were no differences between groups in creatinine, cystatin C, eGFR at each time point. There was a trend for a larger rate of decrease, especially for cystatin C (p = 0.042) in the treatment group but the magnitude was small. AKI was observed in 21 (54%) of control and 16 (36%) of treatment group (p = 0.094). Adjusting for baseline creatinine, the odds ratio for AKI in treatment versus control was 0.31 (p = 0.037); adjusting for clinical characteristics, the odds ratio was 0.34 (p = 0.056). There were no differences in natriuretic peptide or troponin levels between groups. All secondary end points of clinical outcomes were not different. CONCLUSIONS There is suggestion of RIPC delivering some kidney protection in an at-risk pediatric population. Larger, higher risk population studies will be required to determine its efficacy. Trial registration and date: Clinicaltrials.gov NCT01260259; 2021.
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Affiliation(s)
- Yuk M Law
- Pediatric Cardiology, Department of Pediatrics, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
- University of Washington School of Medicine, Seattle, WA, 98115, USA.
| | - Christine Hsu
- Kaiser Permanente of Washington, Seattle, WA, 98105, USA
| | - Sangeeta R Hingorani
- Pediatric Cardiology, Department of Pediatrics, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
- University of Washington School of Medicine, Seattle, WA, 98115, USA
| | - Michael Richards
- Pediatric Cardiology, Department of Pediatrics, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
- University of Washington School of Medicine, Seattle, WA, 98115, USA
| | - David M McMullan
- Pediatric Cardiology, Department of Pediatrics, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
- University of Washington School of Medicine, Seattle, WA, 98115, USA
| | - Howard Jefferies
- Pediatric Cardiology, Department of Pediatrics, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
- University of Washington School of Medicine, Seattle, WA, 98115, USA
| | | | - Ronit Katz
- University of Washington School of Medicine, Seattle, WA, 98115, USA
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Skaff AM, Valikodath NG, Godown J, Parra DA. "In-patient echocardiography utilization post repair of congenital heart disease. Analysis of data from the Pediatric Health Information System from 2010 to 2019". Cardiol Young 2024:1-6. [PMID: 38163984 DOI: 10.1017/s1047951123004407] [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] [Indexed: 01/03/2024]
Abstract
BACKGROUND Echocardiography is a key diagnostic tool for medical decision-making following congenital heart surgery. Overall utilisation of echocardiography for specific congenital heart lesions following cardiac surgery has not previously been reported. This study aims to assess echocardiogram utilisation following the surgical repair of CHD to describe the variation in use across centres and provide clinical benchmarks. METHODS All patients < 18 years of age undergoing surgical repair of CHD were identified from the Pediatric Health Information System from 2010 to 2019. Surgeries were grouped based on their Risk Adjustment for Congenital Heart Surgery-1 scores. Detailed billing data were used to assess the frequency/cost of post-operative echocardiograms, phase of hospital care, and hospital length of stay. RESULTS In total, 37,238 surgical encounters were identified for inclusion across 48 centres. Higher Risk Adjustment for Congenital Heart Surgery scores were associated with an increased median number of post-operative echocardiograms (2 versus 4 in Risk Adjustment for Congenital Heart Surgery score 1 versus 6, p < 0.001), and longer median post-operative length of stay (3 days versus 31 days in Risk Adjustment for Congenital Heart Surgery score 1 versus 6, p < 0.001). After accounting for surgical complexity, there was significant variability in echocardiogram utilisation across centres (median daily echocardiogram utilisation range 0.2/day-0.6/day, p < 0.001). There is no difference in the proportion of patients with high surgical complexity (Risk Adjustment for Congenital Heart Surgery ≥ 4) between centres with high versus low echocardiogram utilisation (p = 0.44). CONCLUSIONS Increasing surgical complexity is associated with longer post-operative length of stay and increased utilisation of echocardiography. There is wide variability in echocardiography resource utilisation across centres, even when accounting for surgical complexity.
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Affiliation(s)
- Adam M Skaff
- Department of Pediatrics, Division of Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nishma G Valikodath
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Justin Godown
- Department of Pediatrics, Division of Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David A Parra
- Department of Pediatrics, Division of Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
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28
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Esmaeili Z, Asgarian F, Aghaei Moghadam E, Khosravi A, Gharib B. Prevalence, risk factors, and outcomes of acute kidney injury in a pediatric cardiac intensive care unit: A cross-sectional study. Health Sci Rep 2024; 7:e1791. [PMID: 38186930 PMCID: PMC10766875 DOI: 10.1002/hsr2.1791] [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: 08/28/2023] [Revised: 11/29/2023] [Accepted: 12/17/2023] [Indexed: 01/09/2024] Open
Abstract
Background and Aims Acute kidney injury (AKI) is a common complication in pediatric cardiac intensive care unit (CICU). This study aims to identify the prevalence, risk factors, and outcomes of AKI in pediatrics admitted to a CICU unit of a tertiary hospital. Methods We retrospectively gathered the data of 253 randomly selected patients admitted to the CICU unit from March 2018 to March 2022. Data were collected from EHRs. We used the Kidney Disease Improving Global Outcomes (KDIGO) criteria for identifying AKI in patients. Results Overall, AKI prevalence was 22.9% in our population. In the multivariable analysis, vancomycin intake (odds ratio [OR]: 2.109, 95% confidence interval [CI]: 1.15-3.84), angiography (OR: 4.38, 95% CI: 1.28-14.93), and mechanical ventilation (OR: 2.08, 95% CI: 1.02-4.23) were independent risk factors of AKI development and patients with AKI had a higher in-hospital mortality rate (OR: 5.81, 95% CI: 2.55-13.19), higher need for cardiopulmonary resuscitation (OR: 3.08, 95% CI: 1.17-8.09), and longer ICU length of stay (OR: 6.49, 95% CI: 3.31-9.67). Furthermore, furosemide administration was associated with lower risk of developing AKI (OR: 0.52, 95% CI: 0.27-0.97). Conclusion AKI is common and is associated with worse outcomes in patients with congenital heart disease. Our results emphasize the importance of early identification and monitoring of AKI in the pediatric CICU setting.
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Affiliation(s)
- Zahra Esmaeili
- School of MedicineTehran University of Medical SciencesTehranIran
| | - Fahimeh Asgarian
- Children's Medical CenterTehran University of Medical SciencesTehranIran
| | | | - Amirali Khosravi
- School of MedicineTehran University of Medical SciencesTehranIran
| | - Behdad Gharib
- Children's Medical CenterTehran University of Medical SciencesTehranIran
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Furnaz S, Shaikh AS, Qureshi R, Fatima S, Bangash SK, Karim M, Amanullah M. Factors associated with poor outcomes after congenital heart surgery in low-resource setting in Pakistan: insight from the IQIC Registry - a descriptive analysis. BMJ Open 2023; 13:e078884. [PMID: 38070894 PMCID: PMC10729235 DOI: 10.1136/bmjopen-2023-078884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/23/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVE This study aimed to assess the International Quality Improvement Collaborative single-site data from a developing country to identify trends in outcomes and factors associated with poor outcomes. DESIGN Retrospective descriptive study. SETTING The National Institute of Cardiovascular Diseases, Karachi, Pakistan. PARTICIPANTS Patients undergoing surgery for congenital heart disease (CHD). OUTCOME MEASURE Key factors were examined, including preoperative, procedural and demographic data, as well as surgical complications and outcomes. We identified risk factors for mortality, bacterial sepsis and 30-day mortality using multivariable logistic regression. RESULTS A total of 3367 CHD surgical cases were evaluated; of these, 59.4% (2001) were male and 82.8% (2787) were between the ages of 1 and 17 years. Only 0.2% (n=6) were infants (≤30 days) and 2.3% (n=77) were adults (≥18 years). The in-hospital mortality rate was 6.7% (n=224), and 4.4% (n=147) and 0.8% (n=27) had bacterial sepsis and surgical site infections, respectively. The 30-day status was known for 90.8% (n=3058) of the patients, of whom 91.6% (n=2800) were alive. On multivariable analysis, the adjusted OR for in-hospital mortality was 0.40 (0.29-0.56) for teenagers compared with infancy/childhood and 1.95 (1.45-2.61) for patients with oxygen saturation <85%. Compared with Risk Adjustment for Congenital Heart Surgery (RACHS-1) risk category 1, the adjusted OR for in-hospital mortality was 1.78 (1.1-2.87) for RACHS-1 risk category 3 and 2.92 (1.03-8.31) for categories 4-6. The adjusted OR for 30-day mortality was 0.40 (0.30-0.55) for teenagers and 1.52 (1.16-1.98) for patients with oxygen saturation <85%. The 30-day mortality rate was significantly higher in RACHS-1 risk category 3 compared with category 1, with an adjusted OR of 1.64 (1.06-2.55). CONCLUSIONS We observed a high prevalence of postoperative infections and mortality, especially for high-risk procedures, according to RACHS-1 risk category, in infancy/childhood, in children with genetic syndrome or those with low oxygen saturation (<85%).
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Affiliation(s)
- Shumaila Furnaz
- National Institute of Cardiovascular Diseases, Karachi, Pakistan
| | | | - Rayyan Qureshi
- National Institute of Cardiovascular Diseases, Karachi, Pakistan
| | - Subhani Fatima
- National Institute of Cardiovascular Diseases, Karachi, Pakistan
| | | | - Musa Karim
- National Institute of Cardiovascular Diseases, Karachi, Pakistan
| | - Muneer Amanullah
- National Institute of Cardiovascular Diseases, Karachi, Pakistan
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30
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Jayaram N, Allen P, Hall M, Karamlou T, Woo J, Crook S, Anderson BR. Adjusting for Congenital Heart Surgery Risk Using Administrative Data. J Am Coll Cardiol 2023; 82:2212-2221. [PMID: 38030351 DOI: 10.1016/j.jacc.2023.09.826] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/11/2023] [Accepted: 09/26/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Congenital heart surgery (CHS) encompasses a heterogeneous population of patients and surgeries. Risk standardization models that adjust for patient and procedural characteristics can allow for collective study of these disparate patients and procedures. OBJECTIVES We sought to develop a risk-adjustment model for CHS using the newly developed Risk Stratification for Congenital Heart Surgery for ICD-10 Administrative Data (RACHS-2) methodology. METHODS Within the Kids' Inpatient Database 2019, we identified all CHSs that could be assigned a RACHS-2 score. Hierarchical logistic regression (clustered on hospital) was used to identify patient and procedural characteristics associated with in-hospital mortality. Model validation was performed using data from 24 State Inpatient Databases during 2017. RESULTS Of 5,902,538 total weighted hospital discharges in the Kids' Inpatient Database 2019, 22,310 pediatric cardiac surgeries were identified and assigned a RACHS-2 score. In-hospital mortality occurred in 543 (2.4%) of cases. Using only RACHS-2, the mortality mode had a C-statistic of 0.81 that improved to 0.83 with the addition of age. A final multivariable model inclusive of RACHS-2, age, payer, and presence of a complex chronic condition outside of congenital heart disease further improved model discrimination to 0.87 (P < 0.001). Discrimination in the validation cohort was also very good with a C-statistic of 0.83. CONCLUSIONS We created and validated a risk-adjustment model for CHS that accounts for patient and procedural characteristics associated with in-hospital mortality available in administrative data, including the newly developed RACHS-2. Our risk model will be critical for use in health services research and quality improvement initiatives.
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Affiliation(s)
| | - Philip Allen
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Matthew Hall
- Children's Hospital Association, Lenexa, Kansas, USA
| | | | - Joyce Woo
- Lurie Children's Hospital, Chicago, Illinois, USA
| | - Sarah Crook
- NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Brett R Anderson
- NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
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Bauer JK, Hocama N, Traub AC, Rutes G, Fachi MM, Moraes J, Lenzi A, Barreto HAG. Chylothorax After Heart Surgery in Children. Pediatr Cardiol 2023; 44:1847-1855. [PMID: 37561171 DOI: 10.1007/s00246-023-03250-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023]
Abstract
Chylothorax is a consequence of a thoracic duct injury that can occur during surgical procedures in patients with congenital heart disease. It is associated with high rates of morbimortality and increased use of clinical and hospital resources. The aim of this study was to evaluate the risk factors, distribution, manifestations, complications, and treatments for chylothorax in patients undergoing cardiac surgery in a tertiary pediatric hospital in southern Brazil. This is a retrospective, quantitative study, in which all medical records (n = 166) of patients with chylothorax after pediatric cardiac surgery between January 2014 and December of 2020 and a matched control group (n = 166) were analyzed. Over the study period, there was an increase in incidence of chylothorax from 4.5% in 2014 to 7.6% in 2020, a trend that has been reported in the literature. After multivariate analysis, the following were identified as risk factors for the diagnosis of chylothorax: genetic syndrome (OR 2.298); prolonged cardiopulmonary bypass time (greater than 120 min) (OR 2.410); fluid overload in the immediate postoperative period (OR 1.110); and SIRS (OR 2.527). Mortality was two times greater (p = 0.021) and there was a higher rate (34.4%) of infection (p < 0.001) in patients who developed chylothorax. In addition, a sensitivity analysis was performed comparing patients with low- and high-output chylothorax (> 20 mL/kg), which confirmed unfavorable outcomes for the latter group. Herein, we show that hemodynamic alterations were important factors for diagnosis. Understanding the risk factors, outcomes, and complications helps early identification and enables the reduction of morbidity and mortality.
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Affiliation(s)
- Juliane Kuster Bauer
- Pequeno Príncipe Hospital, Desembargador Motta st., 80.250-060, Curitiba, PR, 1070, Brasil
| | - Nathalia Hocama
- Pequeno Príncipe Hospital, Desembargador Motta st., 80.250-060, Curitiba, PR, 1070, Brasil
| | - Anna Clara Traub
- Pequeno Príncipe Hospital, Desembargador Motta st., 80.250-060, Curitiba, PR, 1070, Brasil
| | - Gabriel Rutes
- Pequeno Príncipe Hospital, Desembargador Motta st., 80.250-060, Curitiba, PR, 1070, Brasil
| | - Mariana Millan Fachi
- Pequeno Príncipe Hospital, Desembargador Motta st., 80.250-060, Curitiba, PR, 1070, Brasil
| | - Janaina Moraes
- Pequeno Príncipe Hospital, Desembargador Motta st., 80.250-060, Curitiba, PR, 1070, Brasil
| | - Andrea Lenzi
- Pequeno Príncipe Hospital, Desembargador Motta st., 80.250-060, Curitiba, PR, 1070, Brasil
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32
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Danford DA, Yetman AT, Haynatzki G. Derivation and Validation of a General Predictive Model for Long Term Risks for Mortality and Invasive Interventions in Congenital and Acquired Cardiac Conditions Encountered in the Young. Pediatr Cardiol 2023; 44:1763-1777. [PMID: 37069273 DOI: 10.1007/s00246-023-03154-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 03/20/2023] [Indexed: 04/19/2023]
Abstract
Accurate prognostic assessment is a key driver of clinical decision making in heart disease in the young (HDY). This investigation aims to derive, validate, and calibrate multivariable predictive models for time to surgical or catheter-mediated intervention (INT) and for time to death in HDY. 4108 unique subjects were prospectively and consecutively enrolled, and randomized to derivation and validation cohorts. Total follow-up was 26,578 patient-years, with 102 deaths and 868 INTs. Accelerated failure time multivariable predictive models for the outcomes, based on primary and secondary diagnoses, pathophysiologic severity, age, sex, genetic comorbidities, and prior interventional history, were derived using piecewise exponential methodology. Model predictions were validated, calibrated, and evaluated for sensitivity to changes in the independent variables. Model validity was excellent for predicting mortality and INT at 4 months, 1, 5, 10, and 22 years (areas under receiver operating characteristic curves 0.813-0.915). Model calibration was better for INT than for mortality. Age, sex, and genetic comorbidities were significant independent factors, but predicted outcomes were most sensitive to variations in composite predictors incorporating primary diagnosis, pathophysiologic severity, secondary diagnosis, and prior intervention. Despite 22 years of data acquisition, no significant cohort effects were identified in which predicted mortality and intervention varied by study entry date. A piecewise exponential model predicting survival and freedom from INT is derived which demonstrates excellent validity, and performs well on a clinical sample of HDY outpatients. Objective model-based predictions could educate both patient and provider, and inform clinical decision making in HDY.
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Affiliation(s)
- David A Danford
- University of Nebraska Medical Center, Omaha, NE, USA.
- Criss Heart Center at Children's Hospital and Medical Center, Omaha, NE, USA.
- , 804 S. 129th Ave, Omaha, NE, 68154, USA.
| | - Anji T Yetman
- University of Nebraska Medical Center, Omaha, NE, USA
- Criss Heart Center at Children's Hospital and Medical Center, Omaha, NE, USA
| | - Gleb Haynatzki
- School of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
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33
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Lee JH, Denault AY, Beaubien-Souligny W, Kang P, Kim J, Kim HW, Ji SH, Jang YE, Kim EH, Kim HS, Kim JT. Higher portal venous pulsatility is associated with worse clinical outcomes following congenital heart surgery: a single-centre prospective cohort study. Can J Anaesth 2023; 70:1957-1969. [PMID: 37919629 DOI: 10.1007/s12630-023-02605-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 05/02/2023] [Accepted: 05/10/2023] [Indexed: 11/04/2023] Open
Abstract
PURPOSE Increased portal venous flow pulsatility is associated with major complications after adult cardiac surgery. Nevertheless, no data are available for pediatric patients with congenital heart disease. We hypothesized that Doppler parameters including portal flow pulsatility could be associated with postoperative outcomes in children undergoing various cardiac surgeries. METHODS We conducted a prospective observational cohort study in children undergoing congenital cardiac surgery. We obtained postoperative portal, splenic, and hepatic venous Doppler data and perioperative clinical data including major postoperative complications. Portal and splenic venous flow pulsatility were calculated. We evaluated the association between venous Doppler parameters and adverse outcomes. The primary objective was to determine whether postoperative portal flow pulsatility could indicate major complications following congenital heart surgery. RESULTS In this study, we enrolled 389 children, 74 of whom experienced major postoperative complications. The mean (standard deviation) portal pulsatility (44 [30]% vs 25 [14]%; 95% confidence interval [CI] for mean difference, 12 to 26; P < 0.001] and splenic pulsatility indices (41 [30]% vs 26 [16]%; 95% CI, 7 to 23; P < 0.001) were significantly higher in children with postoperative complications than in those without complications. The portal pulsatility index was able to help identify postoperative complications in biventricular patients and univentricular patients receiving bidirectional cavopulmonary shunt whereas it did not in other univentricular patients. An increased postoperative portal pulsatility index was significantly associated with major complications after pediatric cardiac surgery (odds ratio, 1.40; 95% CI, 1.29 to 1.91; P < 0.001). CONCLUSIONS Higher portal venous pulsatility is associated with major postoperative complications in children undergoing cardiac surgery. Nevertheless, more data are needed to conclude the efficacy of portal venous pulsatility in patients with univentricular physiology. STUDY REGISTRATION ClinicalTrials.gov (NCT03990779); registered 19 June 2019.
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Affiliation(s)
- Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - André Y Denault
- Department of Anesthesiology and Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - William Beaubien-Souligny
- Division of Nephrology, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montreal, QC, Canada
| | - Pyoyoon Kang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jay Kim
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Republic of Korea
| | - Hee-Won Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sang-Hwan Ji
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young-Eun Jang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eun-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, # 101 Daehakno, Jongnogu, Seoul, 03080, South Korea.
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Erdem Ö, de Graaff JC, Hilty MP, Kraemer US, de Liefde II, van Rosmalen J, Ince C, Tibboel D, Kuiper JW. Microcirculatory Monitoring in Children with Congenital Heart Disease Before and After Cardiac Surgery. J Cardiovasc Transl Res 2023; 16:1333-1342. [PMID: 37450208 PMCID: PMC10721654 DOI: 10.1007/s12265-023-10407-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023]
Abstract
In this prospective observational study, we investigated whether congenital heart disease (CHD) affects the microcirculation and whether the microcirculation is altered following cardiac surgery with cardiopulmonary bypass (CPB). Thirty-eight children with CHD undergoing cardiac surgery with CPB and 35 children undergoing elective, non-cardiac surgery were included. Repeated non-invasive sublingual microcirculatory measurements were performed with handheld vital microscopy. Before surgery, children with CHD showed similar perfused vessel densities and red blood cell velocities (RBCv) but less perfused vessels (p < 0.001), lower perfusion quality (p < 0.001), and higher small vessel densities (p = 0.039) than children without CHD. After cardiac surgery, perfused vessel densities and perfusion quality of small vessels declined (p = 0.025 and p = 0.032), while RBCv increased (p = 0.032). We demonstrated that CHD was associated with decreased microcirculatory perfusion and increased capillary recruitment. The microcirculation was further impaired after cardiac surgery. Decreased microcirculatory perfusion could be a warning sign for altered tissue oxygenation and requires further exploration.
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Affiliation(s)
- Özge Erdem
- Intensive Care and department of Pediatric Surgery, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Jurgen C de Graaff
- Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Matthias P Hilty
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Ulrike S Kraemer
- Intensive Care and department of Pediatric Surgery, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Inge I de Liefde
- Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Dick Tibboel
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jan Willem Kuiper
- Intensive Care and department of Pediatric Surgery, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
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Yoshida T, Sakura T, Shimizu K, Kimura S, Iwasaki T, Kanazawa T, Morimatsu H. Carboxyhemoglobin and Methemoglobin Levels and Hemolysis in Children Undergoing Cardiac Surgery With Cardiopulmonary Bypass. ASAIO J 2023; 69:1099-1105. [PMID: 37788481 DOI: 10.1097/mat.0000000000002044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Hemolysis is a complication of cardiopulmonary bypass (CPB). Carboxyhemoglobin (COHb) and methemoglobin (MetHb) were suggested as potential hemolysis biomarkers. This retrospective study was based on a prospective registry aimed to determine the association of COHb and MetHb levels with hemolysis in pediatric patients <4 years old who underwent cardiac surgery with CPB. Plasma-free hemoglobin (PFH), COHb, and MetHb levels were measured before CPB; every 30 minutes during CPB; and on postoperative days 1, 2, and 3. Patients were classified into hemolysis and nonhemolysis groups based on the maximum PFH levels during CPB. A total of 193 patients were included. No significant difference was observed in the maximum COHb levels during CPB (COHb CPB ) between the hemolysis and nonhemolysis groups (1.2% [interquartile range {IQR} 0.9-1.4%] vs. 1.1% [IQR: 0.9-1.4%]; p = 0.17). The maximum MetHb levels during CPB (MetHb CPB ) were significantly higher in the hemolysis group than in the nonhemolysis group (1.3% [IQR: 1.1-1.5%] vs. 1.2% [IQR: 1.0-1.4%]; p = 0.007). Areas under the receiver operating curves of COHb CPB and MetHb CPB were 0.557 (95% confidence interval: 0.475-0.640) and 0.615 (95% confidence interval: 0.535-0.695), respectively. Therefore, the predictive ability of both hemolysis biomarkers during CPB is limited.
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Affiliation(s)
- Tsubasa Yoshida
- From the Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Takanobu Sakura
- From the Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan
| | - Kazuyoshi Shimizu
- From the Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan
| | - Satoshi Kimura
- From the Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan
| | - Tatsuo Iwasaki
- From the Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan
| | - Tomoyuki Kanazawa
- From the Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan
| | - Hiroshi Morimatsu
- From the Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan
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Kong X, Zhao L, Pan Z, Li H, Wei G, Wang Q. Acute renal injury after aortic arch reconstruction with cardiopulmonary bypass for children: prediction models by machine learning of a retrospective cohort study. Eur J Med Res 2023; 28:499. [PMID: 37941080 PMCID: PMC10631067 DOI: 10.1186/s40001-023-01455-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 10/17/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Acute renal injury (AKI) after aortic arch reconstruction with cardiopulmonary bypass leads to injury of multiple organs and increases perioperative mortality. The study was performed to explore risk factors for AKI. We aim to develop a prediction model that can be used to accurately predict AKI through machine learning (ML). METHODS A retrospective analysis was performed on 134 patients with aortic arch reconstruction with cardiopulmonary bypass who were treated at our hospital from January 2002 to January 2022. Risk factors for AKI were compositive and were evaluated with comprehensive analyses. Six artificial intelligence (AI) models were used for machine learning to build prediction models and to screen out the best model to predict AKI. RESULTS Weight, eGFR, cyanosis, PDA, newborn birth and duration of renal ischemia were closely related to AKI. By integrating the results of the training cohort and validation cohort, we finally confirmed that the logistic regression model was the most stable model among all the models, and the logistic regression model showed good discrimination, calibration and clinical practicability. Based on 6 independent factors, the dynamic nomogram can be used as a predictive tool for clinical application. CONCLUSIONS DHCA could be considered in aortic arch reconstruction if additional perfusion of lower body were not performed especially when renal ischemia is greater than 30 min. Machine Learning models should be developed for early recognition of AKI. TRIAL REGISTRATION ChiCTR, ChiCTR2200060552. Registered 4 june 2022.
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Affiliation(s)
- Xiangpan Kong
- Department of Urology Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, No.136 Zhongshan Second Road, Yuzhong District, Chongqing, 400014, China
- Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, China
| | - Lu Zhao
- Department of Cardiothoracic Surgery Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Higher Institution Engineering Research Center of Children's Medical Big Data Intelligent Application, No.136 Zhongshan Second Road, Yuzhong District, Chongqing, 400014, China
- Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, China
| | - Zhengxia Pan
- Department of Cardiothoracic Surgery Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Higher Institution Engineering Research Center of Children's Medical Big Data Intelligent Application, No.136 Zhongshan Second Road, Yuzhong District, Chongqing, 400014, China
- Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, China
| | - Hongbo Li
- Department of Cardiothoracic Surgery Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Higher Institution Engineering Research Center of Children's Medical Big Data Intelligent Application, No.136 Zhongshan Second Road, Yuzhong District, Chongqing, 400014, China
- Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, China
| | - Guanghui Wei
- Department of Urology Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, No.136 Zhongshan Second Road, Yuzhong District, Chongqing, 400014, China
- Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, China
| | - Quan Wang
- Department of Cardiothoracic Surgery Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Higher Institution Engineering Research Center of Children's Medical Big Data Intelligent Application, No.136 Zhongshan Second Road, Yuzhong District, Chongqing, 400014, China.
- Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, China.
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Takahashi Y, Ueno K, Nakae K, Kawamura J, Matsuba T, Okamoto Y. Preoperative and Intraoperative Risk Factors for Surgical Site Infection in Pediatric Cardiac Surgery. Pediatr Infect Dis J 2023; 42:949-953. [PMID: 37625108 DOI: 10.1097/inf.0000000000004039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Abstract
BACKGROUND Surgical site infection (SSI) is a major complication of pediatric cardiac surgery. If the risk of developing SSI can be predicted based on the patient's preoperative background, appropriate preoperative management to prevent the development of SSI can be achieved. METHODS We retrospectively studied cases for patients younger than 7 years of age among surgeries performed through a median sternotomy at Kagoshima University Hospital from April 2011 to March 2021. SSI was diagnosed according to the Centers for Disease Control and Prevention guidelines and classified into 3 types: superficial incisional SSI (SiSSI), deep incisional SSI (DiSSI) and mediastinitis. RESULTS Of the 765 consecutive pediatric cardiac surgeries, 597 were included in the analysis based on the exclusion criteria. Of these, 17 (2.8%) developed SSI (3 SiSSI cases, 2 DiSSI cases and 12 mediastinitis cases), with Staphylococcus aureus as the major pathogen. Univariate analysis revealed that low preoperative serum protein ( P = 0.049) and low serum albumin levels ( P = 0.023) were risk factors for the development of SSI. No findings suggested impaired hepatic synthesis, inflammatory disease or protein loss from the kidney or intestinal tract. We concluded that malnutrition caused low serum protein and albumin levels. CONCLUSIONS Low preoperative serum protein and albumin levels are risk factors for SSI development of SSI. Nutritional status should be regularly assessed in children scheduled for cardiac surgery, and interventions, such as nutritional guidance, should be considered if malnutrition is suspected.
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Affiliation(s)
- Yoshihiro Takahashi
- From the Department of Pediatrics, Kagoshima University Hospital, Kagoshima City, Kagoshima, Japan
| | - Kentaro Ueno
- From the Department of Pediatrics, Kagoshima University Hospital, Kagoshima City, Kagoshima, Japan
| | - Koji Nakae
- From the Department of Pediatrics, Kagoshima University Hospital, Kagoshima City, Kagoshima, Japan
| | - Junpei Kawamura
- From the Department of Pediatrics, Kagoshima University Hospital, Kagoshima City, Kagoshima, Japan
| | - Tomoyuki Matsuba
- Department of Cardiovascular and Gastroenterogical Surgery, Kagoshima University Hospital, Kagoshima City, Kagoshima, Japan
| | - Yasuhiro Okamoto
- From the Department of Pediatrics, Kagoshima University Hospital, Kagoshima City, Kagoshima, Japan
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Bartucca LM, Shaykh R, Stock A, Dayton JD, Bacha E, Haque KD, Nellis ME. Epidemiology of severe bleeding in children following cardiac surgery involving cardiopulmonary bypass: use of Bleeding Assessment Scale for critically Ill Children (BASIC). Cardiol Young 2023; 33:1913-1919. [PMID: 36373273 DOI: 10.1017/s1047951122003493] [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: 11/16/2022]
Abstract
OBJECTIVES To describe the epidemiology of severe bleeding in the immediate post-operative period in children who undergo cardiopulmonary bypass surgery using the Bleeding Assessment Scale for critically Ill Children (BASIC). STUDY DESIGN Retrospective cohort study in a paediatric ICU from 2015 to 2020. RESULTS 356 children were enrolled; 59% were male with median (IQR) age 2.1 (0.5-8) years. Fifty-seven patients (16%) had severe bleeding in the first 24 hours post-operatively. Severe bleeding was observed more frequently in younger and smaller children with longer bypass and cross-clamp times (p-values <0.001), in addition to higher surgical complexity (p = 0.048). Those with severe bleeding received significantly more red blood cells, platelets, plasma, and cryoprecipitate in the paediatric ICU following surgery (all p-values <0.001). No laboratory values obtained on paediatric ICU admission were able to predict severe post-operative bleeding. Those with severe bleeding had significantly less paediatric ICU-free days (p = 0.010) and mechanical ventilation-free days (p = 0.013) as compared to those without severe bleeding. CONCLUSIONS Applying the BASIC definition to our cohort, severe bleeding occurred in 16% of children in the first day following cardiopulmonary bypass. Severe bleeding was associated with worse clinical outcomes. Standard laboratory assays do not predict bleeding warranting further study of available laboratory tests.
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Affiliation(s)
- Lisa M Bartucca
- Department of Pediatrics, New York-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Ramzi Shaykh
- Department of Pediatrics, New York-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Arabella Stock
- Department of Pediatrics, Division of Pediatric Critical Care, Weill Cornell Medicine, New York, NY, USA
| | - Jeffrey D Dayton
- Department of Pediatrics, Division of Pediatric Cardiology, Weill Cornell Medicine, New York, NY, USA
| | - Emile Bacha
- Section of Congenital and Pediatric Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Morgan Stanley Children's Hospital and Komansky Weill-Cornell, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Kelly D Haque
- Department of Pediatrics, Division of Pediatric Critical Care, Weill Cornell Medicine, New York, NY, USA
| | - Marianne E Nellis
- Department of Pediatrics, Division of Pediatric Critical Care, Weill Cornell Medicine, New York, NY, USA
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Gürsoy BK, Dilli D, Sarıkaya Y, Akduman H, Çitli R, Örün UA, Taşar M, Zenciroğlu A. Ultrasonographic evaluation of endotracheal tube position in newborns with CHD. Cardiol Young 2023; 33:2049-2053. [PMID: 36517980 DOI: 10.1017/s1047951122003420] [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: 12/23/2022]
Abstract
Many studies have been conducted to determine the most reliable technique for evaluating the position of the endotracheal tube in patients receiving mechanical ventilation support. In this study, we aimed to determine the endotracheal tube position by ultrasonography in intubated patients with a diagnosis of critical CHD followed in the neonatal ICU. METHODS In this prospective observational clinical study, we performed point-of-care ultrasound for endotracheal tube localisation in 65 intubated newborns with critical CHD. After routine radiography, each patient underwent point-of-care ultrasound examination with a portable ultrasonography device for endotracheal tube end-carina measurement. Endotracheal tube end-carina measurements on chest radiographs were compared with ultrasound images. RESULTS The mean gestational age and birth weight were 37.8 ± 2.19 weeks and 2888 ± 595 g, respectively. Ultrasound images were obtained after an average of 2.08 ± 1.6 hours from the radiographs. The average ultrasound time allocated to each patient was 5 minutes. The mean endotracheal tube tip-to-carina distance on chest X-ray and ultrasound were optimally 1.33 ± 0.64 cm and 1.43 ± 0.67 cm, respectively. There was no significant difference between chest X-ray and ultrasound measurements in endotracheal tube end-carina distance values evaluated by the Bland-Altman method (mean difference 0.10 cm, p = 0.068). There was a linear correlation between the endotracheal tube tip-carina distance in ultrasound and radiography evaluation (r2 = 0.60, p < 0.001). CONCLUSION It has been concluded that critical CHDs are frequently accompanied by vascular anomalies, and the endotracheal tube tip-carina distance measurement can be used by determining the carina section as a guide point in the ultrasonographic evaluation of the endotracheal tube location in this patient population.
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Affiliation(s)
- Başak Kaya Gürsoy
- Department of Neonatology, University of Health Sciences of Türkiye, Ankara Dr Sami Ulus Maternity and Children Training and Research Hospital, Ankara, Türkiye
| | - Dilek Dilli
- Department of Neonatology, University of Health Sciences of Türkiye, Ankara Dr Sami Ulus Maternity and Children Training and Research Hospital, Ankara, Türkiye
| | - Yasin Sarıkaya
- Department of Radiology, University of Health Sciences of Türkiye, Ankara Dr Sami Ulus Maternity and Children Training and Research Hospital, Ankara, Türkiye
| | - Hasan Akduman
- Department of Neonatology, University of Health Sciences of Türkiye, Ankara Dr Sami Ulus Maternity and Children Training and Research Hospital, Ankara, Türkiye
| | - Rumeysa Çitli
- Department of Neonatology, University of Health Sciences of Türkiye, Ankara Dr Sami Ulus Maternity and Children Training and Research Hospital, Ankara, Türkiye
| | - Utku Arman Örün
- Department of Pediatric Cardiology, University of Health Sciences of Türkiye, Ankara Dr Sami Ulus Maternity and Children Training and Research Hospital, Ankara, Türkiye
| | - Mehmet Taşar
- Department of Pediatric Cardiovascular Surgery, University of Health Sciences of Türkiye, Ankara Dr Sami Ulus Maternity and Children Training and Research Hospital, Ankara, Türkiye
| | - Ayşegül Zenciroğlu
- Department of Neonatology, University of Health Sciences of Türkiye, Ankara Dr Sami Ulus Maternity and Children Training and Research Hospital, Ankara, Türkiye
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Zürn C, Hübner D, Ziesenitz VC, Höhn R, Schuler L, Schlange T, Gorenflo M, Kari FA, Kroll J, Loukanov T, Klemm R, Stiller B. Model-driven survival prediction after congenital heart surgery. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad089. [PMID: 37279735 PMCID: PMC10493173 DOI: 10.1093/icvts/ivad089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/03/2023] [Indexed: 06/08/2023]
Abstract
OBJECTIVES The objective of the study was to improve postoperative risk assessment in congenital heart surgery by developing a machine-learning model based on readily available peri- and postoperative parameters. METHODS Our bicentric retrospective data analysis from January 2014 to December 2019 of established risk parameters for dismal outcome was used to train and test a model to predict postoperative survival within the first 30 days. The Freiburg training data consisted of 780 procedures; the Heidelberg test data comprised 985 procedures. STAT mortality score, age, aortic cross-clamp time and postoperative lactate values over 24 h were considered. RESULTS Our model showed an area under the curve (AUC) of 94.86%, specificity of 89.48% and sensitivity of 85.00%, resulting in 3 false negatives and 99 false positives.The STAT mortality score and the aortic cross-clamp time each showed a statistically highly significant impact on postoperative mortality. Interestingly, a child's age was barely statistically significant. Postoperative lactate values indicated an increased mortality risk if they were either constantly at a high level or low during the first 8 h postoperatively with an increase afterwards.When considering parameters available before, at the end of and 24 h after surgery, the predictive power of the complete model achieved the highest AUC. This, compared to the already high predictive power alone (AUC 88.9%) of the STAT mortality score, translates to an error reduction of 53.5%. CONCLUSIONS Our model predicts postoperative survival after congenital heart surgery with great accuracy. Compared with preoperative risk assessments, our postoperative risk assessment reduces prediction error by half. Heightened awareness of high-risk patients should improve preventive measures and thus patient safety.
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Affiliation(s)
- Christoph Zürn
- Department of Congenital Heart Defects and Paediatric Cardiology, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - David Hübner
- Machine learning for medical applications, Averbis GmbH, Freiburg, Germany
| | - Victoria C Ziesenitz
- Department of Paediatric Cardiology and Congenital Heart Disease Center for Child and Adolescent Health, Medical Center—University of Heidelberg, Faculty of Medicine, University of Heidelberg, Germany
| | - René Höhn
- Department of Congenital Heart Defects and Paediatric Cardiology, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Lena Schuler
- Department of Congenital Heart Defects and Paediatric Cardiology, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Tim Schlange
- Faculty of Psychology, Ruhr University, Bochum, Germany
| | - Matthias Gorenflo
- Department of Paediatric Cardiology and Congenital Heart Disease Center for Child and Adolescent Health, Medical Center—University of Heidelberg, Faculty of Medicine, University of Heidelberg, Germany
| | - Fabian A Kari
- Department of Cardiovascular Surgery, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Johannes Kroll
- Department of Cardiovascular Surgery, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Tsvetomir Loukanov
- Department of Cardiothoracic Surgery, Medical Center—University of Heidelberg, Faculty of Medicine, University of Heidelberg, Germany
| | - Rolf Klemm
- Department of Cardiovascular Surgery, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Brigitte Stiller
- Department of Congenital Heart Defects and Paediatric Cardiology, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
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Leister N, Commotio S, Menzel C, Yücetepe S, Ulrichs C, Wendt S, Dedden C, Trieschmann U, Hannes T. Human metapneumovirus infection in the cardiac paediatric ICU before and during COVID-19 pandemic: a retrospective cohort analysis. Cardiol Young 2023; 33:1517-1522. [PMID: 35920053 PMCID: PMC9379262 DOI: 10.1017/s1047951122002645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 07/25/2022] [Accepted: 07/25/2022] [Indexed: 11/12/2022]
Abstract
INTRODUCTION This study investigates the hygiene standards in the context of the COVID-19 pandemic and their impact on the perioperative incidence of human metapneumovirus as well as the typical symptom burden of human metapneumovirus-infected children with CHDs. MATERIALS AND METHODS Between March 2018 and July 2021, all patients of a cardiac paediatric ICU of a German university hospital were included in this retrospective cohort analysis. RESULTS A total of 589 patients with CHD were included in the analysis. Three hundred and fifty-two patients (148 females and 204 males) were admitted before the introduction of social distancing and face masks between March 2018 and 15 April 2020 (cohort A). Two hundred and thirty-seven patients (118 females and 119 males) were admitted after the introduction between April 16 and July 2021 (cohort B). In cohort A, human metapneumovirus was detected in 11 out of 352 patients (3.1%) during their stay at cardiac paediatric ICU. In cohort B, one patient out of 237 (0.4%) tested positive for human metapneumovirus. Patients who tested positive for human metapneumovirus stayed in cardiac paediatric ICU for a median of 17.5 days (range, 2-45 days). Patients without a detected human metapneumovirus infection stayed in the cardiac paediatric ICU for a median of 4 days (range, 0.5-114 days). Nine out of 12 (75%) human metapneumovirus-positive patients showed atelectasis. CONCLUSION Perioperative human metapneumovirus infections prolong cardiac paediatric ICU stay in children with CHD. In affected patients, pulmonary impairment with typical symptoms appears. Under certain circumstances, a complication-rich perioperative infection with human metapneumovirus could be prevented in paediatric cardiac high-risk patients by prophylactic hygiene intervention.
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Affiliation(s)
- Nicolas Leister
- Department of Anaesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany
| | - Simone Commotio
- Department of Anaesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany
| | - Christoph Menzel
- Department of Anaesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany
| | - Sirin Yücetepe
- Department of Anaesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany
| | - Christoph Ulrichs
- Department of Anaesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany
| | - Stefanie Wendt
- Department of Cardiothoracic Surgery and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany
| | - Christoph Dedden
- Department of Paediatric Cardiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany
| | - Uwe Trieschmann
- Department of Anaesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany
| | - Tobias Hannes
- Department of Anaesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany
- Department of Paediatric Cardiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Germany
- Department of Neonatology and Paediatric Intensive Care Medicine, Asklepios Children’s Hospital St. Augustin, Sankt Augustin, Germany
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Zmora R, Spector L, Bass J, Thomas A, Knight J, Lakshminarayan K, St Louis J, Kochilas L. Procedure-Specific Center Volume and Mortality After Infantile Congenital Heart Surgery. Ann Thorac Surg 2023; 116:525-531. [PMID: 37100164 PMCID: PMC10524585 DOI: 10.1016/j.athoracsur.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/17/2023] [Accepted: 04/17/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Regionalization of congenital heart surgery (CHS) has been proposed to improve postsurgical outcomes by increasing experience in the care of high-risk patients. We sought to determine whether procedure-specific center volume was associated with mortality after infantile CHS up to 3 years post-procedure. METHODS We analyzed data from 12,263 infants in the Pediatric Cardiac Care Consortium undergoing CHS between 1982 and 2003 at 46 centers within the United States. We used logistic regression to assess the association between procedure-specific center volume and mortality from discharge to 3 years post-procedure, accounting for clustering at the center level and adjusting for patient age and weight at surgery, chromosomal abnormality, and surgical era. RESULTS We found decreased odds for in-hospital mortality for Norwood procedures (odds ratio [OR] 0.955, 95% CI 0.935-0.976), arterial switch operations (OR 0.924, 95% CI 0.889-0.961), tetralogy of Fallot repairs (OR 0.975, 95% CI 0.956-0.995), Glenn shunts (OR 0.971, 95% CI 0.943-1.000), and ventricular septal defect closures (OR 0.974, 95% CI 0.964-0.985). The association persisted up to 3 years post-surgery for Norwood procedures (OR 0.971, 95% CI 0.955-0.988), arterial switches (OR 0.929, 95% CI 0.890-0.970), and ventricular septal defect closures (OR 0.986, 95% CI 0.977-0.995); however, after excluding deaths that occurred within the first 90 days of following surgery, we observed no association between center volume and mortality for any of the procedures studied. CONCLUSIONS These findings suggest that procedure-specific center volume is inversely associated with early postoperative mortality for infantile CHS across the complexity spectrum but has no measurable effect on later mortality.
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Affiliation(s)
- Rachel Zmora
- Section of Preventive Medicine & Epidemiology, Boston University School of Medicine, Boston, Massachusetts.
| | - Logan Spector
- Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - John Bass
- Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Amanda Thomas
- Division of Epidemiology & Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Jessica Knight
- Department of Epidemiology and Biostatistics, University of Georgia College of Public Health, Athens, Georgia
| | - Kamakshi Lakshminarayan
- Division of Epidemiology & Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - James St Louis
- Department of Pediatrics, Medical College of Georgia, Augusta, Georgia
| | - Lazaros Kochilas
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
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Duong SQ, Elfituri MO, Zaniletti I, Ressler RW, Noelke C, Gelb BD, Pass RH, Horowitz CR, Seiden HS, Anderson BR. Neighborhood Childhood Opportunity, Race/Ethnicity, and Surgical Outcomes in Children With Congenital Heart Disease. J Am Coll Cardiol 2023; 82:801-813. [PMID: 37612012 DOI: 10.1016/j.jacc.2023.05.069] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/22/2023] [Accepted: 05/31/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Racial and ethnic disparities in outcomes for children with congenital heart disease (CHD) coexist with disparities in educational, environmental, and economic opportunity. OBJECTIVES We sought to determine the associations between childhood opportunity, race/ethnicity, and pediatric CHD surgery outcomes. METHODS Pediatric Health Information System encounters aged <18 years from 2016 to 2022 with International Classification of Diseases-10th edition codes for CHD and cardiac surgery were linked to ZIP code-level Childhood Opportunity Index (COI), a score of neighborhood educational, environmental, and socioeconomic conditions. The associations of race/ethnicity and COI with in-hospital surgical death were modeled with generalized estimating equations and formal mediation analysis. Neonatal survival after discharge was modeled by Cox proportional hazards. RESULTS Of 54,666 encounters at 47 centers, non-Hispanic Black (Black) (OR: 1.20; P = 0.01), Asian (OR: 1.75; P < 0.001), and Other (OR: 1.50; P < 0.001) groups had increased adjusted mortality vs non-Hispanic Whites. The lowest COI quintile had increased in-hospital mortality in unadjusted and partially adjusted models (OR: 1.29; P = 0.004), but not fully adjusted models (OR: 1.14; P = 0.13). COI partially mediated the effect of race/ethnicity on in-hospital mortality between 2.6% (P = 0.64) and 16.8% (P = 0.029), depending on model specification. In neonatal multivariable survival analysis (n = 13,987; median follow-up: 0.70 years), the lowest COI quintile had poorer survival (HR: 1.21; P = 0.04). CONCLUSIONS Children in the lowest COI quintile are at risk for poor outcomes after CHD surgery. Disproportionally increased mortality in Black, Asian, and Other populations may be partially mediated by COI. Targeted investment in low COI neighborhoods may improve outcomes after hospital discharge. Identification of unmeasured factors to explain persistent risk attributed to race/ethnicity is an important area of future exploration.
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Affiliation(s)
- Son Q Duong
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Mahmud O Elfituri
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai- H+H Elmhurst, New York, New York, USA
| | | | - Robert W Ressler
- Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
| | - Clemens Noelke
- Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
| | - Bruce D Gelb
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robert H Pass
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Carol R Horowitz
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Howard S Seiden
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brett R Anderson
- Department of Pediatrics, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
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Kalfa D, Karamichalis JM, Singh SK, Jiang P, Anderson BR, Vargas D, Choudhury T, Habib A, Bacha E. Operative mortality after Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1 to 3 procedures: Deficiencies and opportunities for quality improvement. J Thorac Cardiovasc Surg 2023; 166:325-333.e3. [PMID: 36621456 DOI: 10.1016/j.jtcvs.2022.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 11/08/2022] [Accepted: 11/12/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVES We examined cases of operative mortality at a single quaternary academic center for patients undergoing relatively lower-risk (Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1-3) procedures, as a means of identifying systemic weaknesses and opportunities for quality improvement. METHODS A retrospective review of all operative mortality events for patients who underwent a Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1, 2, or 3 index procedure (2009-2020) at our institution was performed. After a detailed chart review was performed by 2 independent faculty for each case, factors and system deficiencies that contributed to mortality were identified. RESULTS A total of 42 mortalities were identified. A total of 37 patients (88%) had at least 1 Society of Thoracic Surgeons-designated risk factor, including prior cardiac operations (48%), extracardiac malformations (43%), and preoperative ventilation (33%). Eight patients (19%) had non-Society of Thoracic Surgeons-designated preoperative patient-level variables considered as at potential risk, including severe ventricular dysfunction, pulmonary hypertension, lung hypoplasia, and undiagnosed severe coronary abnormalities. Four patients (10%) had no identified preoperative risk factors. After detailed chart review, 5 broad categories were identified: patient-related factors (n = 33; 78%), postoperative infection (n = 13; 31%), postoperative residual lesions (n = 7; 17%), Fontan physiology failure (n = 4; 10%), and unexplained left ventricular failure after tetralogy of Fallot repair (n = 3; 7%). A total of 74% of patients had at least 1 preoperative, intraoperative, or postoperative system deficiency. A total of 50% of surgeries were urgent or emergency. CONCLUSIONS Operative mortality after Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1 to 3 procedures is related to the presence of multifactorial risk patterns (Society of Thoracic Surgeons and non-Society of Thoracic Surgeons-designated patient-level risk factors and variables, broad risk categories, system deficiencies, emergency surgery). A multidisciplinary approach to care, with early recognition and treatment of modifiable additional burdens, could reduce this risk.
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Affiliation(s)
- David Kalfa
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY.
| | - John M Karamichalis
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Sameer K Singh
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Pengfei Jiang
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Brett R Anderson
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Diana Vargas
- Division of Pediatrics, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Tarif Choudhury
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Anthony Habib
- Division of Anesthesiology, Morgan Stanley Children's Hospital-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's Hospital-New York Presbyterian Hospital, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
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Kang YX, Luo XQ, Zhang NY, Wu SJ, Song GB, Yan P, Duan SB. Association of underweight and obesity with adverse postoperative renal outcomes in infants and young children undergoing congenital heart surgery. Eur J Pediatr 2023; 182:3691-3700. [PMID: 37269377 DOI: 10.1007/s00431-023-05041-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 05/25/2023] [Accepted: 05/26/2023] [Indexed: 06/05/2023]
Abstract
Postoperative acute kidney injury (AKI) is a prevalent condition and associated with increased morbidity and mortality following cardiac surgery. This study aimed to investigate the association of underweight and obesity with adverse postoperative renal outcomes in infants and young children undergoing congenital heart surgery. This retrospective cohort study included patients aged from 1 month to 5 years who underwent congenital heart surgery with cardiopulmonary bypass at the Second Xiangya Hospital of Central South University from January 2016 to March 2022. On the basis of the percentile of body mass index (BMI) for age and sex, eligible participants were divided into three nutritional groups: normal bodyweight, underweight (BMI P5), and obesity (BMI P95). Primary outcomes included postoperative AKI and major adverse kidney events within 30 days (MAKE30). Multivariable logistic regression was performed to determine the association of underweight and obesity with postoperative outcomes. The same analyses were reproduced for classifying patients using weight-for-height instead of BMI. A total of 2,079 eligible patients were included in the analysis, including 1,341 (65%) patients in the normal bodyweight group, 683 (33%) patients in the underweight group, and 55 (2.6%) patients in the obesity group. Postoperative AKI (16% vs. 26% vs. 38%; P < 0.001) and MAKE30 (2.5% vs. 6.4% vs. 9.1%; P < 0.001) were more likely to occur in the underweight and obesity groups. After adjusting for potential confounders, underweight (OR1.39; 95% CI 1.08-1.79; P = 0.008) and obesity (OR 3.85; 95% CI 1.97-7.50; P < 0.001) were found to be associated with an increased risk of postoperative AKI. In addition, both underweight (OR 1.89; 95% CI 1.14-3.14; P = 0.014) and obesity (OR 3.14; 95% CI 1.08-9.09; P = 0.035) were independently associated with MAKE30. Similar results were also found when weight-for-height was used instead of BMI. Conclusion: In infants and young children undergoing congenital heart surgery, underweight and obesity are independently associated with postoperative AKI and MAKE30. These results may help assess prognosis in underweight and obese patients, and will guide future quality improvement efforts. What is Known: • Postoperative acute kidney injury (AKI) is prevalent and associated with increased morbidity and mortality following pediatric cardiac surgery. • Major adverse kidney events within 30 days (MAKE30) have been recommended as a patient-centered endpoint for evaluating AKI clinical trajectories. A growing concern arises for underweight and obesity in children with congenital heart disease. What is New: • Prevalence of underweight and obesity among infants and young children undergoing congenital heart surgery was 33% and 2.6%, respectively. • Both underweight and obesity were independently associated with postoperative AKI and MAKE30 following congenital heart surgery.
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Affiliation(s)
- Yi-Xin Kang
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Xiao-Qin Luo
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Ning-Ya Zhang
- Information Center, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Si-Jie Wu
- Department of Cardiovascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Guo-Bao Song
- Department of Cardiovascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Ping Yan
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, 139 Renmin Road, Changsha, 410011, Hunan, China
| | - Shao-Bin Duan
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Hunan Key Laboratory of Kidney Disease and Blood Purification, 139 Renmin Road, Changsha, 410011, Hunan, China.
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Mayourian J, Brown E, Javalkar K, Bucholz E, Gauvreau K, Beroukhim R, Feins E, Kheir J, Triedman J, Dionne A. Insight into the Role of the Child Opportunity Index on Surgical Outcomes in Congenital Heart Disease. J Pediatr 2023; 259:113464. [PMID: 37172810 DOI: 10.1016/j.jpeds.2023.113464] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/20/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To use neighborhood-level Child Opportunity Index (COI) measures to investigate disparities in congenital heart surgery postoperative outcomes and identify potential targets for intervention. STUDY DESIGN In this single-institution retrospective cohort study, children <18 years old who underwent cardiac surgery between 2010 and 2020 were included. Patient-level demographics and neighborhood-level COI were used as predictor variables. COI-a composite US census tract-based score measuring educational, health/environmental, and social/economic opportunities-was dichotomized as lower (<40th percentile) vs higher (≥40th percentile). Cumulative incidence of hospital discharge was compared between groups using death as a competing risk, adjusting for clinical characteristics associated with outcomes. Secondary outcomes included hospital readmission and death within 30 days. RESULTS Among 6247 patients (55% male) with a median age of 0.8 years (IQR, 0.2-4.3), 26% had lower COI. Lower COI was associated with longer hospital lengths of stay (adjusted HR, 1.2; 95% CI, 1.1-1.2; P < .001) and an increased risk of death (adjusted OR, 2.0; 95% CI. 1.4-2.8; P < .001), but not hospital readmission (P = .6). At the neighborhood level, lacking health insurance coverage, food/housing insecurity, lower parental literacy and college attainment, and lower socioeconomic status were associated with longer hospital length of stay and increased risk of death. At the patient-level, public insurance (adjusted OR, 1.4; 95% CI, 1.0-2.0; P = .03) and caretaker Spanish language (adjusted OR 2.4; 95% CI, 1.2-4.3; P < .01) were associated with an increased risk of death. CONCLUSIONS Lower COI is associated with longer length of stay and higher early postoperative mortality. Risk factors identified including Spanish language, food/housing insecurity, and parental literacy serve as potential intervention targets.
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Affiliation(s)
- Joshua Mayourian
- Department of Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Pediatrics, Boston University, Boston, MA
| | - Ella Brown
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Karina Javalkar
- Department of Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Pediatrics, Boston University, Boston, MA
| | - Emily Bucholz
- Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Kimberlee Gauvreau
- Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Rebecca Beroukhim
- Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Eric Feins
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA
| | - John Kheir
- Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - John Triedman
- Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Audrey Dionne
- Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA.
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Wannaz L, Boillat L, Perez MH, Di Bernardo S. Prophylactic use of levosimendan in preoperative setting for surgical repair of congenital heart disease in children. Front Pediatr 2023; 11:1205971. [PMID: 37539009 PMCID: PMC10394616 DOI: 10.3389/fped.2023.1205971] [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: 04/14/2023] [Accepted: 07/04/2023] [Indexed: 08/05/2023] Open
Abstract
Introduction Low cardiac output syndrome (LCOS) is a significant cause of morbidity and the leading cause of mortality after pediatric cardiac surgery. Levosimendan has been shown safe and effective in pediatrics to treat LCOS. We aimed to review our local strategy with preoperative prophylactic Levosimendan infusion to minimize LCOS after heart surgery in identified high-risk patients. Methods Retrospective monocentric study. As there is no reliable cardiac output measurement in children, we recorded hemodynamic parameters as surrogates of cardiac output after extracorporeal circulation through an electronic patient survey system at different time points. Results Seventy-two children received Levosimendan before surgery between 2010 and 2019. As expected, most patients were newborns and infants with prolonged open-heart surgeries. Median cardiopulmonary bypass time was 182 [137-234] min, and aortic clamping time was 95 [64-126] min. The postoperative hemodynamic parameters, vasoactive-inotropic score, and urine output remained stable throughout the first 48 h. Only a tiny portion of the patients had combined surrogate markers of LCOS with a maximal median arterial lactate of 2.6 [1.9-3.5] mmol/L during the first six postoperative hours, which then progressively normalized. The median arterio-venous difference in oxygen saturation was 31 [23-38] % between 12 and 18 h post-surgery and gradually decreased. The median venous-to-arterial CO2 difference was the highest at 10 [7-12] mmHg between 12 and 18 h post-surgery. Nine patients (13%) required extracorporeal membrane oxygenation. No patient required dialysis or hemofiltration. Mortality was 0%. Conclusion Before congenital heart surgery, preoperative prophylactic administration of Levosimendan seems effective and safe for decreasing occurrence and duration of LCOS in high-risk children.
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Affiliation(s)
- L. Wannaz
- Pediatric Cardiology, Women-Mother-Child Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - L. Boillat
- Pediatric Intensive Care Unit, Women-Mother-Child Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - M. H. Perez
- Pediatric Intensive Care Unit, Women-Mother-Child Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - S. Di Bernardo
- Pediatric Cardiology, Women-Mother-Child Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Meza JM, Blackstone EH, Argo MB, Thuita L, Lowry A, Rajeswaran J, Jegatheeswaran A, Caldarone CA, Kirklin JK, DeCampli WM, Pourmoghadam K, Gruber PJ, McCrindle BW. A dynamic Norwood mortality estimation: Characterizing individual, updated, predicted mortality trajectories after the Norwood operation. JTCVS OPEN 2023; 14:426-440. [PMID: 37425467 PMCID: PMC10329031 DOI: 10.1016/j.xjon.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/28/2023] [Indexed: 07/11/2023]
Abstract
Objective Post-Norwood mortality remains high and unpredictable. Current models for mortality do not incorporate interstage events. We sought to determine the association of time-related interstage events, along with (pre)operative characteristics, with death post-Norwood and subsequently predict individual mortality. Methods From the Congenital Heart Surgeons' Society Critical Left Heart Obstruction cohort, 360 neonates underwent Norwood operations from 2005 to 2016. Risk of death post-Norwood was modeled using a novel application of parametric hazard analysis, in which baseline and operative characteristics and time-related adverse events, procedures, and repeated weight and arterial oxygen saturation measurements were considered. Individual predicted mortality trajectories that dynamically update (increase or decrease) over time were derived and plotted. Results After the Norwood, 282 patients (78%) progressed to stage 2 palliation, 60 patients (17%) died, 5 patients (1%) underwent heart transplantation, and 13 patients (4%) were alive without transitioning to another end point. In total, 3052 postoperative events occurred and 963 measures of weight and oxygen saturation were obtained. Risk factors for death included resuscitated cardiac arrest, moderate or greater atrioventricular valve regurgitation, intracranial hemorrhage/stroke, sepsis, lower longitudinal oxygen saturation, readmission, smaller baseline aortic diameter, smaller baseline mitral valve z-score, and lower longitudinal weight. Each patient's predicted mortality trajectory varied as risk factors occurred over time. Groups with qualitatively similar mortality trajectories were noted. Conclusions Risk of death post-Norwood is dynamic and most frequently associated with time-related postoperative events and measures, rather than baseline characteristics. Dynamic predicted mortality trajectories for individuals and their visualization represent a paradigm shift from population-derived insights to precision medicine at the patient level.
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Affiliation(s)
- James M. Meza
- Division of Cardiothoracic and Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Eugene H. Blackstone
- Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Madison B. Argo
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wis
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lucy Thuita
- Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Ashley Lowry
- Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Anusha Jegatheeswaran
- Division of Cardiovascular Surgery, Great Ormond Street Hospital for Children, London, United Kingdom
| | | | - James K. Kirklin
- Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, Ala
| | - William M. DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Fla
| | - Kamal Pourmoghadam
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Fla
| | - Peter J. Gruber
- Division of Cardiothoracic Surgery, Yale New Haven Children's Hospital, New Haven, Conn
| | - Brian W. McCrindle
- Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada
- Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
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Aldersley T, Brooks A, Human P, Lawrenson J, Comitis G, De Decker R, Fourie B, Manganyi R, Pribut H, Salie S, Swanson L, Zühlke L. The impact of COVID-19 on a South African pediatric cardiac service: implications and insights into service capacity. Front Public Health 2023; 11:1177365. [PMID: 37234766 PMCID: PMC10206042 DOI: 10.3389/fpubh.2023.1177365] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 04/05/2023] [Indexed: 05/28/2023] Open
Abstract
Background and Objectives The Western Cape public pediatric cardiac service is under-resourced. COVID-19 regulations are likely to have long-term effects on patient care but may provide insight into service capacity requirements. As such, we aimed to quantify the impact of COVID-19 regulations on this service. Methods An uncontrolled retrospective pre-post study of all presenting patients over two, one-year periods; the pre-COVID-19 period (01/03/2019-29/02/2020) and the peri-COVID-19 period (01/03/2020-28/02/2021). Results Admissions decreased by 39% (624 to 378) and cardiac surgeries decreased by 29% (293 to 208) in the peri-COVID-19 period, with an increase in urgent cases (PR:5.99, 95%CI:3.58-10.02, p < 0.001). Age at surgery was lower in the peri-COVID-19 period, 7.2 (2.4-20.4) vs. 10.8 (4.8-49.2) months (p < 0.05), likewise, age at surgery for transposition of the great arteries (TGA) was lower peri-COVID-19, 15 (IQR:11.2-25.5) vs. 46 (IQR:11-62.5) days (p < 0.05). Length of stay 6 (IQR:2-14) vs. 3 days (IQR:1-9) (p < 0.001), complications (PR:1.21, 95%CI:1.01-1.43, p < 0.05), and age-adjusted delayed-sternal-closure rates (PR:3.20, 95%CI:1.09-9.33, p < 0.05) increased peri-COVID-19. Conclusion Cardiac procedures were significantly reduced in the peri-COVID-19 period which will have implications on an overburdened service and ultimately, patient outcomes. COVID-19 restrictions on elective procedures freed capacity for urgent cases, demonstrated by the absolute increase in urgent cases and significant decrease in age at TGA-surgery. This facilitated intervention at the point of physiological need, albeit at the expense of elective procedures, and also revealed insights into capacity requirements of the Western Cape. These data emphasize the need for an informed strategy to increase capacity and reduce backlog whilst ensuring minimal morbidity and mortality.Graphical Abstract.
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Affiliation(s)
- Thomas Aldersley
- Department of Pediatrics and Child Health, Pediatric Cardiology, University of Cape Town, Cape Town, South Africa
- Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
| | - Andre Brooks
- Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- Chris Barnard Division of Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa
- Groote Schuur Hospital, Cape Town, South Africa
| | - Paul Human
- Chris Barnard Division of Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa
- Groote Schuur Hospital, Cape Town, South Africa
| | - John Lawrenson
- Department of Pediatrics and Child Health, Pediatric Cardiology, University of Cape Town, Cape Town, South Africa
- Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- Division of Pediatric Cardiology, Department of Pediatrics and Child Health, University of Stellenbosch, Cape Town, South Africa
- Tygerberg Hospital, Cape Town, South Africa
| | - George Comitis
- Department of Pediatrics and Child Health, Pediatric Cardiology, University of Cape Town, Cape Town, South Africa
- Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
| | - Rik De Decker
- Department of Pediatrics and Child Health, Pediatric Cardiology, University of Cape Town, Cape Town, South Africa
- Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
| | - Barend Fourie
- Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- Division of Pediatric Cardiology, Department of Pediatrics and Child Health, University of Stellenbosch, Cape Town, South Africa
- Tygerberg Hospital, Cape Town, South Africa
| | - Rodgers Manganyi
- Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- Chris Barnard Division of Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa
- Groote Schuur Hospital, Cape Town, South Africa
| | - Harold Pribut
- Department of Pediatrics and Child Health, Pediatric Cardiology, University of Cape Town, Cape Town, South Africa
- Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
| | - Shamiel Salie
- Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- Department of Pediatrics and Child Health, Pediatric Intensive and Critical Care Unit, University of Cape Town, Cape Town, South Africa
| | - Lenise Swanson
- Department of Pediatrics and Child Health, Pediatric Cardiology, University of Cape Town, Cape Town, South Africa
- Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
| | - Liesl Zühlke
- Department of Pediatrics and Child Health, Pediatric Cardiology, University of Cape Town, Cape Town, South Africa
- Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- South African Medical Research Council, Cape Town, South Africa
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Köditz H, Drouche A, Dennhardt N, Schmidt M, Schultz M, Schultz B. Depth of anesthesia, temperature, and postoperative delirium in children and adolescents undergoing cardiac surgery. BMC Anesthesiol 2023; 23:148. [PMID: 37131120 PMCID: PMC10152600 DOI: 10.1186/s12871-023-02102-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 04/20/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND After pediatric cardiosurgical interventions, postoperative delirium can occur, which can be associated with undesirable consequences during and after the hospital stay. It is therefore important to avoid any factors causing delirium as far as possible. Electroencephalogram (EEG) monitoring can be used during anesthesia to individually adjust dosages of hypnotically acting drugs. It is necessary to gain knowledge about the relationship between intraoperative EEG and postoperative delirium in children. METHODS In a dataset comprising 89 children (53 male, 36 female; median age: 0.99 (interquartile range: 0.51, 4.89) years) undergoing cardiac surgery involving use of a heart-lung machine, relationships between depth of anesthesia as measured by EEG (EEG index: Narcotrend Index (NI)), sevoflurane dosage, and body temperature were analyzed. A Cornell Assessment of Pediatric Delirium (CAP-D) score ≥ 9 indicated delirium. RESULTS The EEG could be used in patients of all age groups for patient monitoring during anesthesia. In the context of induced hypothermia, EEG monitoring supported individually adjusted sevoflurane dosing. The NI was significantly correlated with the body temperature; decreasing temperature was accompanied by a decreasing NI. A CAP-D score ≥ 9 was documented in 61 patients (68.5%); 28 patients (31.5%) had a CAP-D < 9. Delirious patients with an intubation time ≤ 24 h showed a moderate negative correlation between minimum NI (NImin) and CAP-D (rho = -0.41, 95% CI: -0.70 - -0.01, p = 0.046), i.e., CAP-D decreased with increasing NImin. In the analysis of all patients' data, NImin and CAP-D showed a weak negative correlation (rho = -0.21, 95% CI: -0.40 - 0.01, p = 0.064). On average, the youngest patients had the highest CAP-D scores (p = 0.002). Patients with burst suppression / suppression EEG had a longer median intubation time in the intensive care unit than patients without such EEG (p = 0.023). There was no relationship between minimum temperature and CAP-D score. CONCLUSIONS The EEG can be used to individually adjust sevoflurane dosing during hypothermia. Of the patients extubated within 24 h and classified as delirious, patients with deeper levels of anesthesia had more severe delirium symptoms than patients with lighter levels of anesthesia.
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Affiliation(s)
- H Köditz
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - A Drouche
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - N Dennhardt
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - M Schmidt
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - M Schultz
- Medical University of Vienna, Vienna, Austria
| | - Barbara Schultz
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany.
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