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Griffeth EM, Stephens EH, Dearani JA, Shreve JT, O'Sullivan D, Egbe AC, Connolly HM, Todd A, Burchill LJ. Impact of heart failure on reoperation in adult congenital heart disease: An innovative machine learning model. J Thorac Cardiovasc Surg 2024; 167:2215-2225.e1. [PMID: 37776991 PMCID: PMC10972775 DOI: 10.1016/j.jtcvs.2023.09.045] [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: 05/15/2023] [Revised: 09/09/2023] [Accepted: 09/20/2023] [Indexed: 10/02/2023]
Abstract
OBJECTIVES The study objectives were to evaluate the association between preoperative heart failure and reoperative cardiac surgical outcomes in adult congenital heart disease and to develop a risk model for postoperative morbidity/mortality. METHODS Single-institution retrospective cohort study of adult patients with congenital heart disease undergoing reoperative cardiac surgery between January 1, 2010, and March 30, 2022. Heart failure defined clinically as preoperative diuretic use and either New York Heart Association Class II to IV or systemic ventricular ejection fraction less than 40%. Composite outcome included operative mortality, mechanical circulatory support, dialysis, unplanned noncardiac reoperation, persistent neurologic deficit, and cardiac arrest. Multivariable logistic regression and machine learning analysis using gradient boosting technology were performed. Shapley statistics determined feature influence, or impact, on model output. RESULTS Preoperative heart failure was present in 376 of 1011 patients (37%); those patients had longer postoperative length of stay (6 [5-8] vs 5 [4-7] days, P < .001), increased postoperative mechanical circulatory support (21/376 [6%] vs 16/635 [3%], P = .015), and decreased long-term survival (84% [80%-89%] vs 90% [86%-93%]) at 10 years (P = .002). A 7-feature machine learning risk model for the composite outcome achieved higher area under the curve (0.76) than logistic regression, and ejection fraction was most influential (highest mean |Shapley value|). Additional risk factors for the composite outcome included age, number of prior cardiopulmonary bypass operations, urgent/emergency procedure, and functionally univentricular physiology. CONCLUSIONS Heart failure is common among adult patients with congenital heart disease undergoing cardiac reoperation and associated with longer length of stay, increased postoperative mechanical circulatory support, and decreased long-term survival. Machine learning yields a novel 7-feature risk model for postoperative morbidity/mortality, in which ejection fraction was the most influential.
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Affiliation(s)
| | | | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | | | - Alexander C Egbe
- Division of Structural Heart Disease, Mayo Clinic, Rochester, Minn
| | - Heidi M Connolly
- Division of Structural Heart Disease, Mayo Clinic, Rochester, Minn
| | - Austin Todd
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minn
| | - Luke J Burchill
- Division of Structural Heart Disease, Mayo Clinic, Rochester, Minn.
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Abt BG, Elsayed RS, Bojko M, Baker C, Kazerouni K, Song A, Toubat O, Starnes VA, Kumar SR. Morbidity and Mortality in Adult Congenital Heart Surgery: Physiologic Component Augments Risk Prediction. Ann Thorac Surg 2024; 117:804-811. [PMID: 37527699 DOI: 10.1016/j.athoracsur.2023.07.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 05/25/2023] [Accepted: 07/11/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND We sought to evaluate whether the anatomic and physiologic stratification system (ACAP score), released as part of the American College of Cardiology/American Heart Association updated guidelines for management of adult congenital heart disease (ACHD) in 2018, better estimated mortality and morbidity after cardiac operations for ACHD. METHODS The ACAP score was determined for 318 patients (age ≥18 years) with ACHD undergoing heart surgery at our institution between December 2001 and August 2019. The primary end point was perioperative mortality. The secondary aim was to evaluate the performance of the ACAP, The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) Congenital Heart Surgery Mortality Categories, and ACHS mortality scores/categories at predicting a composite adverse outcome of perioperative mortality, prolonged ventilation, and renal failure requiring replacement therapy. Logistic regression models were built to estimate mortality and the composite outcome using anatomic and physiologic components independently and together. Receiver operating characteristic curves were created, and area under the curves were compared using the Delong test. RESULTS The median age was 37 years (interquartile range, 26.3-50.0 years). There were 9 perioperative mortalities (2.8%). With respect to perioperative mortality, the area under the curve using the anatomic component only was 0.74, which improved to 0.81 after including physiologic severity (P = .05). When physiologic severity was added to the model for the composite outcome, the discriminatory abilities of the ACHS mortality score and the STAT categories increased significantly to 0.83 (95% CI, 0.75-0.91; P = .02) and 0.82 (95% CI, 0.73-0.90; P = .04), comparable to the predictive power of ACAP. CONCLUSIONS Physiologic severity augments ability to predict mortality and morbidity after cardiac surgery for ACHD. There is need for more robust ACHD-specific risk models.
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Affiliation(s)
- Brittany G Abt
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California.
| | - Ramsey S Elsayed
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Markian Bojko
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Craig Baker
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Kayvan Kazerouni
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Abigail Song
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Omar Toubat
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Vaughn A Starnes
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - S Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Erez DL, Lokesh S, Howarth KD, Meloni S, Ballester L, Laskin B, Sullivan KE, Blinder J. Immune urinary biomarkers predict infant cardiac surgery-associated acute kidney injury. Pediatr Nephrol 2024; 39:589-595. [PMID: 37597103 DOI: 10.1007/s00467-023-06051-4] [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: 01/31/2023] [Revised: 05/20/2023] [Accepted: 05/23/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) occurs frequently after infant cardiac surgery and is associated with poor outcomes, including mortality and prolonged length of stay. AKI mechanisms are poorly understood, limiting therapeutic targets. Emerging data implicates dysregulated immune activation in post-cardiac surgery AKI development. We sought to identify immune-mediated AKI biomarkers after infant cardiopulmonary bypass (CPB)-assisted cardiac surgery. METHODS A single-center prospective study of 126 infants less than 1 year old undergoing CPB-assisted surgery enrolled between 10/2017 and 6/2019. Urine samples were collected before CPB and at 6, 24, 48, and 72 h after surgery. Immune-mediated biomarkers were measured using commercial ELISA and Luminex™ multiplex kits. Based on subject age, neonatal KDIGO (< 1 month) or KDIGO criteria defined AKI. The Kruskal-Wallis rank test determined the relationship between urinary biomarker measurements and AKI. RESULTS A total of 35 infants (27%) developed AKI. AKI subjects were younger, underwent more complex surgery, and had longer CPB time. Subjects with AKI vs. those without AKI had higher median urinary chemokine 10 (C-X-C motif) ligand levels at 24, 48, and 72 h, respectively: 14.3 pg/ml vs. 5.3 pg/ml, 3.4 pg/ml vs. 0.8 pg/ml, and 1.15 pg/ml vs. 0.22 pg/ml (p < 0.05) post-CPB. At 6 h post-CPB, median vascular cell adhesion protein 1 (VCAM) levels (pg/mL) were higher among AKI subjects (491 pg/ml vs. 0 pg/ml, p = 0.04). CONCLUSIONS Urinary CXCL10 and VCAM are promising pro-inflammatory biomarkers for early AKI detection and may indicate eventual AKI therapeutic targets. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Daniella Levy Erez
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.
- Schneider Children's Medical Center Israel, 14 Kaplan Street, Petach Tiqva, Israel.
| | - Shah Lokesh
- Division of Pediatric Nephrology, Department of Pediatrics, Stanford University School of Medicine, Stanford, USA
| | - Kathryn D Howarth
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Sherin Meloni
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Lance Ballester
- Biostatistics and Data Management Core, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Benjamin Laskin
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Kathleen E Sullivan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Joshua Blinder
- Division of Cardiac Critical Care, Children's Hospital of Philadelphia, Philadelphia, USA
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, USA
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García-Cruz E, Manzur-Sandoval D, Gopar-Nieto R, Angulo-Cruzado ST, Sánchez-López SV, Torres-Martel JM, Ramírez-Marroquín S, Cervantes-Salazar JL, Benita-Bordes A, Calderon-Colmenero J, García-Montes JA, Díaz-Gallardo LG, Montalvo-Ocotoxtle IG, Escobar-Sibaja LE, Sánchez-Rodríguez CC, Barajas-Campos RL, García-Cruz JC, Villalobos-Pedroza M, Sánchez-Nieto J, Mier y Terán-Morales E, Navarro-Martínez DA, Baranda-Tovar FM. Clinical Characteristics and Outcomes in Adults With Moderate-to-Severe Complexity Congenital Heart Disease Undergoing Palliation or Surgical Repair. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:63-73. [PMID: 37970523 PMCID: PMC10642147 DOI: 10.1016/j.cjcpc.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 10/17/2022] [Indexed: 11/17/2023]
Abstract
Background Congenital heart disease (CHD) survival rate has improved dramatically due to advances in diagnostic and therapeutic techniques. However, concerning the unrepaired CHD population of moderate and severe complexity, the data regarding risk predictors and surgical outcomes are scarce. Our aim was to describe the surgical results and predictors of in-hospital outcomes in adult patients with moderate-to-severe complexity CHD that were not repaired in childhood. Methods We conducted a retrospective cohort study that included 49 adult patients with moderate-to-complex CHD who were treated in a single medical centre. Clinical and echocardiographic variables were obtained on admission, after surgical procedures and during follow-up. Results Most of the patients were female (66%). Left ventricular ejection fraction and right ventricular outflow tract fractional shortening were within the normal range. The median pulmonary artery systolic pressure was 37 (27-55) mm Hg. The median time was 118 (80-181) minutes for extracorporeal circulation and 76 (49-121) minutes for aortic cross-clamping. The most frequent complication was postoperative complete atrioventricular block (12.2%). In-hospital survival rate was 87.7%. The development of low cardiac output syndrome with predominant right ventricle failure in the postoperative period was the most important predictor of in-hospital death (P = 0.03). Conclusions Deciding to treat adults with CHD is challenging in moderate and severe unrepaired cases. Adequate clinical, functional, and imaging evaluation is essential to determine each patient's suitability for surgical management and to achieve the best clinical outcome for this population.
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Affiliation(s)
- Edgar García-Cruz
- Congenital Heart Disease Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Daniel Manzur-Sandoval
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Rodrigo Gopar-Nieto
- Coronary Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | | | | | - José Miguel Torres-Martel
- Congenital Heart Disease Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Samuel Ramírez-Marroquín
- Congenital Heart Disease Surgery Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Jorge Luis Cervantes-Salazar
- Congenital Heart Disease Surgery Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Antonio Benita-Bordes
- Congenital Heart Disease Surgery Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Juan Calderon-Colmenero
- Congenital Heart Disease Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | | | | | | | | | | | | | | | | | - Jorge Sánchez-Nieto
- Coronary Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
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Abhay P, Sharma R, Bhan A, Raina M, Vadhera A, Akole R, Mir FA, Bajpai P, Misri A, Srivastava S, Prakash V, Mondal T, Soundararajan A, Tibrewal A, Bansal SB, Sethi SK. Vasoactive-ventilation-renal score and outcomes in infants and children after cardiac surgery. Front Pediatr 2023; 11:1086626. [PMID: 36891234 PMCID: PMC9986414 DOI: 10.3389/fped.2023.1086626] [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: 11/01/2022] [Accepted: 01/27/2023] [Indexed: 02/22/2023] Open
Abstract
Introduction There is a need to index important clinical characteristics in pediatric cardiac surgery that can be obtained early in the postoperative period and accurately predict postoperative outcomes. Methodology A prospective cohort study was conducted in the pediatric cardiac ICU and ward on all children aged <18 years undergoing cardiac surgery for congenital heart disease from September 2018 to October 2020. The vasoactive-ventilation-renal (VVR) score was analyzed to predict outcomes of cardiac surgeries with a comparison of postoperative variables. Results A total of 199 children underwent cardiac surgery during the study period. The median (interquartile range) age was 2 (0.8-5) years, and the median weight was 9.3 (6-16) kg. The most common diagnoses were ventricular septal defect (46.2%) and tetralogy of Fallot (37.2%). At the 48th h, area under the curve (AUC) (95% CI) values were higher for the VVR score than those for other clinical scores measured. Similarly, at the 48th h, AUC (95% CI) values were higher for the VVR score than those for the other clinical scores measured for the length of stay and mechanical ventilation. Discussion The VVR score at 48 h postoperation was found to best correlate with prolonged pediatric intensive care unit (PICU) stay, length of hospitalization, and ventilation duration, with the greatest AUC-receiver operating characteristic (0.715, 0.723, and 0.843, respectively). The 48-h VVR score correlates well with prolonged ICU, hospital stay, and ventilation.
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Affiliation(s)
- Pota Abhay
- Pediatric Cardiology, Medanta, The Medicity Hospital, Gurgaon, India
| | - Rajesh Sharma
- Pediatric Cardiac Intensive Care, Medanta-The Medicity, Gurgaon, India
| | - Anil Bhan
- CTVS, Medanta-The Medicity, Gurgaon, India
| | - Manan Raina
- Hawken High School, Cleveland, OH, United States
| | | | - Romel Akole
- Pediatric Cardiac Intensive Care, Medanta-The Medicity, Gurgaon, India
| | | | - Pankaj Bajpai
- Pediatric Cardiology, Medanta, The Medicity Hospital, Gurgaon, India
| | - Amit Misri
- Pediatric Cardiology, Medanta, The Medicity Hospital, Gurgaon, India
| | | | | | - Tanmoy Mondal
- Pediatric Cardiac Intensive Care, Medanta-The Medicity, Gurgaon, India
| | - Anvitha Soundararajan
- Akron Nephrology Associates, Akron General Cleveland Clinic, Akron, OH, United States
| | - Abhishek Tibrewal
- Pediatric Nephrology, Akron's Children Hospital, Akron, OH, United States
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Motta P P, Kreeger R, Resheidat AM, Faraoni D, Nasr VG, Mossad EB, Mittnacht AJ. Selected 2021 Highlights in Congenital Cardiac Anesthesia. J Cardiothorac Vasc Anesth 2022; 36:2265-2270. [DOI: 10.1053/j.jvca.2022.03.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 11/11/2022]
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Jacobs JP, Nelson JS, Fuller S, Scholl FG, Kumar SR, Jacobs ML. Risk adjustment for cardiac surgery in adults with congenital heart disease: what do we know and what do we need to learn? Eur J Cardiothorac Surg 2021; 60:1405-1407. [PMID: 34448825 DOI: 10.1093/ejcts/ezab266] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jeffrey P Jacobs
- Departments of Surgery and Pediatrics, Congenital Heart Center, Division of Cardiovascular Surgery, University of Florida, Gainesville, FL, USA
| | - Jennifer S Nelson
- Department of Surgery, College of Medicine, University of Central Florida, Orlando, FL, USA.,Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, FL, USA
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Frank G Scholl
- Department of Surgery, Joe DiMaggio Children's Hospital, Hollywood, FL, USA
| | - S Ram Kumar
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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