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Dutta P, Nathan M, Emani SM, Emani S, Ibla JC. Perioperative Hyper-coagulation and Thrombosis: Cost Analysis After Congenital Heart Surgery. Pediatr Cardiol 2024:10.1007/s00246-024-03554-1. [PMID: 38902366 DOI: 10.1007/s00246-024-03554-1] [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: 05/02/2024] [Accepted: 06/14/2024] [Indexed: 06/22/2024]
Abstract
Thrombosis, a major adverse event of congenital heart surgery, has been associated with poor outcomes. We hypothesized that in CHD patients undergoing cardiac surgery, increased perioperative use of pro-coagulant products may be associated with postoperative thrombosis in the setting of hyperfibrinogenemia, leading to greater hospital and blood product costs. Single-center retrospective study. Data from Boston Children's Hospital's electronic health record database was used in this study. All patients undergoing congenital heart surgery between 2015 and 2018 with postoperative fibrinogen levels above 400 mg/dl were reviewed. Of 334 patients with high plasma fibrinogen levels, 28 (8.4%) developed postoperative thrombosis (median age: one year, 59% male). In our cohort, 25 (7%) demonstrated evidence of baseline hypercoagulability by one or more panel test results. Thrombosis was associated with greater hospital and blood product costs, longer ventilation times, and longer hospital and ICU length of stays. Preoperative hypercoagulable state (odds ratio: 2.58, 95% CI [1.07, 9.99], p = 0.002), postoperative red blood cell transfusion (odds ratio: 1.007, 95% CI [1.000, 1.015], p = 0.04), and single ventricle physiology (univariate odds ratio: 2.94, 95% CI [1.09, 7.89], p = 0.03) were predictors of postoperative thrombosis. Preoperative hypercoagulable state and intraoperative platelet transfusion were predictors of hospital cost. Thrombosis was associated with worse in-hospital outcomes and higher costs. Preoperative hypercoagulable state and postoperative red blood cell transfusion were significant predictors of thrombosis. Risk prediction models that can guide thrombosis prevention are needed to improve outcomes of patients undergoing congenital heart surgery.
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Affiliation(s)
- Puja Dutta
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
- Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Sitaram M Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
- Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Sirisha Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
- Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Juan C Ibla
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02215, USA.
- Department of Anesthesia, Harvard Medical School, Boston, MA, USA.
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Ghosh S, Lien IG, Martinez K, Lin T, Bleiweis MS, Philip J, Jordan LC, Pavlakis SG. Prevalence and Risk Factors for Cerebral Palsy in Children With Congenital Heart Disease Based on Risk of Surgical Mortality. Pediatr Neurol 2024; 155:133-140. [PMID: 38640862 DOI: 10.1016/j.pediatrneurol.2024.02.011] [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: 01/30/2023] [Revised: 12/20/2023] [Accepted: 02/26/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Children with congenital heart disease (CHD) have a higher prevalence of motor impairment secondary to brain injury, resulting in cerebral palsy (CP). The purpose of this study is to determine the prevalence of CP in CHD in a single-center cohort, stratify risk based on surgical mortality using Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) categories and identify risk factors. METHODS Retrospective cohort study of pediatric patients registered in the University of Florida (UF) Society of Thoracic Surgeons Congenital Heart Surgery database from 2006 to 2017 with a diagnosis of CHD who continued follow-up for more than two years at UF. RESULTS A total of 701 children with CHD met inclusion criteria. Children identified to have CP were 54 (7.7%). Most common presentation was spastic hemiplegic CP with a Gross Motor Function Classification System of level 2. Analysis of surgical and intensive care factors between the two groups showed that children with CHD and CP had longer time from admission to surgery (P = 0.003), higher STAT categories 4 and 5 (P = 0.038), and higher frequency of brain injury and seizures (P < 0.001). Developmental disabilities and rehabilitation needs were significantly greater for children with CHD and CP when compared with those with CHD alone (P < 0.001). CONCLUSIONS In our cohort, 7.7% children with CHD develop CP; this is significantly higher than the 2010 US population estimate of 0.3%. Our study suggests higher STAT categories, brain injury, and seizures are associated with developing CP in children with CHD.
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Affiliation(s)
- Suman Ghosh
- State University of New York at Downstate Health Sciences University, Brooklyn, New York; Department of Neurology, New York City Health and Hospitals Corporation Kings County Hospital, Brooklyn, New York.
| | - Ing Grace Lien
- Department of Neurology, University of Florida, Gainesville, Florida
| | - Kerstin Martinez
- Herbert Wertheim College of Engineering, University of Florida, Gainesville, Florida
| | - Tracy Lin
- College of Liberal Arts and Sciences, University of Florida, Gainesville, Florida
| | - Mark S Bleiweis
- University of Florida Health Congenital Heart Center, Gainesville, Florida
| | - Joseph Philip
- University of Florida Health Congenital Heart Center, Gainesville, Florida
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Steven G Pavlakis
- State University of New York at Downstate Health Sciences University, Brooklyn, New York; Department of Neurology, New York City Health and Hospitals Corporation Kings County Hospital, Brooklyn, New York
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Kim ME, Baskar S, Janson CM, Chandler SF, Whitehill RD, Dionne A, Law MA, Domnina Y, Smith-Parrish MN, Bird GL, Banerjee M, Zhang W, Reichle G, Schumacher KR, Czosek RJ, Morales DLS, Alten JA. Epidemiology of Postoperative Junctional Ectopic Tachycardia in Infants Undergoing Cardiac Surgery. Ann Thorac Surg 2024; 117:1178-1185. [PMID: 38484909 DOI: 10.1016/j.athoracsur.2024.03.002] [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: 12/11/2023] [Revised: 01/28/2024] [Accepted: 03/04/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Junctional ectopic tachycardia (JET) complicates congenital heart surgery in 2% to 8.3% of cases. JET is associated with postoperative morbidity in single-center studies. We used the Pediatric Cardiac Critical Care Consortium data registry to provide a multicenter epidemiologic description of treated JET. METHODS This is a retrospective study (February 2019-August 2022) of patients with treated JET. Inclusion criteria were (1) <12 months old at the index operation, and (2) treated for JET <72 hours after surgery. Diagnosis was defined by receiving treatment (pacing, cooling, and medications). A multilevel logistic regression analysis with hospital random effect identified JET risk factors. Impact of JET on outcomes was estimated by margins/attributable risk analysis using previous risk-adjustment models. RESULTS Among 24,073 patients from 63 centers, 1436 (6.0%) were treated for JET with significant center variability (0% to 17.9%). Median time to onset was 3.4 hours, with 34% present on admission. Median duration was 2 days (interquartile range, 1-4 days). Tetralogy of Fallot, atrioventricular canal, and ventricular septal defect repair represented >50% of JET. Patient characteristics independently associated with JET included neonatal age, Asian race, cardiopulmonary bypass time, open sternum, and early postoperative inotropic agents. JET was associated with increased risk-adjusted durations of mechanical ventilation (incidence rate ratio, 1.6; 95% CI, 1.5-1.7) and intensive care unit length of stay (incidence rate ratio, 1.3; 95% CI, 1.2-1.3), but not mortality. CONCLUSIONS JET is treated in 6% of patients with substantial center variability. JET contributes to increased use of postoperative resources. High center variability warrants further study to identify potential modifiable factors that could serve as targets for improvement efforts to ameliorate deleterious outcomes.
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Affiliation(s)
- Michael E Kim
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Shankar Baskar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Christopher M Janson
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Robert D Whitehill
- Division of Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Mark A Law
- Division of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Yuliya Domnina
- Department of Cardiac Critical Care, Children's National Hospital, Washington, DC
| | - Melissa N Smith-Parrish
- Department of Critical Care Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Geoffrey L Bird
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mousumi Banerjee
- Department of Cardiology, C.S. Mott Children's Hospital Congenital Heart Center, Ann Arbor, Michigan
| | - Wenying Zhang
- Department of Cardiology, C.S. Mott Children's Hospital Congenital Heart Center, Ann Arbor, Michigan
| | - Garrett Reichle
- Department of Cardiology, C.S. Mott Children's Hospital Congenital Heart Center, Ann Arbor, Michigan
| | - Kurt R Schumacher
- Department of Cardiology, C.S. Mott Children's Hospital Congenital Heart Center, Ann Arbor, Michigan
| | - Richard J Czosek
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David L S Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey A Alten
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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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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Bencie N, Savorgnan F, Binsalamah Z, Resheidat A, Vener DF, Faraoni D. Cardiac Arrest With or Without Need for Extracorporeal Life Support After Congenital Cardiac Surgery. Ann Thorac Surg 2024; 117:813-819. [PMID: 37704002 DOI: 10.1016/j.athoracsur.2023.09.003] [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: 05/03/2023] [Revised: 08/15/2023] [Accepted: 09/05/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Postoperative cardiac arrest (CA) with or without need for extracorporeal cardiopulmonary resuscitation (ECPR) is one of the most significant complications in the early postoperative period after pediatric cardiac operation. The objective of this study was to develop and to validate a predictive model of postoperative CA with or without ECPR. METHODS In this retrospective cohort study, we reviewed data from patients who underwent cardiac surgery with cardiopulmonary bypass (CPB) between July 20, 2020, and December 31, 2021. Variables included demographic data, presence of preoperative risk factors, The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality categories, perioperative data, residual lesion score (RLS), and vasoactive-inotropic score (VIS). We used multivariable logistic regression analysis to develop a predictive model. RESULTS The incidence of CA with or without ECPR was 4.4% (n = 24/544). Patients who experienced postoperative CA with or without ECPR were younger (age, 130 [54-816.5] days vs 626 [127.5-2497.5] days; P < .050) and required longer CPB (253 [154-332.5] minutes vs 130 [87-186] minutes; P < .010) and cross-clamp (116.5 [75.5-143.5] minutes vs 64 [30-111] minutes; P < .020) times; 37.5% of patients with an outcome had at least 1 preoperative risk factor (vs 16.9%; P < .010). Our multivariable logistic regression determined that the presence of at least 1 preoperative risk factor (P = .005), CPB duration (P = .003), intraoperative residual lesion score (P = .009), and postsurgery vasoactive-inotropic score (P = .010) were predictors of the incidence of CA with or without ECPR. CONCLUSIONS We developed a predictive model of postoperative CA with or without ECPR after congenital cardiac operation. Our model performed better than the individual scores and risk factors.
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Affiliation(s)
- Nicole Bencie
- Warren Alpert Medical School of Brown University, Providence, Rhode Island; Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Fabio Savorgnan
- Department of Pediatric Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Ziyad Binsalamah
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Ashraf Resheidat
- Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - David F Vener
- Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - David Faraoni
- Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.
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Verma A, Williamson CG, Bakhtiyar SS, Hadaya J, Hekking T, Kronen E, Si MS, Benharash P. Center-Level Variation in Failure to Rescue After Pediatric Cardiac Surgery. Ann Thorac Surg 2024; 117:552-559. [PMID: 37182822 DOI: 10.1016/j.athoracsur.2023.05.001] [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: 12/08/2022] [Revised: 04/17/2023] [Accepted: 05/01/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Although failure to rescue (FTR) is increasingly recognized as a quality metric, studies in congenital cardiac surgery remain sparse. Within a national cohort of children undergoing cardiac operations, we characterized the presence of center-level variation in FTR and hypothesized a strong association with mortality but not complications. METHODS All children undergoing congenital cardiac operations were identified in the 2013 to 2019 Nationwide Readmissions Database. FTR was defined as in-hospital death after cardiac arrest, ventricular tachycardia/fibrillation, prolonged mechanical ventilation, pneumonia, stroke, venous thromboembolism, or sepsis, among other complications. Hierarchical models were used to generate hospital-specific, risk-adjusted rates of mortality, complications, and FTR. Centers in the highest decile of FTR were identified and compared with others. RESULTS Of an estimated 74,070 patients, 1.9% died before discharge, at least 1 perioperative complication developed in 43.0%, and 4.1% experienced FTR. After multilevel modeling, decreasing age, nonelective admission, and increasing operative complexity were associated with greater odds of FTR. Variations in overall mortality and FTR exhibited a strong, positive relationship (r = 0.97), whereas mortality and complications had a negligible association (r = -0.02). Compared with others, patients at centers with high rates of FTR had similar distributions of age, sex, chronic conditions, and operative complexity. CONCLUSIONS In the present study, center-level variations in mortality were more strongly explained by differences in FTR than complications. Our findings suggest the utility of FTR as a quality metric for congenital heart surgery, although further study is needed to develop a widely accepted definition and appropriate risk-adjustment models.
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Affiliation(s)
- Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Catherine G Williamson
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California; Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California; Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California; Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Tyson Hekking
- Department of Pediatrics, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Elsa Kronen
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Ming-Sing Si
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California.
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Werho DK, Fisk A, Yeh J, Rooney S, Wilkes R, Shin AY, Zhang W, Banerjee M, Gaies M. Measuring Critical Care Unit Performance Using a Postoperative Mechanical Ventilation Quality Metric. Ann Thorac Surg 2024; 117:440-447. [PMID: 36470563 DOI: 10.1016/j.athoracsur.2022.11.026] [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: 07/01/2022] [Revised: 11/12/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Safely minimizing postoperative mechanical ventilation duration after congenital heart surgery could be a cardiac intensive care unit (CICU) quality measure. We aimed to measure CICU performance using duration of postoperative mechanical ventilation and identify organizational factors associated with this metric. METHODS Observational analysis of 16,848 surgical hospitalizations of patients invasively ventilated on admission from the operating room from 26 Pediatric Cardiac Critical Care Consortium CICUs. We fitted a multivariable model to predict duration of postoperative mechanical ventilation adjusting for pre- and postoperative factors to measure CICU performance accounting for postoperative illness severity. We used our model to calculate observed-to-expected (adjusted) ventilation duration ratios for each CICU, describe variation across CICUs, and characterize outliers based on bias-corrected bootstrap 95% CIs. We explored associations between organizational characteristics and patient-level adjusted ventilation duration by adding these as independent variables to the model. RESULTS We observed wide variation across CICUs in adjusted ventilation duration ratios, ranging from 0.7 to 1.7. Nine of 26 CICUs had statistically better than expected ventilation duration, while 10 were significantly worse than expected. Organizational characteristics associated with shorter adjusted ventilation duration included mixed (60%-90%) staffing by critical care or anesthesia-trained attendings, lower average attending-to-patient ratio, average CICU daily occupancy 80% to 90%, and greater nurse staffing ratios and experience. CONCLUSIONS CICU performance in postoperative duration of mechanical ventilation varies widely across Pediatric Cardiac Critical Care Consortium centers. Several potentially modifiable organizational factors are associated with this metric. Taken together, these findings could spur efforts to improve ventilation duration at outlier hospitals.
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Affiliation(s)
- David K Werho
- Division of Pediatric Cardiology, Department of Pediatrics, Rady Children's Hospital, UC San Diego, San Diego, California.
| | - Anna Fisk
- Cardiovascular and Critical Care Services, Boston Children's Hospital, Boston, Massachusetts
| | - Justin Yeh
- Division of Pediatric Cardiac Intensive Care Medicine, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sydney Rooney
- Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ryan Wilkes
- Division of Pediatric Cardiology, Department of Pediatrics, Levine Children's Hospital, Charlotte, North Carolina
| | - Andrew Y Shin
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Palo Alto, California
| | - Wenying Zhang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Mousumi Banerjee
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Michael Gaies
- Division of Pediatric Cardiology, Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio
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Youssef T, Bitar F, Alogla H, El Khoury M, Moukhaiber J, Alamin F, AlHareth B, Gabriel CC, Youssef R, Abouzahr L, Abdul Sater Z, Bitar F. Establishing a High-Quality Pediatric Cardiac Surgery Program in Post-Conflict Regions: A Model for Limited Resource Countries. Pediatr Cardiol 2024:10.1007/s00246-023-03384-7. [PMID: 38242971 DOI: 10.1007/s00246-023-03384-7] [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: 09/08/2023] [Accepted: 12/12/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND Congenital Heart Disease stands as a prominent cause of infant mortality, with notable disparities in surgical outcomes evident between high-income and low- to middle-income countries. OBJECTIVE This study presents a collaborative partnership between a local governmental entity and an international private organization to establish a high-quality Pediatric Cardiac Surgery Program in a post-conflict limited resource country, Iraq. METHODS A descriptive retrospective study analyzed pediatric cardiac surgery procedures performed by a visiting pediatric heart surgery team from October 2021 to October 2022, funded by the Ministry of Health (MOH). We used the STS-EACTS complexity scoring model (STAT) to assess mortality risks associated with surgical procedures. RESULTS A total of 144 patients underwent 148 procedures. Infants comprised 58.3% of the patients. The most common anomalies included tetralogy of Fallot, ventricular septal defect, and various single ventricle categories, constituting 76% of the patient cohort. The overall surgical mortality rate was 4.1%, with an observed/expected surgical mortality rate of 1.1 (95% CI 0.5, 2.3). There was no significant difference between our observed surgical mortality in Category 2, 3, and 4 and those expected/reported by the STS-EACTS Database (p = 0.07, p = 0.72, and p = 0.12, respectively). The expenses incurred by the MOH for conducting surgeries in Iraq were lower than the alternative of sending patients abroad for the same procedures. CONCLUSION The partnership model between a local public entity committed to infrastructure development and funding and an international private organization delivering clinical and training services can provide the foundation for building sustainable, high-quality in situ programs in upper-middle-income countries.
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Affiliation(s)
| | - Fouad Bitar
- Children's Heart Center, Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon
| | - Hassanain Alogla
- Cardiac Surgery Program at Imam Al Hassan Hospital, Karbala, Iraq
| | - Maya El Khoury
- Children's Heart Center, Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon
| | - Jihan Moukhaiber
- Children's Heart Center, Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon
| | - Farah Alamin
- Children's Heart Center, Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon
| | - Bassam AlHareth
- Marie Curie Children's Hospital Bucharest, Bucharest, Romania
| | | | | | | | - Zahi Abdul Sater
- College of Public Health, Phoenicia University, Mazraat El Daoudiyeh, Lebanon
| | - Fadi Bitar
- Children's Heart Center, Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon.
- Beirut Global Foundation for Congenital Heart Disease, Beirut, Lebanon.
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9
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Abdelrehim AA, Dearani JA, Holst KA, Miranda WR, Connolly HM, Todd AL, Burchill LJ, Schaff HV, Pochettino A, Stephens EH. Risk factors and early outcomes of repeat sternotomy in 1960 adults with congenital heart disease: A 30-year, single-center study. J Thorac Cardiovasc Surg 2023:S0022-5223(23)01090-5. [PMID: 37981102 DOI: 10.1016/j.jtcvs.2023.11.014] [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: 06/20/2023] [Revised: 10/06/2023] [Accepted: 11/05/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVE Patients with congenital heart disease (CHD) increasingly live into adulthood, often requiring cardiac reoperation. We aimed to assess the outcomes of adults with CHD (ACHD) undergoing repeat sternotomy at our institution. METHODS Review of our institution's cardiac surgery database identified 1960 ACHD patients undergoing repeat median sternotomy from 1993 to 2023. The primary outcome was early mortality, and the secondary outcome was a composite end point of mortality and significant morbidity. Univariable and multivariable logistic regression models were used to determine factors independently associated with outcomes. RESULTS Of the 1960 ACHDs patient undergoing repeat sternotomy, 1183 (60.3%) underwent a second, third (n = 506, 25.8%), fourth (n = 168, 8.5%), fifth (n = 70, 3.5%), and sixth sternotomy or greater (n = 33, 1.6%). CHD diagnoses were minor complexity (n = 145, 7.4%), moderate complexity (n = 1380, 70.4%), and major complexity (n = 435, 22.1%). Distribution of procedures included valve (n = 549, 28%), congenital (n = 625, 32%), aortic (n = 104, 5.3%), and major procedural combinations (n = 682, 34.7%). Overall early mortality was 3.1%. Factors independently associated with early mortality were older age at surgery, CHD of major complexity, preoperative renal failure, preoperative ejection fraction, urgent operation, and postoperative blood transfusion. In addition, sternotomy number and bypass time were independently associated with the composite outcome. CONCLUSIONS Despite the increase in early mortality with sternotomy number, sternotomy number was not independently associated with early mortality but with increased morbidity. Improvement strategies should target factors leading to urgent operations, early referral, along with operative efficiency including bypass time and blood conservation.
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Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
| | - Kimberly A Holst
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | - Heidi M Connolly
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
| | - Austin L Todd
- Department of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minn
| | - Luke J Burchill
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
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10
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Brunetti MA, Griffis HM, O'Byrne ML, Glatz AC, Huang J, Schumacher KR, Bailly DK, Domnina Y, Lasa JJ, Moga MA, Zaccagni H, Simsic JM, Gaynor JW. Racial and Ethnic Variation in ECMO Utilization and Outcomes in Pediatric Cardiac ICU Patients. JACC. ADVANCES 2023; 2:100634. [PMID: 38938717 PMCID: PMC11198441 DOI: 10.1016/j.jacadv.2023.100634] [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: 01/31/2023] [Revised: 06/15/2023] [Accepted: 07/26/2023] [Indexed: 06/29/2024]
Abstract
Background Previous studies have reported racial disparities in extracorporeal membrane oxygenation (ECMO) utilization in pediatric cardiac patients. Objectives The objective of this study was to determine if there was racial/ethnic variation in ECMO utilization and, if so, whether mortality was mediated by differences in ECMO utilization. Methods This is a multicenter, retrospective cohort study of the Pediatric Cardiac Critical Care Consortium clinical registry. Analyses were stratified by hospitalization type (medical vs surgical). Logistic regression models were adjusted for confounders and evaluated the association between race/ethnicity with ECMO utilization and mortality. Secondary analyses explored interactions between race/ethnicity, insurance, and socioeconomic status with ECMO utilization and mortality. Results A total of 50,552 hospitalizations from 34 hospitals were studied. Across all hospitalizations, 2.9% (N = 1,467) included ECMO. In medical and surgical hospitalizations, Black race and Hispanic ethnicity were associated with severity of illness proxies. In medical hospitalizations, race/ethnicity was not associated with the odds of ECMO utilization. Hospitalizations of other race had higher odds of mortality (adjusted odds ratio [aOR]: 1.61; 95% CI: 1.22-2.12; P = 0.001). For surgical hospitalizations, Black (aOR: 1.24; 95% CI: 1.02-1.50; P = 0.03) and other race (aOR: 1.50; 95% CI: 1.17-1.93; P = 0.001) were associated with higher odds of ECMO utilization. Hospitalizations of Hispanic patients had higher odds of mortality (aOR: 1.31; 95% CI: 1.03-1.68; P = 0.03). No significant interactions were demonstrated between race/ethnicity and socioeconomic status indicators with ECMO utilization or mortality. Conclusions Black and other races were associated with increased ECMO utilization during surgical hospitalizations. There were racial/ethnic disparities in outcomes not explained by differences in ECMO utilization. Efforts to mitigate these important disparities should include other aspects of care.
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Affiliation(s)
- Marissa A. Brunetti
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Heather M. Griffis
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael L. O'Byrne
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Children’s Hospital of Philadelphia, and Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew C. Glatz
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Children’s Hospital of Philadelphia, and Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jing Huang
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kurt R. Schumacher
- Department of Pediatrics, University of Michigan Medical School and C.S. Mott Children’s Hospital, Ann Arbor, Michigan, USA
| | - David K. Bailly
- Department of Pediatrics, University of Utah and Primary Children’s Hospital, Salt Lake City, Utah, USA
| | - Yuliya Domnina
- Division of Cardiac Critical Care Medicine, George Washington University School of Medicine and Children’s National Hospital, Washington, DC, USA
| | - Javier J. Lasa
- Divisions of Critical Care Medicine and Cardiology, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Michael Alice Moga
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Canada
| | - Hayden Zaccagni
- Section of Cardiac Critical Care Medicine, Department of Pediatrics, Children’s of Alabama and University of Alabama Medicine, Birmingham, Alabama, USA
| | - Janet M. Simsic
- The Heart Center at Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - J. William Gaynor
- Department of Surgery, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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11
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Perry T, Klugman D, Schumacher K, Banerjee M, Zhang W, Bertrandt R, Wolovits JS, Murphy LD, Misfeldt AM, Alten J, Cooper DS. Unplanned Extubation During Pediatric Cardiac Intensive Care: U.S. Multicenter Registry Study of Prevalence and Outcomes. Pediatr Crit Care Med 2023; 24:551-562. [PMID: 37070818 DOI: 10.1097/pcc.0000000000003235] [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: 04/19/2023]
Abstract
OBJECTIVES The epidemiology of unplanned extubations (UEs) and associated adverse outcomes in pediatric cardiac ICUs (CICU). DESIGN Registry data (August 2014 to October 2020). SETTING Forty-five Pediatric Cardiac Critical Care Consortium hospitals. PATIENTS Patients receiving mechanical ventilation (MV) via endotracheal tube (ETT). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Fifty-six thousand five hundred eight MV courses occurred in 36,696 patients, with a crude UE rate of 2.8%. In cardiac surgical patients, UE was associated with longer duration of MV, but we failed to find such association in medical patients. In both cohorts, UE was associated with younger age, being underweight, and airway anomaly. In multivariable logistic regression, airway anomaly was associated with UE in all patients. Younger age, higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score category, longer duration of MV, and initial oral rather than nasal ETT are associated with UE in the surgical group, but we failed to find such associations in the medical group. UE was associated with a higher reintubation rate compared with elective extubation (26.8 vs 4.8%; odds ratio [OR], 7.35; 95% CI, 6.44-8.39; p < 0.0001) within 1 day of event. After excluding patients having redirection of care, UE was associated with at least three-fold greater odds for each of ventilator-associated pneumonia (VAP), cardiac arrest, and use of mechanical circulatory support (MCS). However, we failed to identify an association between UE and greater odds of mortality (1.2 vs 0.8%; OR, 1.48; 95% CI, 0.86-2.54; p = 0.15), but uncertainty remains. CONCLUSIONS UE in CICU patients is associated with greater odds of cardiac arrest, VAP, and MCS. Cardiac medical and surgical patients in the CICU appear to have different explanatory factors associated with UE, and perhaps these may be modifiable and tested in future collaborative population research.
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Affiliation(s)
- Tanya Perry
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Darren Klugman
- Department of Pediatrics, John's Hopkins Children's Hospital Medical Center, Baltimore, MD
| | - Kurt Schumacher
- Congenital Heart Center, University of Michigan, Ann Arbor, MI
| | | | - Wenying Zhang
- Congenital Heart Center, University of Michigan, Ann Arbor, MI
| | - Rebecca Bertrandt
- Division of Pediatric Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Joshua S Wolovits
- Department of Pediatrics, UT Southwestern Medical Center, Children's Medical Center, Dallas, TX
| | - Lee D Murphy
- Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Andrew M Misfeldt
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jeffrey Alten
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - David S Cooper
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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12
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Foote HP, Wu H, Balevic SJ, Thompson EJ, Hill KD, Graham EM, Hornik CP, Kumar KR. Using Pharmacokinetic Modeling and Electronic Health Record Data to Predict Clinical and Safety Outcomes after Methylprednisolone Exposure during Cardiopulmonary Bypass in Neonates. CONGENIT HEART DIS 2023; 18:295-313. [PMID: 37484782 PMCID: PMC10361697 DOI: 10.32604/chd.2023.026262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 02/08/2023] [Indexed: 07/25/2023]
Abstract
Background Infants undergoing cardiac surgery with cardiopulmonary bypass (CPB) frequently receive intraoperative methylprednisolone (MP) to suppress CPB-related inflammation; however, the optimal dosing strategy and efficacy of MP remain unclear. Methods We retrospectively analyzed all infants under 90 days-old who received intra-operative MP for cardiac surgery with CPB from 2014-2017 at our institution. We combined real-world dosing data from the electronic health record (EHR) and two previously developed population pharmacokinetic/pharmacodynamic models to simulate peak concentration (Cmax) and area under the concentration-time curve for 24 h (AUC24) for MP and the inflammatory cytokines interleukin-6 (IL-6) and interleukin-10 (IL-10). We evaluated the relationships between post-operative, safety, and other clinical outcomes obtained from the EHR with each predicted exposure using non-parametric tests. Results A total of 142 infants with median post-natal age 8 (interquartile range [IQR]: 5, 37) days received a total dose of 30 (19, 49) mg/kg of MP. Twelve (8%) died, 37 (26%) met the composite post-operative outcome, 114 (80%) met the composite safety outcome, and 23 (16%) had a major complication. Predicted median Cmax and AUC24 IL-6 exposure was significantly higher for infants meeting the composite post-operative outcome and those with major complications. Predicted median Cmax and AUC24 MP exposure was significantly higher for infants requiring insulin. No exposure was associated with death or other safety outcomes. Conclusions Pro-inflammatory IL-6, but not MP exposure, was associated with post-operative organ dysfunction, suggesting current MP dosing may not adequately suppress IL-6 or increase IL-10 to impact clinical outcomes. Prospective study will be required to define the optimal exposure-efficacy and exposure-safety profiles in these infants.
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Affiliation(s)
| | - Huali Wu
- Duke Clinical Research Institute, Durham, USA
| | - Stephen J. Balevic
- Department of Pediatrics, Duke University, Durham, USA
- Duke Clinical Research Institute, Durham, USA
| | - Elizabeth J. Thompson
- Department of Pediatrics, Duke University, Durham, USA
- Duke Clinical Research Institute, Durham, USA
| | - Kevin D. Hill
- Department of Pediatrics, Duke University, Durham, USA
- Duke Clinical Research Institute, Durham, USA
| | - Eric M. Graham
- Department of Pediatrics, Medical University of South Carolina, Charleston, USA
| | - Christoph P. Hornik
- Department of Pediatrics, Duke University, Durham, USA
- Duke Clinical Research Institute, Durham, USA
| | - Karan R. Kumar
- Department of Pediatrics, Duke University, Durham, USA
- Duke Clinical Research Institute, Durham, USA
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13
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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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14
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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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15
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Kim ME, Kasparian NA, Zang H, Pater C, Chlebowski MM, Marcuccio E, Florez A, Morales DLS, Madsen N, Moore RA. Are Parent Discharge Readiness Scores Effective for the Congenital Heart Disease Patients After Cardiac Surgery? J Pediatr 2023:S0022-3476(23)00120-8. [PMID: 36841508 DOI: 10.1016/j.jpeds.2023.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 01/23/2023] [Accepted: 02/04/2023] [Indexed: 02/27/2023]
Abstract
OBJECTIVE To assess discharge readiness and clinical engagement post-discharge in familes of children undergoing congenital heart surgery (CHS). STUDY DESIGN This prospective cross-sectional study was performed at a major tertiary pediatric cardiac referral center. Eligible parents and caregivers completed a discharge readiness tool, the Readiness for Hospital Discharge Scale for Parents of Hospitalized Children (PedRHDS), via online survey on the day of discharge. Clinical engagement data included subsequent phone calls, clinic visits, emergency department (ED) visits, and hospital readmissions. PedRHDS scores were measured as follows: Very High (9-10), High (8-8.9), Moderate (7-7.9), and Low (<7). Descriptive statistics were used to describe demographic data. RESULTS 128 families enrolled between April and December 2021. Parent discharge readiness scores ranged from 'High' to 'Very High.' Families with lower socioeconomic status and younger patients (especially single ventricle infants or "interstage") had a higher proportion of clinic visits, ED visits, and hospital readmissions within 30-days post-discharge compared with other groups. CONCLUSIONS Discharge readiness scores were not associated with clinical engagement. We identified vulnerable populations as evidenced by a higher frequency of clinical engagement in the immediate post-operative period, particularly younger patients and first time surgeries. While these visits may be appropriate, novel programs could enhance education and emotional support to prevent delay in seeking care or creating excessive stress and anxiety after discharge.
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Affiliation(s)
- Michael E Kim
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati, College of Medicine, Cincinnati, OH.
| | - Nadine A Kasparian
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Huaiyu Zang
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Colleen Pater
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Meghan M Chlebowski
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Elisa Marcuccio
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Amy Florez
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - David L S Morales
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Nicolas Madsen
- The Heart Center, Children's Health, UT Southwestern, Dallas, TX
| | - Ryan A Moore
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati, College of Medicine, Cincinnati, OH
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16
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Implications of Transfusion in Adults with Congenital Heart Disease Undergoing Cardiac Surgery. Pediatr Cardiol 2023; 44:218-227. [PMID: 35963890 DOI: 10.1007/s00246-022-02981-2] [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: 04/05/2022] [Accepted: 07/21/2022] [Indexed: 01/24/2023]
Abstract
The number of adults with congenital heart disease (CHD) requiring cardiovascular (CV) surgery is increasing rapidly in today's era. We hypothesized that exposure to perioperative blood products is associated with worse outcomes in adults. All adults (≥ 18 years old) undergoing CV surgery with Cardio-Pulmonary Bypass (CPB) between 2015 and 2020 were reviewed retrospectively. Associations between transfusion and outcomes were studied by univariable logistic regression and Wilcoxon rank sum tests. Cox/ logistic regression was used to assess (a) postoperative ventilation time and length of stay, and (b) major complications, respectively. Of 323 patients, 170 (53%) received blood products perioperatively. The median age was 27 (interquartile range [IQR]: 22-36) years, there were 181 (46%) males, and 16 (5%) patients had single ventricle anatomy. Patients receiving products experienced more complications (OR: 6.6, 95% CI: [2.9, 14.7], p < 0.001) specifically, cardiac arrest (OR: 8.8, 95% CI: [1.1, 71.9], p = 0.04). Transfusion was associated with greater frequency of thrombosis ((OR: 7.8, 95% CI: [1.8, 34.7], p = 0.01)), longer ventilation time (HR: 3.0, 95% CI: [2.4, 3.9], p < 0.001), and longer hospital length of stay (HR: 2.7, 95% CI: [2.1, 3.4], p < 0.001). Longer CPB time (OR: 1.0, 95% CI: [1.0, 1.1], p < 0.001) and prior cardiac surgery (OR: 1.6, 95% CI: [1.3, 2.1], p < 0.001) were independent predictors of perioperative blood product transfusion. Adults who received perioperative blood products experienced more complications and worse in-hospital outcomes. Future research on optimizing blood product transfusion based on risk prediction is needed to optimize outcomes in adults with CHD.
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Impact of obesity on post-operative arrhythmias after congenital heart surgery in children and young adults. Cardiol Young 2022; 32:1820-1825. [PMID: 34986912 PMCID: PMC9256859 DOI: 10.1017/s1047951121005114] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Obesity increases the risk of post-operative arrhythmias in adults undergoing cardiac surgery, but little is known regarding the impact of obesity on post-operative arrhythmias after CHD surgery. METHODS Patients undergoing CHD surgery from 2007 to 2019 were prospectively enrolled in the parent study. Telemetry was assessed daily, with documentation of all arrhythmias. Patients aged 2-20 years were categorised by body mass index percentile for age and sex (underweight <5, normal 5-85, overweight 85-95, and obese >95). Patients aged >20 years were categorised using absolute body mass index. We investigated the impact of body mass index category on arrhythmias using univariate and multivariate analysis. RESULTS There were 1250 operative cases: 12% underweight, 65% normal weight, 12% overweight, and 11% obese. Post-operative arrhythmias were observed in 38%. Body mass index was significantly higher in those with arrhythmias (18.8 versus 17.8, p = 0.003). There was a linear relationship between body mass index category and incidence of arrhythmias: underweight 33%, normal 38%, overweight 42%, and obese 45% (p = 0.017 for trend). In multivariate analysis, body mass index category was independently associated with post-operative arrhythmias (p = 0.021), with odds ratio 1.64 in obese patients as compared to normal-weight patients (p = 0.036). In addition, aortic cross-clamp time (OR 1.007, p = 0.002) and maximal vasoactive-inotropic score in the first 48 hours (OR 1.03, p = 0.04) were associated with post-operative arrhythmias. CONCLUSION Body mass index is independently associated with incidence of post-operative arrhythmias in children after CHD surgery.
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Clinical implications of acute shunt thrombosis in paediatric patients with systemic-to-pulmonary shunt re-interventions. Cardiol Young 2022; 33:726-732. [PMID: 35638699 DOI: 10.1017/s1047951122001548] [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: 11/07/2022]
Abstract
PURPOSE Systemic-to-pulmonary shunts are used as a source of pulmonary blood flow in palliated Congenital Heart Disease in neonates and young infants. Shunt thrombosis, often requiring shunt interventions during index hospitalisation, is associated with poor outcomes. We hypothesised that extensive use of perioperative pro-coagulant products may be associated with shunt thrombosis. METHODS Children (≤18 years) undergoing systemic-to-pulmonary shunts with in-hospital shunt reinterventions between 2016 and 2020 were reviewed retrospectively. Perioperative associations to shunt thrombosis were examined by univariate logistic regression and Wilcoxon rank sum tests as appropriate. Cox and log transformed linear regression were used to analyse postoperative ventilation duration, length of stay, and cost. RESULTS Of 71 patients requiring in-hospital shunt intervention after systemic-to-pulmonary shunts, 10 (14%) had acute shunt thrombosis, and among them five (50%) died. The median age was four (interquartile range: 0-15) months. There were 40 (56%) males, 41 (58%) had single ventricle anatomy, and 29 (40%) were on preoperative anticoagulants. Patients with acute shunt thrombosis received greater volume of platelets (p = 0.04), cryoprecipitate (p = 0.02), and plasma (p = 0.04) postoperatively in the ICU; experienced more complications (p = 0.01) including re-exploration for bleeding (p = 0.008) and death (p = 0.02), had longer hospital length of stays (p = 0.004), greater frequency of other arterial/venous thrombosis (p = 0.02), and greater hospital costs (p = 0.002). CONCLUSIONS Patients who develop acute shunt thrombosis receive more blood products perioperatively and experience worse hospital outcomes and higher hospital costs. Future research on prevention/early detection of shunt thrombosis is needed to improve outcomes in infants after systemic-to-pulmonary shunt surgery.
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Izumi G, Takeda A, Yamazawa H, Kato N, Kato H, Tachibana T, Sagae O, Yahagi R, Maeno M, Hoshino K, Saito H. Perioperative junctional ectopic tachycardia associated with congenital heart disease: risk factors and appropriate interventions. Heart Vessels 2022; 37:1792-1800. [PMID: 35469049 DOI: 10.1007/s00380-022-02074-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 04/08/2022] [Indexed: 11/28/2022]
Abstract
The risk factors and the appropriate interventions for perioperative junctional ectopic tachycardia (JET) in congenital heart disease (CHD) surgery have not been sufficiently investigated despite the severity of this complication. This study aimed to examine the risk factors and interventions for perioperative JET. From 2013 to 2020, 1062 surgeries for CHD (median patient age: 4.3 years, range 0.0-53.0) with or without a cardiopulmonary bypass (CPB) were performed at Hokkaido University, Japan. We investigated the correlation between perioperative JET morbidity factors, such as age, genetic background, CPB/aortic cross-clamp (ACC) time, use of inotropes and dexmedetomidine, STAT score, and laboratory indices. The efficacy of JET therapies was also evaluated. Of the 1062 patients, 86 (8.1%) developed JET. The 30-day mortality was significantly high in JET groups (7% vs. 0.8%). The independent risk factors for JET included heterotaxy syndrome [odds ratio (OR) 4.83; 95% confidence interval (CI) 2.18-10.07], ACC time exceeding 90 min (OR 1.90; CI 1.27-2.39), and the use of 3 or more inotropes (OR 4.11; CI 3.02-5.60). The combination of anti-arrhythmic drugs and a temporary pacemaker was the most effective therapy for intractable JET. Perioperative JET after CHD surgery remains a common cause of mortality. Inotrope use was a risk factor for developing JET overall surgery risk. In short ACC surgeries, heterotaxy syndrome could increase the risk of JET, which could develop even without inotrope use in long ACC surgeries. It is crucial not to delay the treatment in cases with unstable hemodynamics caused by this arrhythmia. It is recommended to reduce numbers not dose of inotropes.
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Affiliation(s)
- Gaku Izumi
- Department of Pediatrics, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, 060-8638, Japan.
| | - Atsuhito Takeda
- Department of Pediatrics, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, 060-8638, Japan
| | - Hirokuni Yamazawa
- Department of Pediatrics, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, 060-8638, Japan
| | - Nobuyasu Kato
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, 060-8638, Japan
| | - Hiroki Kato
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, 060-8638, Japan
| | - Tsuyoshi Tachibana
- Department of Cardiovascular Surgery, Kanagawa Children's Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama, Kanagawa, 232-8555, Japan
| | - Osamu Sagae
- Division of Medical Engineering Center, Hokkaido University Hospital, North-15 West-7, Sapporo, 060-8638, Japan
| | - Ryogo Yahagi
- Division of Medical Engineering Center, Hokkaido University Hospital, North-15 West-7, Sapporo, 060-8638, Japan
| | - Motoki Maeno
- Division of Medical Engineering Center, Hokkaido University Hospital, North-15 West-7, Sapporo, 060-8638, Japan
| | - Koji Hoshino
- Department of Anesthesiology and Critical Care Medicine, Faculty of Hokkaido University Hospital, North-15 West-7, Sapporo, 060-8638, Japan
| | - Hitoshi Saito
- Department of Anesthesiology and Critical Care Medicine, Faculty of Hokkaido University Hospital, North-15 West-7, Sapporo, 060-8638, Japan
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Arbic N, Venet M, Iriart X, Dragulescu A, Thambo JB, Friedberg MK, Guerra V, Morgan CT, Mertens L, Villemain O. Organization of Pediatric Echocardiography Laboratories: Impact of Sonographers on Clinical, Academic, and Financial Performance. Front Pediatr 2022; 10:891360. [PMID: 35712633 PMCID: PMC9196029 DOI: 10.3389/fped.2022.891360] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/10/2022] [Indexed: 11/23/2022] Open
Abstract
Echocardiography has evolved the first-line imaging for diagnosis and management of pediatric and congenital heart disease all over the world. While it recognized as essential component of pediatric cardiac care delivery, organization of pediatric echocardiography services is very heterogeneous across the world, mainly related to significant differences in material and human resources in heterogeneous health care systems. In this paper, we focus on the role of pediatric sonographers, defined as expert technicians in pediatric echocardiography. While in some services sonographers are an essential part of the organizational structure, other laboratories operate only with physicians trained in echocardiography. The impact of sonographers on clinical, academic and financial performance will be discussed. Two organizational models (with and without sonographers) will be compared, and the advantages and disadvantages of each model will be evaluated. Different models of care provision are possible and decisions on organizational models need to be adjusted to the demands and available resources.
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Affiliation(s)
- Nick Arbic
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Maelys Venet
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Xavier Iriart
- Department of Pediatric and Adult Congenital Cardiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Bordeaux, France.,IHU LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France
| | - Andreea Dragulescu
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Jean-Benoit Thambo
- Department of Pediatric and Adult Congenital Cardiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Bordeaux, France.,IHU LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France
| | - Mark K Friedberg
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Vitor Guerra
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Conall Thomas Morgan
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Luc Mertens
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Olivier Villemain
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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21
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Nelson JS, Jacobs JP, Bhamidipati CM, Yarboro LT, Subramanyan RK, McDonald D, Krohn C, Jones LA, Mayer JE, Scholl FG. Assessment of Current STS Data Elements for Adults with Congenital Heart Disease. Ann Thorac Surg 2021; 114:2323-2329. [PMID: 34906569 DOI: 10.1016/j.athoracsur.2021.11.017] [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] [Received: 07/20/2021] [Revised: 10/29/2021] [Accepted: 11/02/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND To identify opportunities for enhanced ACHD data collection, a structured review of existing variables in the STS Congenital Heart Surgery Database (CHSD) and the STS Adult Cardiac Surgery Database (ACSD) was conducted. METHODS A working group was assembled representing multiple STS Workforces and Task Forces. The ACSD was reviewed systematically over eight 90 minute calls. ACSD version 4.20.2 and CHSD version 3.41 were used, and the ACSD was approached in sections. ACSD variables were classified as either: 1) represented in identical form in the CHSD (no further discussion), 2) represented in similar form in the CHSD (discussed for potential harmonization of definitions), or 3) not represented in the CHSD (discussed for potential inclusion). Variables felt to be relevant to ACHD were noted, and special consideration was given to STS required fields and variables utilized in existing STS adult risk models. Other factors that were examined were the frequency, utilization, and capture of existing ACSD variables. RESULTS Over 22 weeks (8 calls), the existing 1069 variables in version 4.20.2 of the ACSD were discussed. Ultimately, 539 total variables were found to be both 1) relevant to ACHD and 2) not currently collected in the CHSD. These were recommended for inclusion in the next CHSD upgrade for patients older than 18 years. CONCLUSIONS For adult patients having case records entered into the CHSD, the inclusion of a limited set of additional data fields from the ACSD should enhance capture of co-morbidities and other clinical data relevant to the ACHD population.
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Affiliation(s)
- Jennifer S Nelson
- Department of Cardiovascular Services, Nemours Children's Hospital; 6535 Nemours Parkway; Orlando, FL 32827; USA; University of Central Florida College of Medicine; 6850 Lake Nona Blvd, Orlando, FL 32827; USA.
| | - Jeffrey P Jacobs
- Congenital Heart Center, UF Health Shands Children's Hospital, Gainesville, Florida, USA; Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida, USA
| | | | - Leora T Yarboro
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health, Charlottesville, VA; USA
| | - Ram Kumar Subramanyan
- Department of Surgery, Children's Hospital of Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California; USA
| | - Donna McDonald
- Society of Thoracic Surgeons; 633 N. Saint Clair Street; Chicago, Illinois; USA
| | - Carole Krohn
- Society of Thoracic Surgeons; 633 N. Saint Clair Street; Chicago, Illinois; USA
| | - Leigh Ann Jones
- Society of Thoracic Surgeons; 633 N. Saint Clair Street; Chicago, Illinois; USA
| | - John E Mayer
- Department of Thoracic Surgery, Boston Children's Hospital, Harvard Medical School; Boston, Massachusetts; USA
| | - Frank G Scholl
- Department of Surgery, Joe DiMaggio Children's Hospital, Hollywood, Florida; USA
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22
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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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23
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Abstract
Following pre-natal diagnosis of congenital heart defect parents and family face a dramatic psychological crisis because of their state of shock, contradictory information available on potential outcomes, limited availability of time for decisions and for autonomous choices. Counselling the parents can present additional difficulties due to influence of education, cultural and religious background, individual cognitive and emotional processes, and cross-cultural patient care is a challenging issue for the caregivers. Type and quality of messages transmitted by the caregivers determine the counselling process, with the risk of misunderstandings particularly high with reduced available evidence, or with different outcomes accordingly with the various alternatives of treatment. Since the introduction of pre-natal diagnosis for congenital abnormality, interruption of pregnancy became available on these grounds in many Western countries, and the numbers of babies born with congenital heart defects has declined significantly despite concomitant advances in treatment options and outcomes. Detailed and objective information, with all available options, should be provided after pre-natal diagnosis of congenital heart defect. One of the major achievements of pediatric medicine in the last 50 years is the increased understanding of the pathogenetic causal mechanisms of congenital heart defects as well as its treatment. For congenital heart defects the progress of surgical treatments allowed a huge proportion of these children to reach adult life with a decent quality of life and social integration. Therefore, must be a considerable concern that universal pre-natal diagnosis widespread pregnancy interruption may obviate those gains. A reduction in the post-natal population undergoing treatment may have a significantly deleterious effect on the expertise of the caregivers, producing a reduction in outcome quality. With all respect for the parental choices and the obligations to follow the national laws, is necessary to remark that our society is genuinely ambivalent.
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Affiliation(s)
- Antonio F Corno
- Houston Children's Heart Institute, Memorial Hermann Children's Hospital, University Texas Health, McGovern Medical School, Houston, TX, USA
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24
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25
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Pabst von Ohain J, Sarris G, Tobota Z, Maruszewski B, Vida VL, Hörer J. Risk evaluation in adult congenital heart surgery: analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database risk models on data from the European Congenital Heart Surgeons Association Congenital Database. Eur J Cardiothorac Surg 2021; 60:1397-1404. [PMID: 34058002 DOI: 10.1093/ejcts/ezab229] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We sought to evaluate the predictive power of the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) mortality score and the adult congenital heart surgery (ACHS) mortality score for the adults undergoing congenital heart operations entered into the European Congenital Heart Surgeons Association (ECHSA) database. METHODS The data set comprised 17 662 major operations performed between 1997 and 2019, on patients 18 years of age or older, in European centres participating in the ECHSA database. Each operation was assigned a STAT mortality score and category and an ACHS mortality score. Operative mortality was based on the 30-day status and on the status at hospital discharge. The discriminatory power of the STAT and ACHS scores was assessed using the area under the receiver operating characteristic curve (c-index). RESULTS A total of 17 214 (97.46%) operations were assigned ACHS scores. The 3 most frequent primary procedures were closure of the atrial septal defect (19.0%), aortic valve replacement (8.8%) and non-valve-sparing aortic root replacement (6.1%). Operative mortality for ACHS-coded operations was 2.07%. The procedures with the highest mortality were atrial septal defect creation/enlargement (19.0%), lung transplantation (18.8%) and heart transplantation (18.2%). A total of 17 638 (99.86%) operations were assigned a STAT score and category. The operative mortality for STAT-coded operations was 2.27%. The c-index for mortality was 0.720 for the STAT mortality score and 0.701 for the ACHS score. CONCLUSIONS The ACHS mortality score and the STAT mortality score reached similar, moderate predictive power in adult patients undergoing congenital heart surgery in ECHSA database.
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Affiliation(s)
- Jelena Pabst von Ohain
- Department of Congenital and Paediatric Heart Surgery, German Heart Centre Munich, Munich, Germany.,Division of Congenital and Paediatric Heart Surgery, University Hospital of Munich, Munich, Germany
| | - Georgios Sarris
- Department of Pediatric Heart Surgery, Athens Heart Surgery Institute, Athens, Greece
| | - Zdzislaw Tobota
- Department for Pediatric Cardiothoracic Surgery, Paediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - Bohdan Maruszewski
- Department for Pediatric Cardiothoracic Surgery, Paediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - Vladimiro L Vida
- Paediatric and Cardiac Surgery Unit, Department of Cardio-Thoracic Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - J Hörer
- Department of Congenital and Paediatric Heart Surgery, German Heart Centre Munich, Munich, Germany.,Division of Congenital and Paediatric Heart Surgery, University Hospital of Munich, Munich, Germany
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26
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Hörer J, Hirata Y, Tachimori H, Ono M, Vida V, Herbst C, Kansy A, Jacobs JP, Tobota Z, Sakamoto K, Ebels T, Maruszewski B. Pediatric Cardiac Surgical Patterns of Practice and Outcomes in Japan and Europe. World J Pediatr Congenit Heart Surg 2021; 12:312-319. [PMID: 33942682 DOI: 10.1177/2150135120988634] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The Japan Cardiovascular Surgery Database-Congenital section (JCVSD-Congenital) and the European Congenital Heart Surgeons Association (ECHSA) Congenital Heart Surgery Database (CHSD) share the same nomenclature. We aimed at comparing congenital cardiac surgical patterns of practice and outcomes in Japan and Europe using the JCVSD-Congenital and ECHSA-CHSD. METHODS AND RESULTS We examined Japanese (120 units, 63,365 operations) and European (96 units, 90,098 operations) data in JCVSD-Congenital and ECHSA-CHSD from 2011 to 2017. Patients' age and weight, periprocedural times, mortality at hospital discharge, and postoperative length of stay were calculated for ten benchmark operations. There was a significantly higher proportion of ventricular septal defect closures and Glenn operations and a significantly lower proportion of coarctation repairs, tetralogy of Fallot repairs, atrioventricular septal defect repairs, arterial switch operations, truncus repairs, Norwood operations, and Fontan operations in JCVSD-Congenital compared to ECHSA-CHSD. Postoperative length of stay was significantly longer following all benchmark operations in JCVSD-Congenital compared to ECHSA-CHSD. Mean STAT mortality score (Society of Thoracic Surgeons European Association for Cardio-Thoracic Surgery mortality score) was significantly higher in JCVSD-Congenital (0.78) compared to ECHSA-CHSD (0.71). Mortality at hospital discharge was significantly lower in JCVSD-Congenital (4.2%) compared to ECHSA-CHSD (6.0%, P < .001). CONCLUSIONS The distribution of the benchmark procedures and age at the time of surgery differ between Japan and Europe. Postoperative length of stay is longer, and the mean complexity is higher in Japan compared to European data. These comparisons of patterns of practice and outcomes demonstrate opportunities for continuing bidirectional transcontinental collaboration and quality improvement.
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Affiliation(s)
- Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, 9184Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Yasutaka Hirata
- Department of Cardiac Surgery, The University of Tokyo Hospital, Japan
| | - Hisateru Tachimori
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Japan.,Translational Medical Center, National Center of Neurology and Psychiatry, Japan
| | - Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, 9184Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Vladimiro Vida
- Pediatric and Congenital Cardiac Surgery Unit, University of Padua, Italy
| | - Claudia Herbst
- Department of Surgery, Division of Cardiac Surgery and Pediatric Heart Center, Medical University Vienna, Austria
| | - Andrzej Kansy
- Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - Jeffrey P Jacobs
- Congenital Heart Center, Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Zdzislaw Tobota
- Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - Kisaburo Sakamoto
- Department of Cardiovascular Surgery, Mt Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | - Tjark Ebels
- Department Cardiothoracic Surgery, University Medical Center Groningen, the Netherlands
| | - Bohdan Maruszewski
- Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
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27
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Registro de intervenciones en pacientes con cardiopatía congénita de la Sociedad Española de Cirugía Cardiovascular y Endovascular: 2019 y retrospectiva de los últimos 8 años. CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2021.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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28
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Bertsimas D, Zhuo D, Dunn J, Levine J, Zuccarelli E, Smyrnakis N, Tobota Z, Maruszewski B, Fragata J, Sarris GE. Adverse Outcomes Prediction for Congenital Heart Surgery: A Machine Learning Approach. World J Pediatr Congenit Heart Surg 2021; 12:453-460. [PMID: 33908836 DOI: 10.1177/21501351211007106] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Risk assessment tools typically used in congenital heart surgery (CHS) assume that various possible risk factors interact in a linear and additive fashion, an assumption that may not reflect reality. Using artificial intelligence techniques, we sought to develop nonlinear models for predicting outcomes in CHS. METHODS We built machine learning (ML) models to predict mortality, postoperative mechanical ventilatory support time (MVST), and hospital length of stay (LOS) for patients who underwent CHS, based on data of more than 235,000 patients and 295,000 operations provided by the European Congenital Heart Surgeons Association Congenital Database. We used optimal classification trees (OCTs) methodology for its interpretability and accuracy, and compared to logistic regression and state-of-the-art ML methods (Random Forests, Gradient Boosting), reporting their area under the curve (AUC or c-statistic) for both training and testing data sets. RESULTS Optimal classification trees achieve outstanding performance across all three models (mortality AUC = 0.86, prolonged MVST AUC = 0.85, prolonged LOS AUC = 0.82), while being intuitively interpretable. The most significant predictors of mortality are procedure, age, and weight, followed by days since previous admission and any general preoperative patient risk factors. CONCLUSIONS The nonlinear ML-based models of OCTs are intuitively interpretable and provide superior predictive power. The associated risk calculator allows easy, accurate, and understandable estimation of individual patient risks, in the theoretical framework of the average performance of all centers represented in the database. This methodology has the potential to facilitate decision-making and resource optimization in CHS, enabling total quality management and precise benchmarking initiatives.
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Affiliation(s)
- Dimitris Bertsimas
- Operations Research Center and Sloan School of Management, 2167Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Daisy Zhuo
- Alexandria Health, Cambridge, MA.,Alexandria Health, Providence, RI, USA
| | - Jack Dunn
- Alexandria Health, Cambridge, MA.,Alexandria Health, Providence, RI, USA
| | - Jordan Levine
- Alexandria Health, Cambridge, MA.,Alexandria Health, Providence, RI, USA
| | - Eugenio Zuccarelli
- Operations Research Center and Sloan School of Management, 2167Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Nikos Smyrnakis
- Operations Research Center, 2167Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Zdzislaw Tobota
- Department for Pediatric Cardiothoracic Surgery, 49805Children's Memorial Health Institute, Warsaw, Poland
| | - Bohdan Maruszewski
- Department for Pediatric Cardiothoracic Surgery, 49805Children's Memorial Health Institute, Warsaw, Poland
| | - Jose Fragata
- Hospital de Santa Marta and NOVA University, Lisbon, Portugal
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Gaies M, Romano JC, Whiteside W. An Intensivist, a Surgeon, and an Interventionalist Walk Into a Bar…. JACC Cardiovasc Interv 2021; 13:2865-2867. [PMID: 33357523 DOI: 10.1016/j.jcin.2020.09.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/29/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Michael Gaies
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA.
| | - Jennifer C Romano
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA; Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Wendy Whiteside
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Padiyath A, Lo BD, Ong CS, Goswami D, Steppan DA, Frank SM, Steppan J. Red blood cell storage duration and peri-operative outcomes in paediatric cardiac surgery. Vox Sang 2021; 116:965-975. [PMID: 33761164 DOI: 10.1111/vox.13098] [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: 11/19/2020] [Revised: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Prior research on red blood cell (RBC) storage duration and clinical outcomes in paediatric cardiac surgery has shown conflicting results. The purpose of this study was to evaluate whether blood stored for a longer duration is harmful in these patients. METHODS We performed a retrospective cohort study of paediatric patients undergoing cardiac surgery at our institution between January 2011 and June 2015. Patients were stratified based on whether they were transfused RBCs stored for ≤15 days (fresher blood) or >15 days (older blood). The primary outcome was composite morbidity, with prolonged length of stay (LOS) as a secondary outcome. Subgroup analyses were performed after stratification by RBC transfusion volume (≤2 vs. >2 RBC units). Multivariable logistic regression models were used to assess the impact of RBC storage duration on composite morbidity and prolonged LOS. RESULTS Of 461 patients, 122 (26·5%) received fresher blood and 339 (73·5%) received older blood. The overall rate of composite morbidity was 18·0% (n = 22) for patients receiving fresher blood and 13·6% (n = 46) for patients receiving older blood (P = 0·24). In the risk-adjusted model, patients receiving older blood did not exhibit an increased risk of composite morbidity (OR: 0·74, 95% CI: 0·37-1·47, P = 0·40) or prolonged LOS (OR: 0·72, 95% CI: 0·38-1·35, P = 0·30) compared to patients receiving fresher blood. Similar results were seen after stratification by RBC transfusion volume. CONCLUSIONS Transfusing RBCs stored for a longer duration was not associated with an increased risk of morbidity or prolonged LOS in paediatric cardiac surgery patients.
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Affiliation(s)
- Asif Padiyath
- Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Brian D Lo
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chin Siang Ong
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Dheeraj Goswami
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Diana A Steppan
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jochen Steppan
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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31
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Long JB, Engorn BM, Hill KD, Feng L, Chiswell K, Jacobs ML, Jacobs JP, Goswami D. Postoperative Hematocrit and Adverse Outcomes in Pediatric Cardiac Surgery Patients: A Cross-Sectional Study From the Society of Thoracic Surgeons and Congenital Cardiac Anesthesia Society Database Collaboration. Anesth Analg 2021; 133:1077-1088. [PMID: 33721876 DOI: 10.1213/ane.0000000000005416] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND We sought to examine potential associations between pediatric postcardiac surgical hematocrit values and postoperative complications or mortality. METHODS A retrospective, cross-sectional study from the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) and Congenital Cardiac Anesthesia Society Database Module (2014-2019) was completed. Multivariable logistic regression models, adjusting for covariates in the STS-CHSD mortality risk model, were used to assess the relationship between postoperative hematocrit and the primary outcomes of operative mortality or any major complication. Hematocrit was assessed as a continuous variable using linear splines to account for nonlinear relationships with outcomes. Operations after which the oxygen saturation is typically observed to be <92% were classified as cyanotic and ≥92% as acyanotic. RESULTS In total, 27,462 index operations were included, with 4909 (17.9%) being cyanotic and 22,553 (82.1%) acyanotic. For cyanotic patients, each 5% incremental increase in hematocrit over 42% was associated with a 1.31-fold (95% confidence interval [CI], 1.10-1.55; P = .003) increase in the odds of operative mortality and a 1.22-fold (95% CI, 1.10-1.36; P < .001) increase in the odds of a major complication. For acyanotic patients, each 5% incremental increase in hematocrit >38% was associated with a 1.45-fold (95% CI, 1.28-1.65; P < .001) increase in the odds of operative mortality and a 1.21-fold (95% CI, 1.14-1.29; P < .001) increase in the odds of a major complication. CONCLUSIONS High hematocrit on arrival to the intensive care unit (ICU) is associated with increased operative mortality and major complications in pediatric patients following cardiac surgery.
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Affiliation(s)
- Justin B Long
- From the Department of Pediatric Anesthesiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Branden M Engorn
- Department of Anesthesiology and Critical Care Medicine, Rady Children's Hospital, San Diego, California
| | | | - Liqi Feng
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeffrey P Jacobs
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Congenital Heart Center, University of Florida, Gainesville, Florida
| | - Dheeraj Goswami
- Department of Anesthesiology and Critical Care Medicine, Bloomberg Children's Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland
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32
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Huisenga D, La Bastide‐Van Gemert S, Van Bergen A, Sweeney J, Hadders‐Algra M. Developmental outcomes after early surgery for complex congenital heart disease: a systematic review and meta-analysis. Dev Med Child Neurol 2021; 63:29-46. [PMID: 32149404 PMCID: PMC7754445 DOI: 10.1111/dmcn.14512] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2020] [Indexed: 01/25/2023]
Abstract
AIM (1) To systematically review the literature on developmental outcomes from infancy to adolescence of children with complex congenital heart disease (CHD) who underwent early surgery; (2) to run a meta-regression analysis on the Bayley Scales of Infant Development, Second Edition Mental Developmental Index and Psychomotor Developmental Index (PDI) of infants up to 24 months and IQs of preschool-aged children to adolescents; (3) to assess associations between perioperative risk factors and outcomes. METHOD We searched pertinent literature (January 1990 to January 2019) in PubMed, Embase, CINAHL, and PsycINFO. Selection criteria included infants with complex CHD who had primary surgery within the first 9 weeks of life. Methodological quality, including risk of bias and internal validity, were assessed. RESULTS In total, 185 papers met the inclusion criteria; the 100 with high to moderate methodological quality were analysed in detail. Substantial heterogeneity in the group with CHD and in methodology existed. The outcome of infants with single-ventricle CHD was inferior to those with two-ventricle CHD (respectively: average scores for PDI 77 and 88; intelligence scores 92 and 98). Perioperative risk factors were inconsistently associated with developmental outcomes. INTERPRETATION The literature on children undergoing surgery in early infancy suggests that infants with a single ventricle are at highest risk of adverse developmental outcomes.
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Affiliation(s)
- Darlene Huisenga
- Department of Pediatric Rehabilitation and DevelopmentAdvocate Children’s HospitalOak LawnILUSA,University of GroningenUniversity Medical Center GroningenDepartment of PaediatricsDivision of Developmental NeurologyGroningenthe Netherlands
| | - Sacha La Bastide‐Van Gemert
- University of GroningenUniversity Medical Center GroningenDepartment of EpidemiologyGroningenthe Netherlands
| | - Andrew Van Bergen
- Department of Pediatric Rehabilitation and DevelopmentAdvocate Children’s HospitalOak LawnILUSA,Advocate Children’s Heart Institute Division of Pediatric Cardiac Critical CareAdvocate Children’s HospitalOak LawnILUSA
| | - Jane Sweeney
- Pediatric Science Doctoral ProgramRocky Mountain University of Health ProfessionsProvoUTUSA
| | - Mijna Hadders‐Algra
- University of GroningenUniversity Medical Center GroningenDepartment of PaediatricsDivision of Developmental NeurologyGroningenthe Netherlands
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Anderson BR, Blancha Eckels VL, Crook S, Duchon JM, Kalfa D, Bacha EA, Krishnamurthy G. The Risks of Being Tiny: The Added Risk of Low Weight for Neonates Undergoing Congenital Heart Surgery. Pediatr Cardiol 2020; 41:1623-1631. [PMID: 32729052 PMCID: PMC7704774 DOI: 10.1007/s00246-020-02420-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 07/18/2020] [Indexed: 11/29/2022]
Abstract
The aims of this study were (1) to describe the additive risk of performing cardiac surgery in neonates born ≤ 2.0 kg, after accounting for the baseline risks of low birth weight, and (2) to describe the additive risk of being born ≤ 2.0 kg in neonates undergoing cardiac surgery. We used a risk difference analysis in a retrospective cohort, 2006-2016. Neonates born ≤ 2.0 kg undergoing congenital heart surgery during initial postnatal admission were included. Data were standardized alternatingly for birth weight and cardiac surgical risk using national population data to estimate the number of deaths expected had they not required cardiac surgery or were they of normal weight. Of 105 neonates ≤ 2 kg, median birth weight was 1.6 kg (IQR 1.3-1.8 kg). Median gestational age was 33 weeks (IQR 31-35 weeks). Observed operative mortality was 14.3%; 0% for neonates ≤ 1.0 kg (CI 0-33.6%), 20.6% for neonates > 1.0-1.5 kg (CI 8.7-37.9%), and 12.9% for neonates > 1.5-2.0 kg (CI 5.7-23.9%). Among neonates ≤ 2.0 kg not undergoing cardiac surgery, expected mortality was 4.8% (CI 1.6-10.8); cardiac surgery increased the risk of mortality 9.5% (CI 1.7-17.4%). Conversely, the expected risk for normal birth weight neonates undergoing cardiac surgery was 5.7% (CI 2.1-12.0%); low birth weight increased the risk of mortality 8.6% (CI 0.5-16.6%). To continue making advancements in cardiac surgery, we must understand that the rate of mortality observed in normal weight infants is not a realistic target and that, despite advances, the risk attributable to the surgery remains higher among low birth weight patients.
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Affiliation(s)
- Brett R Anderson
- Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Broadway, CH-2N, New York, NY, 10032, USA.
| | | | - Sarah Crook
- Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children’s Hospital, Columbia University Irving Medical Center, New York, NY
| | - Jennifer M Duchon
- Division of Neonatology, NewYork-Presbyterian/Morgan Stanley Children’s Hospital, Columbia University Irving Medical Center, New York, NY
| | - David Kalfa
- Division of Cardiothoracic Surgery, NewYork-Presbyterian/Morgan Stanley Children’s Hospital, Columbia University Irving Medical Center, New York, NY
| | - Emile A Bacha
- Division of Cardiothoracic Surgery, NewYork-Presbyterian/Morgan Stanley Children’s Hospital, Columbia University Irving Medical Center, New York, NY
| | - Ganga Krishnamurthy
- Division of Neonatology, NewYork-Presbyterian/Morgan Stanley Children’s Hospital, Columbia University Irving Medical Center, New York, NY
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Rebolledo MA, Kumar TKS, Tansey JB, Pickens B, Allen J, Hanafin HJ, Boston US, Knott-Craig CJ. Single Institution Experience With International Referrals for Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg 2020; 11:727-732. [PMID: 33164680 DOI: 10.1177/2150135120937230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pediatric cardiac surgery in developing countries poses many challenges. The practice of referring patients from abroad via nongovernmental organizations has occurred for many years. We describe our experience with international referrals for pediatric cardiac surgery via Gift of Life Mid-South to the Heart Institute, Le Bonheur Children's Hospital in Memphis, Tennessee. METHODS We performed a retrospective descriptive review of data collected in our Society of Thoracic Surgeons Congenital Heart Surgery Database (STS CHSD) along with data from our electronic medical record from January 1, 2007, to December 31, 2017. Available data included patient demographics, diagnoses, surgical procedure, entire inpatient length of stay (LOS), complications, and operative mortality. Cardiac surgeries were grouped according to the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Categories (STAT Mortality Categories). Complications were defined according to the STS CHSD. RESULTS In this retrospective descriptive study, case complexity level varied; however, 38% cardiac surgeries were in STAT Mortality Category 3 or 4. Honduras was the most common referral source with a total of 18 countries represented. Operative mortality remained very low (1 [1.4%] of 71 cardiac surgeries) despite patients being referred beyond infancy. There were an increasing number of complications and longer inpatient LOS (with greater variance) in STAT Mortality Category 4. CONCLUSIONS International patients referred for congenital heart surgery can be successfully treated with an acceptable mortality rate despite late referrals. Inpatient LOS is related to surgical complexity. Follow-up studies are needed to determine the long-term outcomes of these patients.
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Affiliation(s)
- Michael A Rebolledo
- The University of Tennessee Health Science Center and The Heart Institute, 14505Le Bonheur Children's Hospital, Memphis, TN, USA
| | | | - James B Tansey
- College of Medicine, 12325The University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Jerry Allen
- The University of Tennessee Health Science Center and The Heart Institute, 14505Le Bonheur Children's Hospital, Memphis, TN, USA
| | - H Jane Hanafin
- The University of Tennessee Health Science Center and The Heart Institute, 14505Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Umar S Boston
- The University of Tennessee Health Science Center and The Heart Institute, 14505Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Christopher J Knott-Craig
- The University of Tennessee Health Science Center and The Heart Institute, 14505Le Bonheur Children's Hospital, Memphis, TN, USA
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Hospital-Acquired Infection in Pediatric Subjects With Congenital Heart Disease Postcardiotomy Supported on Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2020; 21:e1020-e1025. [PMID: 32590829 DOI: 10.1097/pcc.0000000000002409] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine prevalence of and risk factors for infection in pediatric subjects with congenital heart disease status postcardiotomy supported on extracorporeal membrane oxygenation, as well as outcomes of these subjects. DESIGN Retrospective cohort from the Extracorporeal Life Support Organization. SETTING U.S. and international medical centers providing care to children with congenital heart disease status postcardiotomy. PATIENTS Critically ill pediatric subjects less than 8 years old admitted to medical centers between January 1, 2013, and December 31, 2015, who underwent cardiac surgery for congenital heart disease and required extracorporeal membrane oxygenation support within the first 14 postoperative days. Subjects were excluded if they underwent orthotopic heart transplantation, required preoperative extracorporeal membrane oxygenation, and had more than one postoperative extracorporeal membrane oxygenation run. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 1,314 extracorporeal membrane oxygenation subject encounters in the Extracorporeal Life Support Organization registry met inclusion criteria. Neonates comprised 53% (n = 696) of the cohort, whereas infants made up 33% (n = 435). Of the 994 subjects with Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery categorizable surgery, 33% (n = 325) were in Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category 4 and 23% (n = 231) in Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category 5. While on extracorporeal membrane oxygenation, 229 subjects (17%) acquired one or more extracorporeal membrane oxygenation-related infections, which represents an occurrence rate of 67 infections per 1,000 extracorporeal membrane oxygenation days. Gram-negative (62%) and Gram-positive (42%) infections occurred most commonly. Forty percent had positive blood cultures. Infants and children were at higher infection risk compared with neonatal subjects; subjects undergoing less complex surgery had higher infection rates. Unadjusted survival to hospital discharge was lower in infected subjects compared with noninfected subjects (43% vs 51%; p = 0.01). After adjusting for confounders via propensity matching, we identified no significant mortality difference between infected and noninfected subjects. CONCLUSIONS Neonatal and pediatric subjects in this study have a high rate of acquired infection. Infants and children were at higher infection risk compared with neonatal subjects. There was not, however, a significant association between extracorporeal membrane oxygenation-related infection and survival to hospital discharge after propensity matching.
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36
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Extubation After Neonatal and Pediatric Cardiac Surgery: Where and When? Pediatr Crit Care Med 2020; 21:910-911. [PMID: 33009306 DOI: 10.1097/pcc.0000000000002499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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37
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Bagdure DN, Custer JW, Foster CB, Blackwelder WC, Mishcherkin V, Portenoy A, Bhutta A. The Impact of Dedicated Cardiac Intensive Care Units on Outcomes in Pediatric Cardiac Surgery: A Virtual Pediatric Systems Database Analysis. J Pediatr Intensive Care 2020; 10:174-179. [PMID: 34395034 DOI: 10.1055/s-0040-1714718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/26/2020] [Indexed: 10/23/2022] Open
Abstract
Care of children undergoing cardiac surgery occurs in dedicated cardiac intensive care units (CICU) or mixed intensive care units. In this article, we analyzed data from Virtual Pediatric Systems (VPS, LLC) database (2009-2014) for children < 18 years of age undergoing cardiac surgery, classified according to Society of Thoracic Surgery-European Association of Cardiothoracic Surgery (STS-EACTS) risk category. We had 25,052 (52%) patients in 53 mixed units (mortality rate, 2.99%), and 22,762 (48%) patients in 19 dedicated CICUs (mortality rate, 2.62%). There was a direct relationship between STS-EACTS risk category and death rate in both units. By multivariable logistic and linear regression, there was no difference in mortality between mixed unit and CICU death rates within STS-EACTS risk categories. We found no difference in outcomes for children undergoing cardiac surgery based on the unit type (dedicated CICU or mixed unit).
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Affiliation(s)
- Dayanand N Bagdure
- Department of Pediatrics, Division of Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Jason W Custer
- Department of Pediatrics, Division of Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Cortney B Foster
- Department of Pediatrics, Division of Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - William C Blackwelder
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Vladimir Mishcherkin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Allison Portenoy
- Graduate Medical Education, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Adnan Bhutta
- Department of Pediatrics, Division of Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States
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Central Venous Catheter Utilization and Complications in the Pediatric Cardiac ICU: A Report From the Pediatric Cardiac Critical Care Consortium (PC4). Pediatr Crit Care Med 2020; 21:729-737. [PMID: 32453921 DOI: 10.1097/pcc.0000000000002306] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Current central venous catheter utilization in patients within pediatric cardiac ICUs is not well elucidated. We aim to describe current use of central venous catheters in a multi-institutional cohort and to explore the prevalence and risk factors for central line-associated thrombosis and central line-associated bloodstream infections. DESIGN Observational analysis. SETTING Pediatric Cardiac Critical Care Consortium hospitals. PATIENTS Hospitalizations with at least one cardiac ICU admission from October 2013 to July 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 17,846 hospitalizations and 69% included greater than or equal to one central venous catheter. Central venous catheter use was higher in younger patients (86% neonates). Surgical hospitalizations included at least one central venous catheter 88% of the time compared with 35% of medical hospitalizations. The most common location for central venous catheters was internal jugular (46%). Central venous catheters were in situ a median of 4 days (interquartile range, 2-10). There were 248 hospitalizations (2% overall, 1.8% medical, and 2.1% surgical) with at least one central line-associated thrombosis (271 total thromboses). Thrombosis was diagnosed at a median of 7 days (interquartile range, 4-14) after catheter insertion. There were 127 hospitalizations (1% overall, 1.4% medical, and 1% surgical) with at least one central line-associated bloodstream infection (136 total infections) with no association with catheter type or location. Central line-associated bloodstream infection was diagnosed at a median of 19 days (interquartile range, 8-36) after catheter insertion. Significant risk factors for central line-associated thrombosis and central line-associated bloodstream infection were younger age, greater surgical complexity, and total catheter days. CONCLUSIONS Utilization of central venous catheters in pediatric cardiac ICUs differs according to indication for hospitalization. Although thrombosis and central line-associated bloodstream infection are infrequent complications of central venous catheter use in cardiac ICU patients, these events can have important short- and long-term consequences for patients. Total central venous catheter line days were the only modifiable risk factor identified. Future study must focus on understanding central venous catheter practices in high-risk patient subgroups that reduce the prevalence of thrombosis and central line-associated bloodstream infection.
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Hill KD, Baldwin HS, Bichel DP, Ellis AM, Graham EM, Hornik CP, Jacobs JP, Jaquiss RDB, Jacobs ML, Kannankeril PJ, Li JS, Torok R, Turek JW, O'Brien SM. Overcoming underpowering: Trial simulations and a global rank end point to optimize clinical trials in children with heart disease. Am Heart J 2020; 226:188-197. [PMID: 32599259 DOI: 10.1016/j.ahj.2020.05.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 05/14/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Randomized controlled trials (RCTs) in children with heart disease are challenging and therefore infrequently performed. We sought to improve feasibility of perioperative RCTs for this patient cohort using data from a large, multicenter clinical registry. We evaluated potential enrollment and end point frequencies for various inclusion cohorts and developed a novel global rank trial end point. We then performed trial simulations to evaluate power gains with the global rank end point and with use of planned covariate adjustment as an analytic strategy. METHODS Data from the Society of Thoracic Surgery-Congenital Heart Surgery Database (STS-CHSD, 2011-2016) were used to support development of a consensus-based global rank end point and for trial simulations. For Monte Carlo trial simulations (n = 50,000/outcome), we varied the odds of outcomes for treatment versus placebo and evaluated power based on the proportion of trial data sets with a significant outcome (P < .05). RESULTS The STS-CHSD study cohort included 35,967 infant index cardiopulmonary bypass operations from 103 STS-CHSD centers, including 11,411 (32%) neonatal cases and 12,243 (34%) high-complexity (Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality category ≥4) cases. In trial simulations, study power was 21% for a mortality-only end point, 47% for a morbidity and mortality composite, and 78% for the global rank end point. With covariate adjustment, power increased to 94%. Planned covariate adjustment was preferable to restricting to higher-risk cohorts despite higher event rates in these cohorts. CONCLUSIONS Trial simulations can inform trial design. Our findings, including the newly developed global rank end point, may be informative for future perioperative trials in children with heart disease.
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Affiliation(s)
- Kevin D Hill
- Duke Pediatric and Congenital Heart Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
| | | | - David P Bichel
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alicia M Ellis
- Duke Clinical Research Institute, Durham, North Carolina
| | - Eric M Graham
- Medical University of South Carolina, Charleston, South Carolina
| | - Christoph P Hornik
- Duke Pediatric and Congenital Heart Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Jeffrey P Jacobs
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | - Jennifer S Li
- Duke Pediatric and Congenital Heart Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Rachel Torok
- Duke Pediatric and Congenital Heart Center, Durham, North Carolina
| | - Joseph W Turek
- Duke Pediatric and Congenital Heart Center, Durham, North Carolina
| | - Sean M O'Brien
- Duke Clinical Research Institute, Durham, North Carolina
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40
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Tadphale SD, Ramakrishnan K, Spentzas T, Kumar TKS, Allen J, Staffa SJ, Zurakowski D, Bigelow WA, Gopal SH, Boston US, Jonas RA, Knott-Craig CJ. Impact of Different Cardiopulmonary Bypass Strategies on Renal Injury After Pediatric Heart Surgery. Ann Thorac Surg 2020; 111:1374-1379. [PMID: 32603703 DOI: 10.1016/j.athoracsur.2020.05.056] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/09/2020] [Accepted: 05/07/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The purpose of this study is to compare the incidence and severity of acute kidney injury (AKI) after open heart surgery in neonates and infants for two different cardiopulmonary bypass (CPB) strategies. METHODS In all, 151 infants undergoing cardiac surgery were prospectively enrolled between June 2017 and June 2018 at two centers, one using conventional CPB (2.4 L · min-1 · m-2, 150 mL · kg-1 · min-1) with reduction of flow rates with moderate hypothermia and with a targeted hematocrit greater than 25% (center 1, n = 91), and the other using higher bypass flow rates (175 to 200 mL · kg-1 · min-1) and higher minimum hematocrit (greater than 32%) CPB (center 2, n = 60). The primary endpoint was the incidence of postoperative AKI as defined by Acute Kidney Injury Network criteria and risk factors associated with AKI. RESULTS Preoperative characteristics and complexity of surgery were comparable between centers. The overall incidence of early postoperative AKI was 10.6% (16 of 151), with 15.4% (14 of 91) in center 1 and 3.3% (2 of 60) in center 2 (P = .02). Mean lowest flow rates on CPB were 78 mL · kg-1 · min-1 vs 118 mL · kg-1 · min-1 and mean highest hematocrit on separation from CPB were 33% vs 43% at center 1 and 2, respectively (P < .001). Center 1 used less packed red blood cells but more fresh frozen plasma than center 2 (P = .001). By multivariate analysis, only lower flows on CPB (78 vs 96 mL · kg-1 · min-1, P = .043) and lower hematocrit at the end of CPB (33% vs 37%, P = .007) were associated with AKI. CONCLUSIONS In this contemporary comparative study, higher flow rates and higher hematocrit during cardiopulmonary bypass were associated with better preservation of renal function.
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Affiliation(s)
- Sachin D Tadphale
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee; Le Bonheur Children's Hospital, Memphis, Tennessee; Department of Cardiovascular Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Karthik Ramakrishnan
- Department of Pediatric Cardiovascular Surgery, Children's National Medical Center, Washington, DC; George Washington University School of Medicine and Health Sciences, Washington DC
| | - Thomas Spentzas
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee; Le Bonheur Children's Hospital, Memphis, Tennessee; Department of Cardiovascular Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - T K Susheel Kumar
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee; Le Bonheur Children's Hospital, Memphis, Tennessee; Department of Cardiovascular Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Jerry Allen
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee; Le Bonheur Children's Hospital, Memphis, Tennessee; Department of Cardiovascular Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Zurakowski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - William A Bigelow
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee; Le Bonheur Children's Hospital, Memphis, Tennessee; Department of Cardiovascular Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Srirupa Hari Gopal
- Department of Pediatrics, University of Tennessee College of Medicine, Chattanooga, Tennessee
| | - Umar S Boston
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee; Le Bonheur Children's Hospital, Memphis, Tennessee; Department of Cardiovascular Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Richard A Jonas
- Department of Pediatric Cardiovascular Surgery, Children's National Medical Center, Washington, DC; George Washington University School of Medicine and Health Sciences, Washington DC
| | - Christopher J Knott-Craig
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee; Le Bonheur Children's Hospital, Memphis, Tennessee; Department of Cardiovascular Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee.
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Modestini M, Hoffmann L, Niezen C, Armocida B, Vos JJ, Scheeren TWL. Cerebral oxygenation during pediatric congenital cardiac surgery and its association with outcome: a retrospective observational study. Can J Anaesth 2020; 67:1170-1181. [PMID: 32557197 PMCID: PMC7299246 DOI: 10.1007/s12630-020-01733-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 03/25/2020] [Accepted: 05/01/2020] [Indexed: 11/16/2022] Open
Abstract
Purpose Non-invasive cerebral oxygen saturation (ScO2) monitoring is an established tool in the intraoperative phase of pediatric congenital cardiac surgery (CCS). This study investigated the association between ScO2 and postoperative outcome by investigating both baseline ScO2 values and intraoperative desaturations from baseline. Methods All CCS procedures performed in the period 2010-2017 in our institution in which ScO2 was monitored were included in this historical cohort study. Baseline ScO2 was determined after tracheal intubation, before surgical incision. Subgroups were based on cardiac pathology and degree of intracardiac shunting. Poor outcome was defined based on length of stay (LOS) in the intensive care unit (ICU)/hospital, duration of mechanical ventilation (MV), and 30-day mortality. Intraoperatively, ScO2 total time below baseline (TBBL) and ScO2 time-weighted average (TWA) were calculated. Results Data from 565 patients were analyzed. Baseline ScO2 was significantly associated with LOS in ICU (odds ratio [OR] per percentage decrease in baseline ScO2, 0.95; 95% confidence interval [CI], 0.93 to 0.97; P < 0.001), with LOS in hospital (OR, 0.93; 95% CI, 0.91 to 0.96; P < 0.001), with MV duration (OR, 0.92; 95% CI, 0.90 to 0.95; P < 0.001) and with 30-day mortality (OR, 0.94; 95% CI, 0.91 to 0.98; P = 0.007). Cerebral oxygen saturation TWA had no associations, while ScO2 TBBL had only a small association with LOS in ICU (OR, 1.02; 95% CI, 1.01 to 1.03; P < 0.001), MV duration (OR,1.02; 95% CI, 1.01 to 1.03; P = 0.002), and LOS in hospital (OR, 1.02; 95% CI, 1.01 to 1.04; P < 0.001). Conclusion In pediatric patients undergoing cardiac surgery, low baseline ScO2 values measured after tracheal intubation were associated with several adverse postoperative outcomes. In contrast, the severity of actual intraoperative cerebral desaturation was not associated with postoperative outcomes. Baseline ScO2 measured after tracheal intubation may help identify patients at increased perioperative risk.
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Affiliation(s)
- Marco Modestini
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Lisa Hoffmann
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,European Medical School Oldenburg-Groningen, Oldenburg, Germany
| | - Caren Niezen
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Benedetta Armocida
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jaap Jan Vos
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Thomas W L Scheeren
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Gaies M, Pasquali SK, Banerjee M, Dimick JB, Birkmeyer JD, Zhang W, Alten JA, Chanani N, Cooper DS, Costello JM, Gaynor JW, Ghanayem N, Jacobs JP, Mayer JE, Ohye RG, Scheurer MA, Schwartz SM, Tabbutt S, Charpie JR. Improvement in Pediatric Cardiac Surgical Outcomes Through Interhospital Collaboration. J Am Coll Cardiol 2020; 74:2786-2795. [PMID: 31779793 DOI: 10.1016/j.jacc.2019.09.046] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/01/2019] [Accepted: 09/05/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Patients undergoing complex pediatric cardiac surgery remain at considerable risk of mortality and morbidity, and variation in outcomes exists across hospitals. The Pediatric Cardiac Critical Care Consortium (PC4) was formed to improve the quality of care for these patients through transparent data sharing and collaborative learning between participants. OBJECTIVES The purpose of this study was to determine whether outcomes improved over time within PC4. METHODS The study analyzed 19,600 hospitalizations (18 hospitals) in the PC4 clinical registry that included cardiovascular surgery from August 2014 to June 2018. The primary exposure was 2 years of PC4 participation; this provided adequate time for hospitals to accrue data and engage in collaborative learning. Aggregate case mix-adjusted outcomes were compared between the first 2 years of participation (baseline) and all months post-exposure. We also evaluated outcomes from the same era in a cohort of similar, non-PC4 hospitals. RESULTS During the baseline period, there was no evidence of improvement. We observed significant improvement in the post-exposure period versus baseline for post-operative intensive care unit mortality (2.1% vs. 2.7%; 22% relative reduction [RR]; p = 0.001), in-hospital mortality (2.5% vs. 3.3%; 24% RR; p = 0.001), major complications (10.1% vs. 11.5%; 12% RR; p < 0.001), intensive care unit length of stay (7.3 days vs. 7.7 days; 5% RR; p < 0.001), and duration of ventilation (61.3 h vs. 70.6 h; 13% RR; p = 0.01). Non-PC4 hospitals showed no significant improvement in mortality, complications, or hospital length of stay. CONCLUSIONS This analysis demonstrates improving cardiac surgical outcomes at children's hospitals participating in PC4. This change appears unrelated to secular improvement trends, and likely reflects PC4's commitment to transparency and collaboration.
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Affiliation(s)
- Michael Gaies
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Justin B Dimick
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Wenying Zhang
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Jeffrey A Alten
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Nikhil Chanani
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - David S Cooper
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - John M Costello
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - J William Gaynor
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nancy Ghanayem
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | | | - John E Mayer
- Department of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts
| | - Richard G Ohye
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Mark A Scheurer
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Steven M Schwartz
- Departments of Pediatrics and Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Tabbutt
- Department of Pediatrics, University of California, San Francisco School of Medicine, San Francisco, California
| | - John R Charpie
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
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ST2 Predicts Risk of Unplanned Readmission Within 1 Year After Pediatric Congenital Heart Surgery. Ann Thorac Surg 2020; 110:2070-2075. [PMID: 32246937 DOI: 10.1016/j.athoracsur.2020.02.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/21/2020] [Accepted: 02/24/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Approximately 10% to 20% of children are readmitted after congenital heart surgery. Very little is known about biomarkers as predictors of risk of unplanned readmission after pediatric congenital heart surgery. Novel cardiac biomarker ST2 may be associated with risk of unplanned readmission. ST2 concentrations are believed to reflect cardiovascular stress and fibrosis. Our objective was to explore the relationship between pre- and postoperative ST2 biomarker levels and risk of readmission within 1 year after congenital heart surgery. METHODS We prospectively enrolled pediatric patients aged < 18 years who underwent at least 1 congenital heart operation at Johns Hopkins Hospital from 2010 to 2014. Plasma samples were collected immediately before surgery and at the end of bypass. We used Kaplan-Meier survival analysis and multivariable Cox regression models to adjust for variables used in The Society of Thoracic Surgeons Congenital Heart Surgery Database mortality risk model. RESULTS Of our cohort of 145 patients, we found 39 children with readmissions within 365 days. The median time to unplanned readmission was 54 days (interquartile range, 10-153). Kaplan-Meier analysis demonstrated a significant difference across terciles of pre- and postoperative ST2 biomarker levels. After adjustment, elevated serum levels of ST2 measured preoperatively and postoperatively were associated with increased risk of readmission (hazard ratio, 2.5-3.7; all P < .05). CONCLUSIONS Elevated levels of ST2 are significantly associated with increased risk of unplanned readmission within 1 year after pediatric congenital heart surgery. Novel serum biomarker ST2 can be used for risk stratification or estimating postsurgical prognosis.
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Nawata K, D’Agostino RS, Habib RH, Kumamaru H, Hirahara N, Miyata H, Motomura N, Takamoto S, Shahian DM, Grover FL. First Database Comparison Between the United States and Japan: Coronary Artery Bypass Grafting. Ann Thorac Surg 2020; 109:1159-1164. [DOI: 10.1016/j.athoracsur.2019.07.095] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 06/24/2019] [Accepted: 07/29/2019] [Indexed: 11/30/2022]
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Ciociola EC, Kumar KR, Zimmerman KO, Thompson EJ, Harward M, Sullivan LN, Turek JW, Hornik CP. Association between preoperative respiratory support and outcomes in paediatric cardiac surgery. Cardiol Young 2020; 30:66-73. [PMID: 31771666 PMCID: PMC7018562 DOI: 10.1017/s1047951119002786] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Preoperative mechanical ventilation is associated with morbidity and mortality following CHD surgery, but prior studies lack a comprehensive analysis of how preoperative respiratory support mode and timing affects outcomes. METHODS We retrospectively collected data on children <18 years of age undergoing cardiac surgery at an academic tertiary care medical centre. Using multivariable regression, we examined the association between modes of preoperative respiratory support (nasal cannula, high-flow nasal cannula/noninvasive ventilation, or invasive mechanical ventilation), escalation of preoperative respiratory support, and invasive mechanical ventilation on the day of surgery for three outcomes: operative mortality, postoperative length of stay, and postoperative complications. We repeated our analysis in a subcohort of neonates. RESULTS A total of 701 children underwent 800 surgical procedures, and 40% received preoperative respiratory support. Among neonates, 243 patients underwent 253 surgical procedures, and 79% received preoperative respiratory support. In multivariable analysis, all modes of preoperative respiratory support, escalation in preoperative respiratory support, and invasive mechanical ventilation on the day of surgery were associated with increased odds of prolonged length of stay in children and neonates. Children (odds ratio = 3.69, 95% CI 1.2-11.4) and neonates (odds ratio = 8.97, 95% CI 1.31-61.14) on high-flow nasal cannula/noninvasive ventilation had increased odds of operative mortality compared to those on room air. CONCLUSION Preoperative respiratory support is associated with prolonged length of stay and mortality following CHD surgery. Knowing how preoperative respiratory support affects outcomes may help guide surgical timing, inform prognostic conversations, and improve risk stratification models.
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Affiliation(s)
- Elizabeth C. Ciociola
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Karan R. Kumar
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Kanecia O. Zimmerman
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Elizabeth J. Thompson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Melissa Harward
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Laura N. Sullivan
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Joseph W. Turek
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Christoph P. Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
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Polo López L, Centella Hernández T, López Menéndez J, Cuerpo Caballero G, Sánchez Pérez R, Bautista Hernández V, Silva Guisasola J, Gascón García-Verdugo P, Hornero Sos F. Registro de intervenciones de la Sociedad Española de Cirugía Torácica-Cardiovascular en pacientes con cardiopatía congénita: 2018 y retrospectiva de los últimos 7 años. CIRUGIA CARDIOVASCULAR 2019. [DOI: 10.1016/j.circv.2019.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Abstract
OBJECTIVES To identify modifiable factors leading to unplanned readmission and characterize differences in adjusted unplanned readmission rates across hospitals. DESIGN Retrospective cohort study using prospectively collected clinical registry data SETTING:: Pediatric Cardiac Critical Care Consortium clinical registry. PATIENTS Patients admitted to a pediatric cardiac ICU at Pediatric Cardiac Critical Care Consortium hospitals. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We examined pediatric cardiac ICU encounters in the Pediatric Cardiac Critical Care Consortium registry from October 2013 to March 2016. The primary outcomes were early (< 48 hr from pediatric cardiac ICU transfer) and late (2-7 d) unplanned readmission. Generalized logit models identified independent predictors of unplanned readmission. We then calculated observed-to-expected ratios of unplanned readmission and identified higher-than or lower-than-expected unplanned readmission rates for those with an observed-to-expected ratios greater than or less than 1, respectively, and a 95% CI that did not cross 1. Of 11,301 pediatric cardiac ICU encounters (16 hospitals), 62% were surgical, and 18% were neonates. There were 175 (1.6%) early unplanned readmission, and 300 (2.7%) late unplanned readmission, most commonly for respiratory (31%), or cardiac (28%) indications. In multivariable analysis, unique modifiable factors were associated with unplanned readmission. Although shorter time between discontinuation of vasoactive infusions and pediatric cardiac ICU transfer was associated with early unplanned readmission, nighttime discharge was independently associated with a greater likelihood of late unplanned readmission. Two hospitals had lower-than-expected unplanned readmission in both the early and late categories, whereas two other hospitals were higher-than-expected in both. CONCLUSIONS This analysis demonstrated time from discontinuation of critical care therapies to pediatric cardiac ICU transfer as a significant, modifiable predictor of unplanned readmission. We identified two hospitals with lower-than-expected adjusted rates of both early and late unplanned readmission, suggesting that their systems are well designed to prevent unplanned readmission. This offers the possibility of disseminating best practices to other hospitals through collaborative learning.
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Reagor JA, Clingan S, Gao Z, Morales DLS, Tweddell JS, Bryant R, Young W, Cavanaugh J, Cooper DS. Higher Flow on Cardiopulmonary Bypass in Pediatrics Is Associated With a Lower Incidence of Acute Kidney Injury. Semin Thorac Cardiovasc Surg 2019; 32:1015-1020. [PMID: 31425753 DOI: 10.1053/j.semtcvs.2019.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 08/12/2019] [Indexed: 12/31/2022]
Abstract
Adequate perfusion is of paramount concern during cardiopulmonary bypass (CPB) and different methodologies are employed to optimize oxygen delivery. Temperature, hematocrit, and cardiac index (CI) are all modulated during CPB to ensure appropriate support. This study examines 2 different perfusion strategies and their impact on various outcome measures including acute kidney injury (AKI), urine output on CPB, ICU length of stay, time to extubation, and mortality. Predicated upon surgeon preference, the study institution employs 2 different perfusion strategies (PS) during congenital cardiac surgery requiring CPB. One method utilizes a targeted 2.4 L/min/m2 CI and nadir hematocrit of 28% (PS1), the other a 3.0 L/min/m2 CI with a nadir hematocrit of 25% (PS2). This study retrospectively examines CPB cases during which the 2 perfusion strategies were applied to determine potential differences in packed red blood cell administration, urine output during CPB, AKI post-CPB as defined by the KDIGO criteria, and operative survival as defined by the Society of Thoracic Surgeons. Significant differences were found in urine output while on CPB (P < 0.01) and all combined stages of postoperative AKI (P = 0.01) with the PS2 group faring better in both measures. No significant difference was found between the 2 groups for packed red blood cell administration, mortality, time to extubation, or ICU length of stay. Avoiding a nadir hematocrit less than 25% has been well established but maintaining anything greater than that may not be necessary to achieve adequate oxygen delivery on CPB. Our results indicate that higher CI and oxygen delivery on CPB are associated with a lower rate of AKI and this may be achieved with increased flow rather than increasing the hematocrit thus avoiding unnecessary transfusion.
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Affiliation(s)
- James A Reagor
- Department of Cardiovascular Perfusion, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Sean Clingan
- Department of Cardiovascular Perfusion, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Zhiqian Gao
- Heart Institute Research Core, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David L S Morales
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - James S Tweddell
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Roosevelt Bryant
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - William Young
- Information Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jesse Cavanaugh
- Information Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David S Cooper
- Cardiac Intensive Care Unit, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Biomarkers improve prediction of 30-day unplanned readmission or mortality after paediatric congenital heart surgery. Cardiol Young 2019; 29:1051-1056. [PMID: 31290383 PMCID: PMC6711799 DOI: 10.1017/s1047951119001471] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate the association between novel pre- and post-operative biomarker levels and 30-day unplanned readmission or mortality after paediatric congenital heart surgery. METHODS Children aged 18 years or younger undergoing congenital heart surgery (n = 162) at Johns Hopkins Hospital from 2010 to 2014 were enrolled in the prospective cohort. Collected novel pre- and post-operative biomarkers include soluble suppression of tumorgenicity 2, galectin-3, N-terminal prohormone of brain natriuretic peptide, and glial fibrillary acidic protein. A model based on clinical variables from the Society of Thoracic Surgery database was developed and evaluated against two augmented models. RESULTS Unplanned readmission or mortality within 30 days of cardiac surgery occurred among 21 (13%) children. The clinical model augmented with pre-operative biomarkers demonstrated a statistically significant improvement over the clinical model alone with a receiver-operating characteristics curve of 0.754 (95% confidence interval: 0.65-0.86) compared to 0.617 (95% confidence interval: 0.47-0.76; p-value: 0.012). The clinical model augmented with pre- and post-operative biomarkers demonstrated a significant improvement over the clinical model alone, with a receiver-operating characteristics curve of 0.802 (95% confidence interval: 0.72-0.89; p-value: 0.003). CONCLUSIONS Novel biomarkers add significant predictive value when assessing the likelihood of unplanned readmission or mortality after paediatric congenital heart surgery. Further exploration of the utility of these novel biomarkers during the pre- or post-operative period to identify early risk of mortality or readmission will aid in determining the clinical utility and application of these biomarkers into routine risk assessment.
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Jacobs JP, O’Brien SM, Hill KD, Kumar SR, Austin EH, Gaynor JW, Gruber PJ, Jonas RA, Pasquali SK, Pizarro C, St. Louis JD, Meza J, Thibault D, Shahian DM, Mayer JE, Jacobs ML. Refining The Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model With Enhanced Risk Adjustment for Chromosomal Abnormalities, Syndromes, and Noncardiac Congenital Anatomic Abnormalities. Ann Thorac Surg 2019; 108:558-566. [DOI: 10.1016/j.athoracsur.2019.01.069] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/26/2019] [Accepted: 01/29/2019] [Indexed: 12/22/2022]
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