Unplanned cardiac reoperations and interventions during long-term follow-up after the Norwood procedure†

A dynamic Norwood mortality estimation: Characterizing individual, updated, predicted mortality trajectories after the Norwood operation

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.

Parent and Physician Understanding of Prognosis in Hospitalized Children With Advanced Heart Disease

Background

The unpredictable trajectory of pediatric advanced heart disease makes prognostication difficult for physicians and informed decision‐making challenging for families. This study evaluated parent and physician understanding of disease burden and prognosis in hospitalized children with advanced heart disease.

Methods and Results

A longitudinal survey study of parents and physicians caring for patients with advanced heart disease age 30 days to 19 years admitted for ≥7 days was performed over a 1‐year period (n=160 pairs). Percentage agreement and weighted kappa statistics were used to assess agreement. Median patient age was 1 year (interquartile range, 1–5), 39% had single‐ventricle lesions, and 37% were in the cardiac intensive care unit. Although 92% of parents reported understanding their child's prognosis “extremely well” or “well,” 28% of physicians thought parents understood the prognosis only “a little,” “somewhat,” or “not at all.” Better parent‐reported prognostic understanding was associated with greater preparedness for their child's medical problems (odds ratio, 4.7; 95% CI, 1.4–21.7, P=0.02). There was poor parent–physician agreement in assessing functional class, symptom burden, and likelihood of limitations in physical activity and learning/behavior; on average, parents were more optimistic. Many parents (47%) but few physicians (6%) expected the child to have normal life expectancy.

Conclusions

Parents and physicians caring for children with advanced heart disease differed in their perspectives regarding prognosis and disease burden. Physicians tended to underestimate the degree of parent‐reported symptom burden. Parents were less likely to expect limitations in physical activity, learning/behavior, and life expectancy. Combined interventions involving patient‐reported outcomes, parent education, and physician communication tools may be beneficial.

Double-arterial cannulation: a strategy for whole body perfusion during aortic arch reconstruction

OBJECTIVES

Double-arterial cannulation enables cerebral perfusion and lower body perfusion during aortic arch reconstruction. The aim of this study was to analyse and report our experience of using this cannulation and perfusion technique on paediatric patients.

METHODS

A retrospective single-centre study was carried out on 407 consecutive paediatric patients who underwent an aortic arch reconstruction under double-arterial cannulation between 2003 and 2015. The median age of the patients at surgery was 8 (range 2-5570) days, and body weight was 3.3 (range 1.8-60) kg. All operations were performed through standard median sternotomy. One arterial cannula was inserted into the innominate artery and the second one into the supradiaphragmatic descending aorta. Primary end points were 30-day mortality, acute renal failure requiring dialysis and time until lactate level decreased to ≤2 mmol/l postoperatively.

RESULTS

We found an in-hospital mortality of 8.6%. Lethal incident was not associated with the cannulation method, and 1 intraoperative lesion of the descending aorta could be repaired immediately. The median lactate level of the patients on arrival at the intensive care unit was 3.5 mmol/l [quartile (Q)1: 2.3-Q3: 4.7] and creatinine was 0.48 mg/100 ml (Q1: 0.40-Q3: 0.58). The longest duration until the lactate level decreased to ≤ 2 mmol/l was found in the group of 264 univentricular patients (median 11 h, Q1: 6-Q3: 24). Seven (1.7%) patients of the whole cohort required peritoneal dialysis postoperatively.

CONCLUSIONS

Double-arterial cannulation is a simple and safe method for perfusing the brain and the lower parts of the body during aortic arch reconstruction. Perioperative survival and freedom from procedure-related complications in this demanding patient population are encouraging.

Palliative care and paediatric cardiology: current evidence and future directions

Although outcomes for children with heart disease have improved substantially over the past several decades, heart disease remains one of the leading causes of paediatric mortality. For children who progress to advanced heart disease, disease morbidity is high, with many children requiring multiple surgical interventions and long-term intensive care hospitalisations. Care for children with advanced heart disease requires a multidisciplinary approach, and opportunities for earlier integration of palliative care are being explored. This Viewpoint summarises the relevant literature over the past decade. We also identify gaps in parent and provider understanding of prognosis and communication, propose indications for palliative care consultation in paediatric advanced heart disease, and summarise attitudes and perceived barriers to palliative care consultation. Areas for additional research that we identify include paediatric cardiologist education, parental distress, socioeconomic disparities, and patient-reported outcomes. Interdisciplinary clinical and research efforts are required to further advance the field and improve integration of palliative care in the care of children with heart disease.