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Sturmer D, Beaty C, Clingan S, Jenkins E, Peters W, Si MS. Recent innovations in perfusion and cardiopulmonary bypass for neonatal and infant cardiac surgery. Transl Pediatr 2018; 7:139-150. [PMID: 29770295 PMCID: PMC5938255 DOI: 10.21037/tp.2018.03.05] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The development and refinement of cardiopulmonary bypass (CPB) has made the repair of complex congenital heart defects possible in neonates and infants. In the past, the primary goal for these procedures was patient survival. Now that substantial survival rates have been achieved for even the most complex of repairs in these patients, focus has been given to the reduction of morbidity. Although a necessity for these complex neonatal and infant heart defect repairs, CPB can also be an important source of perioperative complications. Recent innovations have been developed to mitigate these risks and is the topic of this review. Specifically, we will discuss improvements in minimizing blood transfusions, CPB circuit design, monitoring, perfusion techniques, temperature management, and myocardial protection, and then conclude with a brief discussion of how further systematic improvements can be made in these areas.
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Affiliation(s)
- David Sturmer
- Department of Perfusion, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Claude Beaty
- Department of Cardiac Surgery, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Sean Clingan
- Deprtment of Perfusion, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Eric Jenkins
- Department of Perfusion, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Whitney Peters
- Department of Perfusion, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Ming-Sing Si
- Department of Cardiac Surgery, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
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Lopez C, Hanson CC, Yorke D, Johnson JK, Mill MR, Brown KJ, Barach P. Improving communication with families of patients undergoing pediatric cardiac surgery. PROGRESS IN PEDIATRIC CARDIOLOGY 2017. [DOI: 10.1016/j.ppedcard.2016.11.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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3
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Holst KA, Said SM, Nelson TJ, Cannon BC, Dearani JA. Current Interventional and Surgical Management of Congenital Heart Disease: Specific Focus on Valvular Disease and Cardiac Arrhythmias. Circ Res 2017; 120:1027-1044. [PMID: 28302746 DOI: 10.1161/circresaha.117.309186] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 02/20/2017] [Accepted: 02/20/2017] [Indexed: 01/15/2023]
Abstract
Successful outcome in the care of patients with congenital heart disease depends on a comprehensive multidisciplinary team. Surgery is offered for almost every heart defect, despite complexity. Early mortality for cardiac surgery in the neonatal period is ≈10% and beyond infancy is <5%, with 90% to 95% of patients surviving with a good quality of life into the adult years. Advances in imaging have facilitated accurate diagnosis and planning of interventions and surgical procedures. Similarly, advances in the perioperative medical management of patients, particularly with intensive care, has also contributed to improving outcomes. Arrhythmias and heart failure are the most common late complications for the majority of defects, and reoperation for valvar problems is common. Lifelong surveillance for monitoring of recurrent or residual structural heart defects, as well as periodic assessment of cardiac function and arrhythmia monitoring, is essential for all patients. The field of congenital heart surgery is poised to incorporate new innovations such as bioengineered cells and scaffolds that will iteratively move toward bioengineered patches, conduits, valves, and even whole organs.
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Affiliation(s)
- Kimberly A Holst
- From the Department of Cardiovascular Surgery (K.A.H., S.M.S., J.A.D.), Departments of Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics (T.J.N., B.C.C.), and Division of Pediatric Cardiology (T.J.N., B.C.C.), Mayo Clinic, Rochester, MN
| | - Sameh M Said
- From the Department of Cardiovascular Surgery (K.A.H., S.M.S., J.A.D.), Departments of Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics (T.J.N., B.C.C.), and Division of Pediatric Cardiology (T.J.N., B.C.C.), Mayo Clinic, Rochester, MN
| | - Timothy J Nelson
- From the Department of Cardiovascular Surgery (K.A.H., S.M.S., J.A.D.), Departments of Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics (T.J.N., B.C.C.), and Division of Pediatric Cardiology (T.J.N., B.C.C.), Mayo Clinic, Rochester, MN
| | - Bryan C Cannon
- From the Department of Cardiovascular Surgery (K.A.H., S.M.S., J.A.D.), Departments of Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics (T.J.N., B.C.C.), and Division of Pediatric Cardiology (T.J.N., B.C.C.), Mayo Clinic, Rochester, MN
| | - Joseph A Dearani
- From the Department of Cardiovascular Surgery (K.A.H., S.M.S., J.A.D.), Departments of Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics (T.J.N., B.C.C.), and Division of Pediatric Cardiology (T.J.N., B.C.C.), Mayo Clinic, Rochester, MN.
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Matsuda H, Ichikawa H, Ueno T, Sawa Y. Heart transplantation for adults with congenital heart disease: current status and future prospects. Gen Thorac Cardiovasc Surg 2017; 65:309-320. [PMID: 28439697 DOI: 10.1007/s11748-017-0777-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 04/10/2017] [Indexed: 02/07/2023]
Abstract
Increased survival rates after corrective or palliative surgery for complex congenital heart disease (CHD) in infancy and childhood are now being coupled with increased numbers of patients who survive to adulthood with various residual lesions or sequelae. These patients are likely to deteriorate in cardiac function or end-organ function, eventually requiring lifesaving treatment including heart transplantation. Although early and late outcomes of heart transplantation have been improving for adult survivors of CHD, outcomes and pretransplant management could still be improved. Survivors of Fontan procedures are a vulnerable cohort, particularly when single ventricle physiology fails, mostly with protein-losing enteropathy and hepatic dysfunction. Therefore, we reviewed single-institution and larger database analyses of adults who underwent heart transplantation for CHD, to enable risk stratification by identifying the indications and outcomes. As the results, despite relatively high early mortality, long-term results were encouraging after heart transplantation. However, further investigations are needed to improve the indication criteria for complex CHD, especially for failed Fontan. In addition, the current system of status criteria and donor heart allocation system in heart transplantation should be arranged as suitable for adults with complex CHD. Furthermore, there is a strong need to develop ventricular assist devices as a bridge to transplantation or destination therapy, especially where right-sided circulatory support is needed.
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Affiliation(s)
- Hikaru Matsuda
- Professor Emeritus Osaka University, Cardiovascular Surgery, Higashi-Takarazuka Satoh Hospital, Nagao-cho 2-1, Takarazuka, Hyogo, Japan.
| | - Hajime Ichikawa
- Division of Pediatric Cardiac Sergey, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Takayoshi Ueno
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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Outcomes Analysis and Quality Improvement in Children With Congenital and Acquired Cardiovascular Disease. Pediatr Crit Care Med 2016; 17:S362-6. [PMID: 27490624 DOI: 10.1097/pcc.0000000000000785] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES In this review, the current state of outcomes analysis and quality improvement in children with acquired and congenital cardiovascular disease will be discussed, with an emphasis on defining and measuring outcomes and quality in pediatric cardiac critical care medicine and risk stratification systems. DATA SOURCE MEDLINE and PubMed CONCLUSION : Measuring quality and outcomes in the pediatric cardiac critical care environment is challenging owing to many inherent obstacles, including a diverse patient mix, difficulty in determining how the care of the ICU team contributes to outcomes, and the lack of an adequate risk-adjustment method for pediatric cardiac critical care patients. Despite these barriers, new solutions are emerging that capitalize on lessons learned from other quality improvement initiatives, providing opportunities to build upon previous successes.
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The science of assessing the outcomes and improving the quality of the congenital and paediatric cardiac care. Curr Opin Cardiol 2015; 30:100-11. [PMID: 25469591 DOI: 10.1097/hco.0000000000000133] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Although significant progress has been made in the care of patients with paediatric and congenital cardiac disease, optimization of outcomes remains a constant goal. This review article will discuss the latest advances in the science of assessing the outcomes and improving the quality of the congenital and paediatric cardiac care, and will also review some of the latest associated research. RECENT FINDINGS Important advances continue to be made in each of the following domains: standardized nomenclature; established uniform core dataset; evaluation of case complexity; verification of the completeness and accuracy of the data; collaboration between subspecialties; strategies for longitudinal follow-up; and incorporating quality improvement. In January 2015, the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) will begin voluntary public reporting of programmatic congenital cardiac surgical outcomes using a new risk model that includes both procedural risk (as defined by the procedure itself and STAT Categories) and a number of patient-specific characteristics including age, weight, prior cardiothoracic operation, prematurity, chromosomal abnormalities, syndromes, noncardiac congenital anatomic abnormalities and preoperative factors. Clinical databases have been linked with administrative database to answer questions neither dataset can answer independently, providing new information about long-term mortality, rates of rehospitalization, long-term morbidity, comparative effectiveness of various treatments, and the cost of healthcare. Multiple research initiatives have recently been published using STS-CHSD. SUMMARY The science of assessing the outcomes and improving the quality of congenital and paediatric cardiac care continues to evolve. Recent advances will facilitate the continued evolution of a meaningful method of multiinstitutional outcomes analysis for congenital and paediatric cardiac surgery.
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Abstract
Public health research is an integral part of the study of congenital heart disease. While this type of research has become more popular, particularly over the past decade, it has a history that stretches back to almost the beginnings of pediatric cardiology as a field. This review aims to introduce the concepts and methodologies of public health and how they relate to congenital heart disease, describe some of the challenges of traditional research methods in congenital heart disease, describe the history of public health research, and demonstrate the relevance of public health research, particularly databases, to pediatric cardiology fellows.
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Affiliation(s)
- Diego A Lara
- The Lillie Frank Abercrombie Section of Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex, USA
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Romley JA, Chen AY, Goldman DP, Williams R. Hospital costs and inpatient mortality among children undergoing surgery for congenital heart disease. Health Serv Res 2014; 49:588-608. [PMID: 24138064 PMCID: PMC3976188 DOI: 10.1111/1475-6773.12120] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2013] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To determine the association between hospital costs and risk-adjusted inpatient mortality among children undergoing surgery for congenital heart disease (CHD) in U.S. acute-care hospitals. DATA SOURCES/STUDY SETTINGS Retrospective cohort study of 35,446 children in 2003, 2006, and 2009 Kids' Inpatient Database (KID). STUDY DESIGN Cross-sectional logistic regression of risk-adjusted inpatient mortality and hospital costs, adjusting for a variety of patient-, hospital-, and community-level confounders. DATA COLLECTION/EXTRACTION METHODS We identified relevant discharges in the KID using the AHRQ Pediatric Quality Indicator for pediatric heart surgery mortality, and linked these records to hospital characteristics from American Hospital Association Surveys and community characteristics from the Census. PRINCIPAL FINDINGS Children undergoing CHD surgery in higher cost hospitals had lower risk-adjusted inpatient mortality (p=.002). An increase from the 25th percentile of treatment costs to the 75th percentile was associated with a 13.6 percent reduction in risk-adjusted mortality. CONCLUSIONS Greater hospital costs are associated with lower risk-adjusted inpatient mortality for children undergoing CHD surgery. The specific mechanisms by which greater costs improve mortality merit further exploration.
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Affiliation(s)
- John A Romley
- Address correspondence to John A. Romley, Ph.D., Price School of Public Policy, University of Southern California, 3335 S. Figueroa St., Unit A, Los Angeles, CA 90089; e-mail:
| | - Alex Y Chen
- Price School of Public Policy, University of Southern California3335 S. Figueroa St., Unit A, Los Angeles, CA 90089
- Keck School of Medicine, University of Southern California, Children's Hospital Los AngelesLos Angeles, CA
- Price School of Public Policy and the School of Pharmacy at the University of Southern CaliforniaLos Angeles, CA
| | - Dana P Goldman
- Price School of Public Policy, University of Southern California3335 S. Figueroa St., Unit A, Los Angeles, CA 90089
- Keck School of Medicine, University of Southern California, Children's Hospital Los AngelesLos Angeles, CA
- Price School of Public Policy and the School of Pharmacy at the University of Southern CaliforniaLos Angeles, CA
| | - Roberta Williams
- Price School of Public Policy, University of Southern California3335 S. Figueroa St., Unit A, Los Angeles, CA 90089
- Keck School of Medicine, University of Southern California, Children's Hospital Los AngelesLos Angeles, CA
- Price School of Public Policy and the School of Pharmacy at the University of Southern CaliforniaLos Angeles, CA
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Safety of cardiac devices in children. PROGRESS IN PEDIATRIC CARDIOLOGY 2012. [DOI: 10.1016/j.ppedcard.2012.02.003] [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: 11/22/2022]
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Gaies MG, Jeffries HE, Jacobs JP, Laussen PC. Measuring quality and outcomes in pediatric cardiac critical care. PROGRESS IN PEDIATRIC CARDIOLOGY 2012. [DOI: 10.1016/j.ppedcard.2011.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Jacobs JP, Jacobs ML, Austin EH, Mavroudis C, Pasquali SK, Lacour–Gayet FG, Tchervenkov CI, Walters H, Bacha EA, del Nido PJ, Fraser CD, Gaynor JW, Hirsch JC, Morales DLS, Pourmoghadam KK, Tweddell JS, Prager RL, Mayer JE. Quality measures for congenital and pediatric cardiac surgery. World J Pediatr Congenit Heart Surg 2012; 3:32-47. [PMID: 23804682 PMCID: PMC3827684 DOI: 10.1177/2150135111426732] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This article presents 21 "Quality Measures for Congenital and Pediatric Cardiac Surgery" that were developed and approved by the Society of Thoracic Surgeons (STS) and endorsed by the Congenital Heart Surgeons' Society (CHSS). These Quality Measures are organized according to Donabedian's Triad of Structure, Process, and Outcome. It is hoped that these quality measures can aid in congenital and pediatric cardiac surgical quality assessment and quality improvement initiatives.
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Affiliation(s)
- Jeffrey Phillip Jacobs
- Division of Thoracic and Cardiovascular Surgery, The Congenital Heart Institute of Florida (CHIF), All Children’s Hospital, Cardiac Surgical Associates of Florida (CSAoF), University of South Florida College of Medicine, St Petersburg and Tampa, FL, USA
| | - Marshall Lewis Jacobs
- Center for Pediatric and Congenital Heart Diseases, Children’s Hospital, Cleveland Clinic, Cleveland, OH, USA
| | - Erle H. Austin
- Kosair Children’s Hospital, University of Louisville, Louisville, KY, USA
| | - Constantine Mavroudis
- Department of Pediatric and Congenital Heart Surgery, Cleveland Clinic, Cleveland Clinic Lerner School of Medicine, Cleveland, OH, USA
| | - Sara K. Pasquali
- Department of Pediatrics, Duke University School of Medicine, and Duke Clinical Research Institute, Durham, NC, USA
| | | | - Christo I. Tchervenkov
- Division of Pediatric Cardiovascular Surgery, The Montreal Children’s Hospital of the McGill University Health Centre, Montréal, Quebec, Canada
| | - Hal Walters
- Children’s Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI, USA
| | - Emile A. Bacha
- Morgan Stanley Children’s Hospital of New York (CHONY)/Columbia University, New York, NY, USA
| | - Pedro J. del Nido
- Children’s Hospital Boston, Harvard University Medical School, Boston, MA, USA
| | - Charles D. Fraser
- Division of Congenital Heart Surgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | - J. William Gaynor
- Cardiac Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer C. Hirsch
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - David L. S. Morales
- Division of Congenital Heart Surgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | | | - James S. Tweddell
- Department of Cardiothoracic Surgery, Children’s Hospital of Wisconsin, Milwaukee, WI, USA
| | - Richard L. Prager
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - John E. Mayer
- Children’s Hospital Boston, Harvard University Medical School, Boston, MA, USA
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