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Prabhu NK, Moya-Mendez ME, Kang L, Medina CK, McCrary AW, Allareddy V, Overbey D, Turek JW. Textbook Outcome for Superior Cavopulmonary Connection: A Metric for Single Ventricle Heart Surgery. World J Pediatr Congenit Heart Surg 2024; 15:303-312. [PMID: 38263731 DOI: 10.1177/21501351231215261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
Background: To develop a more holistic measure of congenital heart center performance beyond mortality, we created a composite "textbook outcome" (TO) for the Glenn operation. We hypothesized that meeting TO would have a positive prognostic and financial impact. Methods: This was a single center retrospective study of patients undergoing superior cavopulmonary connection (bidirectional Glenn or Kawashima ± concomitant procedures) from 2005 to 2021. Textbook outcome was defined as freedom from operative mortality, reintervention, 30-day readmission, extracorporeal membrane oxygenation, major thrombotic complication, length of stay (LOS) >75th percentile (17d), and mechanical ventilation duration >75th percentile (2d). Multivariable logistic regression and Cox proportional hazards modeling were used. Results: Fifty-one percent (137/269) of patients met TO. Common reasons for TO failure were prolonged LOS (78/132, 59%) and ventilator duration (67/132, 51%). In multivariable analysis, higher weight [odds ratio, OR: 1.44 (95% confidence interval, CI: 1.15-1.84), P = .002] was a positive predictor of TO achievement while right ventricular dominance [OR 0.47 (0.27-0.81), P = .007] and higher preoperative pulmonary vascular resistance [OR 0.58 (0.40-0.82), P = .003] were negative predictors. After controlling for preoperative factors and excluding operative mortalities, TO achievement was independently associated with a decreased risk of death over long-term follow-up [hazard ratio: 0.50 (0.25-0.99), P = .049]. Textbook outcome achievement was also associated with lower direct cost of care [$137,626 (59,333-167,523) vs $262,299 (114,200-358,844), P < .0001]. Conclusion: Achievement of the Glenn TO is associated with long-term survival and lower costs and can be predicted by certain risk factors. As outcomes continue to improve within congenital heart surgery, operative mortality will become a less informative metric. Textbook outcome analysis may represent a more balanced measure of a successful outcome.
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Affiliation(s)
- Neel K Prabhu
- Congenital Heart Surgery Research and Training Laboratory, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mary E Moya-Mendez
- Congenital Heart Surgery Research and Training Laboratory, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Lillian Kang
- Congenital Heart Surgery Research and Training Laboratory, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Cathlyn K Medina
- Congenital Heart Surgery Research and Training Laboratory, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Andrew W McCrary
- Duke Children's Pediatric and Congenital Heart Center, Duke University Medical Center, Durham, NC, USA
| | - Veerajalandhar Allareddy
- Duke Children's Pediatric and Congenital Heart Center, Duke University Medical Center, Durham, NC, USA
| | - Douglas Overbey
- Congenital Heart Surgery Research and Training Laboratory, Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Children's Pediatric and Congenital Heart Center, Duke University Medical Center, Durham, NC, USA
| | - Joseph W Turek
- Congenital Heart Surgery Research and Training Laboratory, Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Children's Pediatric and Congenital Heart Center, Duke University Medical Center, Durham, NC, USA
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Lee AY, Larson EL, Chinedozi ID, Lawton JS, Aziz H. Use of veno-venous extracorporeal membrane oxygenation for stabilization prior to redo sternotomy for aortic pseudoaneurysm repair. Glob Cardiol Sci Pract 2024; 2024:e202406. [PMID: 38404656 PMCID: PMC10886875 DOI: 10.21542/gcsp.2024.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 11/11/2023] [Indexed: 02/27/2024] Open
Abstract
Background: Aortic pseudoaneurysms are particularly dangerous because of the risk of rupture and compression of mediastinal structures, including the trachea, and resultant respiratory distress. If respiratory distress progresses to respiratory failure, extracorporeal membrane oxygenation may be used to provide oxygenation prior to or during pseudoaneurysm repair. Case presentation: A 62-year-old male with a history of emergent aortic ascending and arch replacement for Stanford Type A dissection 10 months prior presented to his primary care physician with dyspnea. Chest radiography revealed a widened mediastinum, and subsequent computed tomography angiogram revealed a pseudoaneurysm at the distal suture line of the aortic arch replacement. Due to the location of the pseudoaneurysm, the patient's trachea was compressed, and he was emergently placed on veno-venous (VV) extracorporeal membrane oxygenation (ECMO) following unsuccessful intubation for respiratory distress. Two days later, the patient underwent a redo sternotomy and repair of a 2-3 mm defect in the anterior aspect of the distal suture line of the prior aortic arch replacement. The patient progressed well and was discharged on postoperative day 13. What we learned: Using a combination of peripheral bypass, hypothermic circulatory arrest, delayed closure, and respiratory support, this case demonstrates how even complex patients can be successfully treated with multiple strategies.
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Affiliation(s)
- Anson Y. Lee
- University of Hawaii, John A. Burns School of Medicine, Honolulu, HI, USA
| | - Emily L. Larson
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ifeanyi D. Chinedozi
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer S. Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hamza Aziz
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Stack KO, Schluger C, Roberts AL, Lawrence K, Balsara S, Hunt M, Kaplinski M, Gardner MM, Ravishankar C, Rossano J, Goldberg DJ, Mahle M, O'Connor MJ, Mascio CE, Gaynor JW, Burstein D. Impact of Ventricular Dysfunction and Atrioventricular Valve Regurgitation on Pre-Fontan Attrition. Ann Thorac Surg 2023; 116:778-785. [PMID: 37429514 DOI: 10.1016/j.athoracsur.2023.05.046] [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: 01/24/2023] [Revised: 05/18/2023] [Accepted: 05/30/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND There is a significant incidence of pre-Fontan attrition-defined as failure to undergo Fontan completion-after superior cavopulmonary connection. This study investigated the impact of at least moderate ventricular dysfunction (VD) and atrioventricular valve regurgitation (AVVR) on pre-Fontan attrition. METHODS This single-center retrospective cohort study included all infants who underwent Norwood palliation from 2008 to 2020 and subsequently underwent superior cavopulmonary connection. Pre-Fontan attrition was defined as death, listing for heart transplantation before Fontan completion, or unsuitability for Fontan completion. The study's secondary outcome was transplant-free survival. RESULTS Pre-Fontan attrition occurred in 34 of 267 patients (12.7%). Isolated VD was not associated with attrition. However, patients with isolated AVVR had 5 times the odds of attrition (odds ratio, 5.4; 95% CI 1.8-16.2), and patients with both VD and AVVR had 20 times the odds of attrition (odds ratio, 20.1; 95% CI 7.7-52.8) compared with patients without VD or AVVR. Only patients with both VD and AVVR had significantly worse transplant-free survival compared with patients without VD or AVVR (hazard ratio, 7.7; 95% CI 2.8-21.6). CONCLUSIONS The additive effect of VD and AVVR is a powerful contributor to pre-Fontan attrition. Future research investigating therapies that can mitigate the degree of AVVR may help improve Fontan completion rates and long-term outcomes.
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Affiliation(s)
- Kathryn O Stack
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Charlotte Schluger
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Amy L Roberts
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kendall Lawrence
- Division of Cardiothoracic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sheri Balsara
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mallory Hunt
- Division of Cardiothoracic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle Kaplinski
- Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Monique M Gardner
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Division of Cardiac Critical Care, Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chitra Ravishankar
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph Rossano
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David J Goldberg
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Marlene Mahle
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew J O'Connor
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christopher E Mascio
- Division of Pediatric Cardiothoracic Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Danielle Burstein
- Division of Pediatric Cardiology, Department of Pediatrics, Larner College of Medicine at University of Vermont, Burlington, Vermont
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Euringer C, Kido T, Ruf B, Burri M, Heinisch PP, Vodiskar J, Strbad M, Cleuziou J, Dilber D, Hager A, Ewert P, Hörer J, Ono M. Management of failing bidirectional cavopulmonary shunt: Influence of additional systemic-to-pulmonary-artery shunt with classic Glenn physiology. JTCVS OPEN 2022; 11:373-387. [PMID: 36172411 PMCID: PMC9510880 DOI: 10.1016/j.xjon.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 06/03/2022] [Indexed: 11/02/2022]
Abstract
Objectives Methods Results Conclusions
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Ukil Isildak F, Yavuz Y. The role of neutrophil-to-lymphocyte ratio in predicting mortality after bidirectional Glenn procedure. Cardiol Young 2022; 32:1-7. [PMID: 35491699 DOI: 10.1017/s1047951122001457] [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
This study aimed to address the role of various inflammation-related blood indices for the assessment of in-hospital outcomes in subjects undergoing Glenn procedure. Subjects who underwent the Glenn procedure for hypoplastic left heart syndrome were analysed retrospectively. Subjects were divided into two groups: Group 1 consisted of 78 patients who were discharged, and Group 2 included 12 patients who died after surgery. Post-operative third-day neutrophil count and neutrophil-to-lymphocyte ratio value were significantly higher in the exitus group compared to the discharged group (p = 0.006 and p = 0.003, respectively). Third-day neutrophil-to-lymphocyte ratio was positively correlated with duration of intubation (r = 0.253, p = 0.018), length of stay in ICU (r = 0.296, p = 0.006) and length of hospital stay (r = 0.297, p = 0.005). Multiple logistic regression analysis revealed that patients with high third-day neutrophil-to-lymphocyte ratio (≥6) had 14.227-fold higher risk of death compared to those with lower values. In addition, higher pulmonary arterial pressure was associated with increased risk of death. Receiver operating characteristics analysis revealed that neutrophil-to-lymphocyte ratio had 66.67% sensitivity, 84% specificity, 81.61% accuracy, 40.00% positive predictive value and 94.03% negative predictive value with a cut-off point of ≥6 to predict mortality. Third-day neutrophil-to-lymphocyte ratio and increased post-operative pulmonary arterial pressure are significant predictors for in-hospital mortality in Glenn procedure recipients. A cut-off value of ≥6 for third-day neutrophil-to-lymphocyte ratio predicts mortality with 66.67% sensitivity and 84% specificity. Given its simplicity and availability, post-operative neutrophil-to-lymphocyte ratio should be monitored on a daily basis to identify patients with high risk for mortality after Glenn procedure.
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Affiliation(s)
- Fatma Ukil Isildak
- Department of Anesthesia and Reanimation, Istanbul Provincial Health Directorate Kartal Kosuyolu High Speciality Training and Research Hospital, Istanbul, Turkey
| | - Yasemin Yavuz
- Department of Anesthesia and Reanimation, Istanbul Provincial Health Directorate Kartal Kosuyolu High Speciality Training and Research Hospital, Istanbul, Turkey
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