Using cryopreserved allogeneic pericardium to repair congenital heart defects in children

Patches prepared from autologous, allogeneic, or xenogeneic tissues are widely used in the repair of congenital heart defects in children. Since 2002, cryopreserved allogeneic pericardial patches have been prepared in our institution as an alternative to commercially available patches. This study retrospectively reviewed donor and patient data concerning cryopreservation time and the clinical use of the pericardium in 382 children who were operated on at a single center between 2004 and 2021. There were 177 donors: 98 males and 79 females. The median donor age was 13 years (range: 1 month to 53 years) and the median cryopreservation time was 72 days (range: 3-685). There were 382 pediatric patients: 224 males and 158 females. The median patient age was 1 month (range: 3 days to 17.8 years). The patches were used for primary surgeries in 228 patients and for reoperations in 154. The patches were implanted into the right heart or venous circulation in 209 patients, the left heart or arterial circulation in 246 patients, and both sides of the circulatory system in 73. Extracardiac patch implantation was performed in 339 patients, intracardiac in 79 patients, and both intracardiac and extracardiac in 36 patients. Our study presents a single-center experience in the use of cryopreserved allogeneic pericardium. The pericardium can be used on the systemic and pulmonary sides of the circulatory system, in either extracardiac or intracardiac positions. However, there is no uniform strategy for selecting the "patch of choice" for correcting congenital heart defects in children, especially since there are few studies comparing several types of patches.

Prognostic impact of preoperative atrial fibrillation in patients undergoing heart surgery in cardiogenic shock

Surgical intervention in the setting of cardiogenic shock (CS) is burdened with high mortality. Due to acute condition, detailed diagnoses and risk assessment is often precluded. Atrial fibrillation (AF) is a risk factor for perioperative complications and worse survival but little is known about AF patients operated in CS. Current analysis aimed to determine prognostic impact of preoperative AF in patients undergoing heart surgery in CS. We analyzed data from the Polish National Registry of Cardiac Surgery (KROK) Procedures. Between 2012 and 2021, 332,109 patients underwent cardiac surgery in 37 centers; 4852 (1.5%) patients presented with CS. Of those 624 (13%) patients had AF history. Cox proportional hazards models were used for computations. Propensity score (nearest neighbor) matching for the comparison of patients with and without AF was performed. Median follow-up was 4.6 years (max.10.0), mean age was 62 (± 15) years and 68% patients were men. Thirty-day mortality was 36% (1728 patients). The origin of CS included acute myocardial infarction (1751 patients, 36%), acute aortic dissection (1075 patients, 22%) and valvular dysfunction (610 patients, 13%). In an unadjusted analysis, patients with underlying AF had almost 20% higher mortality risk (HR 1.19, 95% CIs 1.06-1.34; P = 0.004). Propensity score matching returned 597 pairs with similar baseline characteristics; AF remained a significant prognostic factor for worse survival (HR 1.19, 95% CI 1.00-1.40; P = 0.045). Among patients with CS referred for cardiac surgery, history of AF was a significant risk factor for mortality. Role of concomitant AF ablation and/or left atrial appendage occlusion or more aggressive perioperative circulatory support should be addressed in the future.

Congenital Heart Surgery Machine Learning-Derived In-Depth Benchmarking Tool

BACKGROUND

We previously showed that machine learning-based methodologies of optimal classification trees (OCTs) can accurately predict risk after congenital heart surgery and assess case-mix-adjusted performance after benchmark procedures. We extend this methodology to provide interpretable, easily accessible, and actionable hospital performance analysis across all procedures.

METHODS

The European Congenital Heart Surgeons Association Congenital Cardiac Database data subset of 172,888 congenital cardiac surgical procedures performed in European centers between 1989 and 2022 was analyzed. OCT models (decision trees) were built predicting hospital mortality (area under the curve [AUC], 0.866), prolonged postoperative mechanical ventilatory support time (AUC, 0.851), or hospital length of stay (AUC, 0.818), thereby establishing case-adjusted benchmarking standards reflecting the overall performance of all participating hospitals, designated as the "virtual hospital." OCT analysis of virtual hospital aggregate data yielded predicted expected outcomes (both aggregate and for risk-matched patient cohorts) for the individual hospital's own specific case-mix, readily available on-line.

RESULTS

Raw average rates were hospital mortality, 4.9%; mechanical ventilatory support time, 14.5%; and length of stay, 15.0%. Of 146 participating centers, compared with each hospital's overall case-adjusted predicted hospital mortality benchmark, 20.5% statistically (<90% CI) overperformed and 20.5% underperformed. An interactive tool based on the OCT analysis automatically reveals 14 hospital-specific patient cohorts, simultaneously assessing overperformance or underperformance, and enabling further analysis of cohort strata in any chosen time frame.

CONCLUSIONS

Machine learning-based OCT benchmarking analysis provides automatic assessment of hospital-specific case-adjusted performance after congenital heart surgery, not only overall but importantly, also by similar risk patient cohorts. This is a tool for hospital self-assessment, particularly facilitated by the user-accessible online-platform.

Combining Congenital Heart Surgical and Interventional Cardiology Outcome Data in a Single Database: The Development of a Patient-Centered Collaboration of the European Congenital Heart Surgeons Association (ECHSA) and the Association for European Paediatric and Congenital Cardiology (AEPC)

The European Congenital Heart Surgeons Association (ECHSA) Congenital Database (CD) is the second largest clinical pediatric and congenital cardiac surgical database in the world and the largest in Europe, where various smaller national or regional databases exist. Despite the dramatic increase in interventional cardiology procedures over recent years, only scattered national or regional databases of such procedures exist in Europe. Most importantly, no congenital cardiac database exists in the world that seamlessly combines both surgical and interventional cardiology data on an international level; therefore, the outcomes of surgical and interventional procedures performed on the same or similar patients cannot easily be tracked, assessed, and analyzed. In order to fill this important gap in our capability to gather and analyze information on our common patients, ECHSA and The Association for European Paediatric and Congenital Cardiology (AEPC) have embarked on a collaborative effort to expand the ECHSA-CD with a new module designed to capture data about interventional cardiology procedures. The purpose of this manuscript is to describe the concept, the structure, and the function of the new AEPC Interventional Cardiology Part of the ECHSA-CD, as well as the potentially valuable synergies provided by the shared interventional and surgical analyses of outcomes of patients. The new AEPC Interventional Cardiology Part of the ECHSA-CD will allow centers to have access to robust surgical and transcatheter outcome data from their own center, as well as robust national and international aggregate outcome data for benchmarking. Each contributing center or department will have access to their own data, as well as aggregate data from the AEPC Interventional Cardiology Part of the ECHSA-CD. The new AEPC Interventional Cardiology Part of the ECHSA-CD will allow cardiology centers to have access to aggregate cardiology data, just as surgical centers already have access to aggregate surgical data. Comparison of surgical and catheter interventional outcomes could potentially strengthen decision processes. A study of the wealth of information collected in the database could potentially also contribute toward improved early and late survival, as well as enhanced quality of life of patients with pediatric and/or congenital heart disease treated with surgery and interventional cardiac catheterization across Europe and the world.

Combining Congenital Heart Surgical and Interventional Cardiology Outcome Data in a Single Database: The Development of a Patient-Centered Collaboration of the European Congenital Heart Surgeons Association (ECHSA) and the Association for European Paediatric and Congenital Cardiology (AEPC)

The European Congenital Heart Surgeons Association (ECHSA) Congenital Database (CD) is the second largest clinical pediatric and congenital cardiac surgical database in the world and the largest in Europe, where various smaller national or regional databases exist. Despite the dramatic increase in interventional cardiology procedures over recent years, only scattered national or regional databases of such procedures exist in Europe. Most importantly, no congenital cardiac database exists in the world that seamlessly combines both surgical and interventional cardiology data on an international level; therefore, the outcomes of surgical and interventional procedures performed on the same or similar patients cannot easily be tracked, assessed, and analyzed. In order to fill this important gap in our capability to gather and analyze information on our common patients, ECHSA and The Association for European Paediatric and Congenital Cardiology (AEPC) have embarked on a collaborative effort to expand the ECHSA-CD with a new module designed to capture data about interventional cardiology procedures. The purpose of this manuscript is to describe the concept, the structure, and the function of the new AEPC Interventional Cardiology Part of the ECHSA-CD, as well as the potentially valuable synergies provided by the shared interventional and surgical analyses of outcomes of patients. The new AEPC Interventional Cardiology Part of the ECHSA-CD will allow centers to have access to robust surgical and transcatheter outcome data from their own center, as well as robust national and international aggregate outcome data for benchmarking. Each contributing center or department will have access to their own data, as well as aggregate data from the AEPC Interventional Cardiology Part of the ECHSA-CD. The new AEPC Interventional Cardiology Part of the ECHSA-CD will allow cardiology centers to have access to aggregate cardiology data, just as surgical centers already have access to aggregate surgical data. Comparison of surgical and catheter interventional outcomes could potentially strengthen decision processes. A study of the wealth of information collected in the database could potentially also contribute toward improved early and late survival, as well as enhanced quality of life of patients with pediatric and/or congenital heart disease treated with surgery and interventional cardiac catheterization across Europe and the world.

The impact of sex on in-hospital and long-term mortality rates in patients undergoing surgical aortic valve replacement: The SAVR and SEX study

BACKGROUND

Surgical aortic valve replacement (SAVR) is among the most commonly performed valvular surgeries. Despite many previous studies conducted in this setting, the impact of sex on outcomes in patients undergoing SAVR is still unclear.

AIMS

This study aimed to define sex differences in short- and long-term mortality in patients undergoing SAVR.

METHODS

We analyzed retrospectively all the patients undergoing isolated SAVR from January 2006 to March 2020 in the Department of Cardiovascular Surgery and Transplantology in John Paul II Hospital in Kraków. The primary endpoint was in-hospital and long-term mortality. Secondary endpoints included the duration of hospital stay and perioperative complications. Groups of men and women were compared with regard to the prosthesis type. Propensity score matching was performed to adjust for differences in baseline characteristics.

RESULTS

A total number of 4 510 patients undergoing isolated surgical SAVR were analyzed. A follow- up median (interquartile range [IQR]) was 2120 (1000-3452) days. Females made up 41.55% of the cohort and were older, displayed more non-cardiac comorbidities, and faced a higher operative risk. In both sexes, bioprostheses were more often applied (55.5% vs. 44.5%; P <0.0001). In univariable analysis, sex was not linked to in-hospital mortality (3.7% vs. 3%; P = 0.15) and late mortality rates (23.37% vs. 23.52 %; P = 0.9). Upon adjustment for baseline characteristics (propensity score matching analysis) and considering 5-year survival, a long-term prognosis turned out to be better in women (86.8%) compared to men (82.7%, P = 0.03).

CONCLUSIONS

A key finding from this study suggests that female sex was not associated with higher in-hospital and late mortality rates compared to men. Further studies are needed to confirm longterm benefits in women undergoing SAVR.

Tricuspid intervention for less-than-severe regurgitation simultaneously with minimally invasive mitral valve surgery in patients with atrial fibrillation

BACKGROUND

While tackling moderate tricuspid regurgitation (TR) simultaneously with left-side heart surgery is recommended by the guidelines, the procedure is still seldom performed, especially in the minimally invasive setting. Atrial fibrillation (AF) is a known marker of both mortality and TR progression after mitral valve surgery.

AIMS

This study aimed to investigatev the safety of performing tricuspid intervention and minimally invasive mitral valve surgery (MIMVS) in patients with preoperative AF.

METHODS

We retrospectively analyzed data from the Polish National Registry of Cardiac Surgery Procedures collected between 2006 and 2021. We included all patients who underwent MIMVS (mini-thoracotomy, totally thoracoscopic, or robotic surgery) and had presented with moderate tricuspid regurgitation and AF preoperatively. The primary endpoint was death from any cause at 30 days and at the longest available follow-up after MIMVS with tricuspid intervention vs. MIMVS alone. We used propensity score (PS) matching to account for baseline differences between groups.

RESULTS

We identified 1545 patients with AF undergoing MIMVS, 54.7% were men aged 66.7 (mean [standard deviation, SD], 9.2) years. Of those, 733 (47.4%) underwent concomitant tricuspid valve intervention. At 13 years of follow-up, the addition of tricuspid intervention was associated with 33% higher mortality as compared to MIMVS alone (hazard ratio [HR], 1.33; 95% confidence interval [CI], 1.05-1.69; P = 0.02). PS matching resulted in identifying 565 well-balanced pairs. Concomitant tricuspid intervention did not influence long-term follow-up (HR, 1.01; 95 CI, 0.74-1.38; P = 0.94).

CONCLUSIONS

After adjusting for baseline confounders, the addition of tricuspid intervention for moderate tricuspid regurgitation to MIMVS did not increase perioperative mortality nor influence long-term survival.

Outcomes of Transannular Repair of Tetralogy of Fallot With a Contegra® Monocuspid Patch

BACKGROUND

Surgical repair of tetralogy of Fallot (ToF) depends on the anatomical variations of the heart defect. A group of patients with a hypoplastic pulmonary valve annulus required a transannular patch. This study aimed to evaluate the early and late outcomes of ToF repair with a transannular Contegra® monocuspid patch in a single center.

METHODS

A retrospective review of medical records was conducted. This study included 224 children with a median age of 13 months who underwent ToF repair with a Contegra® transannular patch in over 20 years of observation. The primary outcomes were hospital mortality and need for early reoperations. The secondary outcomes were late death and event-free survival.

RESULTS

The hospital mortality in our group was 3.1%, whereas two patients required early reoperation. Three patients were excluded from the study because follow-up data were not available. In the remaining group of patients (212 patients), the median follow-up was 116 (range, 1-206) months. One patient died because of sudden cardiac arrest at home six months after surgery. Event-free survival was observed in 181 patients (85.4%), whereas the remaining 30 patients (14.1%) required graft replacement. The median time to reoperation was 99 (range, 4-183) months.

CONCLUSIONS

Although surgical treatment of ToF has been performed for more than 60 years worldwide, the optimal approach in children with a hypoplastic pulmonary valve annulus remains debatable. Among options, the Contegra® monocuspid patch can be effectively used in transannular repair of ToF with good long-term results.

Ten Years of Data Verification: The European Congenital Heart Surgeons Association Congenital Database Audits

BACKGROUND

Congenital heart surgery databases are tools for internal programmatic evaluation, benchmarking institutional results to multi-institutional aggregate data, and research. Therefore, it is essential to ensure the completeness and accuracy of data. This study analyzes the results of ten years of on-site source data verification of the European Congenital Heart Surgeons Association Congenital Heart Surgery Database (ECHSA CHSD).

METHODS

All data forms verified between 2009 and 2018 were analyzed. The data form consists of 12 data elements: dates of birth, admission, surgery, discharge, and death; weight; case category; cardiopulmonary bypass time; aortic cross-clamp time; validation rules; diagnoses; and procedures. Descriptive data calculation and rates of completeness and accuracy were determined. The trend of error rate of seven centers with ≥5 visits was analyzed.

RESULTS

Sixty-nine on-site verification visits took place at 17 centers. A total of 26,245 cases were verified; 2,841 of these 26,245 cases (10.8%) showed an error. The total mean error rate of centers for all years was 12.3 ± 2.1%. Rates of completeness and accuracy were 99% and 89.2%, respectively. Coded diagnoses and procedure analysis revealed that 716 (2.7%) and 456 (1.7%) datasets were incorrect, respectively. Rates of completeness and accuracy of dates were 100%, and 97.1%, respectively. Validation fields showed no errors.

CONCLUSION

Source data verification is an appropriate tool to determine completeness and accuracy of data. The ECHSA CHSD verification analysis of a ten-year period showed a high level of completeness and accuracy. The verified data of the ECHSA CHSD are well-suited for benchmarking and research.

Burden of hospitalizations in newly diagnosed heart failure patients in Poland: real world population based study in years 2013-2019

Aims

We aim to report trends in unplanned hospitalizations among newly diagnosed heart failure patients with regard to hospitalizations types and their impact on outcomes.

Methods and results

A nation‐wide study of all citizens in Poland with newly diagnosed heart failure based on ICD‐10 coding who were beneficiaries of either public primary, secondary, or hospital care between 2013 and 2018 in Poland. Between 1 January 2013 and 31 December 2019, there were 1 124 118 newly diagnosed heart failure patients in Poland in both out‐ and inpatient settings. The median observation time was 946 days. As many as 49% experienced at least one acute heart failure hospitalization. Once hospitalized, 44.6% patients experienced at least one all‐cause rehospitalization and 26% another heart failure rehospitalization. The latter had the highest Charlson co‐morbidity index (1.36). The 30 day heart failure readmission rate was 2.96%. Kaplan–Meier analysis revealed very early readmissions (up to 1–7 days) were associated with better survival compared with rehospitalization between 8 and 30 days. All‐cause mortality was related to the number of hospitalization with adjusted estimated hazard ratios: 1.550 (95% CI: 1.52–158) for the second HF hospitalization, 2.158 (95% CI: 2.098–2.219) for third, and 2.788 (95% CI: 2.67–2.91) for the fourth HF hospitalization and subsequent ones, as compared with the first hospitalization.

Conclusions

Among newly diagnosed heart failure patients in Poland between 2013 and 2019, nearly half required at least one unplanned heart failure hospitalization. The risk of death was growing with every other hospital reoccurrence due to heart failure.

Benchmarking in Congenital Heart Surgery Using Machine Learning-Derived Optimal Classification Trees

Background: We have previously shown that the machine learning methodology of optimal classification trees (OCTs) can accurately predict risk after congenital heart surgery (CHS). We have now applied this methodology to define benchmarking standards after CHS, permitting case-adjusted hospital-specific performance evaluation. Methods: The European Congenital Heart Surgeons Association Congenital Database data subset (31 792 patients) who had undergone any of the 10 "benchmark procedure group" primary procedures were analyzed. OCT models were built predicting hospital mortality (HM), and prolonged postoperative mechanical ventilatory support time (MVST) or length of hospital stay (LOS), thereby establishing case-adjusted benchmarking standards reflecting the overall performance of all participating hospitals, designated as the "virtual hospital." These models were then used to predict individual hospitals' expected outcomes (both aggregate and, importantly, for risk-matched patient cohorts) for their own specific cases and case-mix, based on OCT analysis of aggregate data from the "virtual hospital." Results: The raw average rates were HM = 4.4%, MVST = 15.3%, and LOS = 15.5%. Of 64 participating centers, in comparison with each hospital's specific case-adjusted benchmark, 17.0% statistically (under 90% confidence intervals) overperformed and 26.4% underperformed with respect to the predicted outcomes for their own specific cases and case-mix. For MVST and LOS, overperformers were 34.0% and 26.4%, and underperformers were 28.3% and 43.4%, respectively. OCT analyses reveal hospital-specific patient cohorts of either overperformance or underperformance. Conclusions: OCT benchmarking analysis can assess hospital-specific case-adjusted performance after CHS, both overall and patient cohort-specific, serving as a tool for hospital self-assessment and quality improvement.

Cefazolin prophylaxis in children undergoing cardiac surgery with the use of cardiopulmonary bypass-is the dosing correct?

OBJECTIVES

To determine the recommended concentrations of cefazolin to be used for antibiotic prophylaxis during paediatric cardiac surgery with extracorporeal circulation (ECC).

METHODS

Twenty paediatric patients undergoing cardiac surgery with ECC and cefazolin antibiotic prophylaxis were included in the study. Blood samples for measurement of total cefazolin plasma concentration were collected at the following measurement time points: directly after skin incision, 15 min after ECC start, 5 min after ECC cessation and at skin closure. The target concentration was set for ≥40 mg/l, which corresponded to ≥8 mg/l of unbound cefazolin concentration.

RESULTS

The median total cefazolin plasma concentrations at the measurement time points were 62.8, 67.7, 45.8 and 34.2 mg/l, respectively, and target concentrations were achieved in 90%, 85%, 65% and 40% of children, respectively. Among patients who received ≥30 mg of cefazolin per 100 ml of ECC priming, target concentrations after ECC cessation were reached in 80% of patients, while in those with <30 mg cefazolin per 100 ml in 20% of patients (P = 0.031).

CONCLUSIONS

Direct extrapolation of antibiotic prophylaxis recommendations from adults to children may result in suboptimal antibiotic concentrations. An additional cefazolin dose to ECC priming appears necessary and the dosing should be based on ECC priming volume rather than on the weight of the patient.

The European Registry for Patients with Mechanical Circulatory Support (EUROMACS): second EUROMACS Paediatric (Paedi-EUROMACS) report

OBJECTIVES

A second paediatric report has been generated from the European Registry for Patients with Mechanical Circulatory Support (EUROMACS). The purpose of EUROMACS, which is operated by the European Association for Cardio-Thoracic Surgery, is to gather data related to durable mechanical circulatory support for scientific purposes and to publish reports with respect to the course of mechanical circulatory support therapy. Since the first report issued, efforts to increase compliance and participation have been extended. Additionally, the data provided the opportunity to analyse patients of younger age and lower weight.

METHODS

Participating hospitals contributed pre-, peri- and long-term postoperative data on mechanical circulatory support implants to the registry. Data for all implants in paediatric patients (≤19 years of age) performed from 1 January 2000 to 1 July 2019 were analysed. This report includes updates of patient characteristics, implant frequency, outcome (including mortality rates, transplants and recovery rates) as well as adverse events including neurological dysfunction, device malfunction, major infection and bleeding.

RESULTS

Twenty-nine hospitals contributed 398 registered implants in 353 patients (150 female, 203 male) to the registry. The most frequent aetiology of heart failure was any form of cardiomyopathy (61%), followed by congenital heart disease and myocarditis (16.4% and 16.1%, respectively). Competing outcomes analysis revealed that a total of 80% survived to transplant or recovery or are ongoing; at the 2-year follow-up examination, 20% died while on support. At 12 months, 46.7% received transplants, 8.7% were weaned from their device and 18.5% died. The 3-month adverse events rate was 1.69 per patient-year for device malfunction including pump exchange, 0.48 for major bleeding, 0.64 for major infection and 0.78 for neurological events.

CONCLUSIONS

The overall survival rate was 81.5% at 12 months following ventricular assist device implant. The comparison of survival rates of the early and later eras shows no significant difference. A focus on specific subgroups showed that survival was less in patients of younger age (<1 year of age) (P = 0.01) and lower weight (<20 kg) (P = 0.015). Transplant rates at 6 months continue to be low (33.2%) The fact that the EUROMACS registry is embedded within the European Association for Cardio-Thoracic Surgery Quality Improvement Programme offers opportunities to focus on improving outcomes.

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

 

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.

Current Status of Training and Certification for Congenital Heart Surgery Around the World: Proceedings of the Meetings of the Global Council on Education for Congenital Heart Surgery of the World Society for Pediatric and Congenital Heart Surgery

The optimal training of the highly specialized congenital heart surgeon is a long and complex process, which is a significant challenge in most parts of the world. The World Society for Pediatric and Congenital Heart Surgery (WSPCHS) has established the Global Council on Education for Congenital Heart Surgery as a nonprofit organization with the goal of assessing current training and certification and ultimately establishing standardized criteria for the training, evaluation, and certification of congenital heart surgeons around the world. The Global Council and the WSPCHS have reviewed the present status of training and certification for congenital cardiac surgery around the world. There is currently lack of consensus and standardized criteria for training in congenital heart surgery, with significant disparity between continents and countries. This represents significant obstacles to international job mobility of competent congenital heart surgeons and to the efforts to improve the quality of care for patients with Congenital Heart Disease worldwide. The purpose of this article is to summarize and document the present state of training and certification in congenital heart surgery around the world.

Pediatric Cardiac Surgical Patterns of Practice and Outcomes in Japan and Europe

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.

Adverse Outcomes Prediction for Congenital Heart Surgery: A Machine Learning Approach

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.

Anomalous left coronary artery from pulmonary artery repair: Outcomes from the European Congenital Heart Surgeons Association Database

INTRODUCTION

We sought to determine the surgical outcomes of patients with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) enrolled in the European Congenital Heart Surgeons Association (ECHSA) database.

MATERIALS AND METHODS

From 1999 to 2019, 907 patients with ALCAPA underwent surgical repair and were included in the current study. The primary outcome was in-hospital mortality. Secondary outcomes included frequency and results of concomitant mitral valve surgery and postoperative mechanical circulatory support (MCS).

RESULTS

The overall in-hospital mortality was 6% (54/907) and was significantly higher in neonates (p = .01), patients with lower body surface area (BSA) (p = .01), and those requiring postoperative MCS (p = .001). Associated mitral valve surgery was performed in 144 patients (15.9%) and was associated with longer cardiopulmonary bypass (CPB) and aortic cross-clamp times (AOX) (p ≤ .0001) but was not significantly related to an increase in in-hospital mortality. Postoperative MCS was required in 66 patients (7.3%). These patients were younger (p ≤ .001), had a lower BSA (p ≤ .001), and required a longer CPB (p ≤ .001) and AOX time (p ≤ .001).

CONCLUSIONS

ALCAPA repair can be achieved successfully, and with low surgical risk. Concomitant mitral valve procedures can be performed without increasing operative mortality. The use of MCS remains a valuable option, especially in younger patients.

AN INVITATION TO THE MEDICAL STUDENTS OF THE WORLD TO JOIN THE GLOBAL COALITION TO IMPROVE CARE FOR CHILDREN AND ADULTS WITH CONGENITAL HEART DISEASE ACROSS THE WORLD

N/A

Bioprosthetic or mechanical heart valves: prosthesis choice for borderline patients?-Results from 9,616 cases recorded in Polish national cardiac surgery registry

Background

In middle-aged patients undergoing aortic valve replacement (AVR), the selection of prosthesis type is a complex process. Current guidelines do not unequivocally indicate the type of prosthesis (bioprosthetic or mechanical) recommended for patients between 60–70 years of age. The aim of the study was to present the trends in AVR prosthesis selection in borderline patients over a 10-year period, based on real-life registry data.

Methods

The study population comprised of 9,616 consecutive patients aged between 60–70 years, who underwent isolated AVR between 2006 and 2016 in all cardiac surgery departments in Poland. Data were extracted from the Polish National Registry of Cardiac Surgery.

Results

Among 27,797 consecutive AVR procedures, patients aged 60–70 years represented 34.6% of the population operated on. From 2006 to 2016, bioprosthetic valves (BVs) were implanted in 53.9% cases, (and) mechanical valves (MVs) in 42.1%. The proportion of different valve types changed in time: from 77.5% of MVs vs. 22.5% of BVs in 2006 to 23.2% of MVs vs. 76.8% of BVs in 2016 (P<0.001). The most commonly implanted BV was the Hancock II (used in 36.4% of BV implantations), the most commonly used MV was the Saint Jude Mechanical prosthesis (implanted in 36.4% of MV implantation cases). A multivariable model identified smaller annulus [OR (95% CI) 0.89 (0.86–0.92), P<0.001], atrial fibrillation [OR (95% CI) 1.32 (1.05–1.67), P=0.017], male sex [OR (95% CI) 1.47 (1.24–1.74), P<0.001] and year of implantation [OR (95% CI) 0.75 (0.71–0.79), P<0.001] as predictors of MV implantation.

Conclusions

Patients aged 60–70 years represent more than one-third of all AVR patients. Between 2006 and 2016, the proportion of implanted prostheses has changed dramatically. In 2016 BVs were implanted in nearly 75% of AVR cases, three times more often than in 2006.

Rehospitalization as a predictor of mortality in Polish population of heart failure patients-national registry

Background

High mortality risk in heart failure (HF) is related to repeat HF hospitalizations but also individual patient characteristics.

Purpose

To evaluate the impact of HF re-/hospitalizations and patient-related factors (sex, HF etiology, age, comorbidity) on all-cause mortality.

Methods

Our study represents one of the most extensive retrospective cohort analyses consisting of 1,686,861 adult Polish HF patients who presented into public health system in years 2013–2018. It is a part of a nationwide National Health Fund registry covering out- and in-patient data for the entire Polish population (38,495,659 in 2013) since 2009. HF hospitalizations were extracted using ICD-10 coding, whereas the comorbidity was evaluated by means of Charlson Comorbidity Index (CCI).

Results

In years 2013–2018 the absolute number of HF hospitalizations in Poland grew by 33% to 264,808 in 2018, whereas the number of rehospitalizations increased 1.5-fold to reach 137,708 in 2018.

In fact, nearly half of HF patients (n=817,432; 48.5%) experienced at least one hospitalization, while 15.4% (n=259,868) were rehospitalized during the study period. After initial hospitalization the readmission rate due to HF/all circulatory diseases at 30, 60, 180, 360, and 720 days was 10.4%/15.1%, 21.2%/28.3%, 43.9%/52.8%, 62%/70.4%, and 81%/87%, respectively.

As compared to patients who were hospitalized just once, those who underwent at least one rehospitalization were more often female (p&lt;0.001), slightly older (p&lt;0.001), and with higher burden of comorbidities based on CCI (p&lt;0.001).

Patient survival was highly dependent on hospitalization frequency (Fig. 1). Mean survival rate at day 720 was 66.4%, 59.8%, 54.9%, 51%, and 43.9% for 1st, 2nd, 3rd, 4th, and ≥5th hospitalization, respectively.

After adjusting for age, sex, etiology (ischemic/non-ischemic) and CCI using a multivariate stratified Cox regression model, the estimated hazard ratios (HR) for all-cause mortality amounted to 1.22 (95% CI: 1.21–1.23, p&lt;0.001) for 2nd, 1.4 (95% CI: 1.39–1.42, p&lt;0.001) for 3rd, 1.58 (95% CI: 1.56–1.6, p&lt;0.001) for 4th, and 1.97 (95% CI: 1.95–1.98 p&lt;0.001) for 5th and subsequent hospitalizations, as compared to the first hospitalization.

Conclusions

Hospitalization rate in Poland is alarmingly high. Repeat HF hospitalizations strongly predict mortality rate for HF patients even after adjustment for age, sex, etiology, and comorbidity burden.

Figure 1. Kaplan-Meier for survival post hosp.

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): The project is co-financed by the European Union from the European Social Fund under the Operational Programme Knowledge Education Development and it is being carried out by the Analyses and Strategies Department of the Polish Ministry of Health.

Cardiac rehabilitation effectively reduces the number of deaths in the heart failure population (propensity score matched analysis)

Background

Numerous cardiac rehabilitation (CR) studies have demonstrated functional benefits, improvement in quality of life and clinical outcomes from exercise training in patients with heart failure (HF), so CR is consistently recommend for HF patients. However its influence on survival in HF population is unknown.

Purpose

To assess the influence of CR on survival rate in HF patients.

Methods

It is a retrospective analysis of 1 620 686 HF patients in Poland in years 2013–2018, based on nationwide Polish Ministry of Health registry, that provides public universal healthcare coverage to all residents and collects detailed information for the entire Polish population (38,495,659 in 2013) since 2009. Within registry, we identified the experimental group of 11 512 HF patients ≥18 years old who underwent CR in 2013–2018.

From entire HF population we identified a 1:1 propensity score matched cohort of HF patients, who did not get CR.

Results

After propensity-score matching, we identified 11,512 patient pairs who underwent/not CR. Average age was approximately 66 years (18–39: 2.1 vs 2.0%; 40–49: 491 – 4.3 vs 4.2%; 50–59: 17.0 vs 17.1%; 60–69: 34.9 vs 35.2%; 70–79: 31.3 vs 31.4%; 80+: 10.4 vs 10.3% respectively), 61% of the participants were males, mainly urban residence nearly 70%, with HF diagnose put during hospitalization 74.5%. Both groups were similar also by comorbidities evaluated by Charlson Comorbidity Index.

Patients subjected to CR compared CR negative significantly increased survival risk at 1st, 2nd, 3rd, 4th and 5th year (CR vs CR negative 97.4% vs. 84.9%; 93.9% vs. 77.9%; 89.9% vs. 71.9%; 85.2% vs 66.0%; 81.8% vs 62.1% respectively) – Figure 1.

Conclusion

Our analysis showed that in heart failure patients, CR was associated with an increased survival rate among HF patients as treated in routine health care system.

Figure1

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): European Union from the European Social Fund

Real world heart failure epidemiology and outcome: a population-based analysis of 1,990,162 heart failure patients

Background

Heart failure (HF) is the leading cause of death and hospitalization in developed countries. Most of the information about HF is based on selected cohorts, the real epidemiology of HF is scarce.

Purpose

To assess trends in the real world incidence, prevalence and mortality of all in-and outpatients with HF who presented in public health system in 2009–2018 in Poland.

Methods

It is a retrospective analysis of 1,990,162 patients who presented with HF in Poland in years 2009–2018. It is a part of nationwide Polish Ministry of Health registry that collects detailed information for the entire Polish population (38,495,659 in 2013) since 2009. Detailed data within the registry were collected since 2013. HF was recorded if HF diagnosis was coded (ICD-10).

Results

The incidence of HF in Poland fell down from 2013 to reach 127,036 newly diagnosed cases (330 per 100,000 population) in 2018 that equals to 43.6% drop. This decrease was mainly driven by marked reduction in females (p&lt;0.001; Fig. 1A) and HF of ischaemic etiology (HF-IE vs HF-nonIE, Fig. 1B. p&lt;0.001). The HF incidence per 100,000 population decreased across all age groups with the greatest drop in the youngest (Table 1).

The prevalence rose by 11.6% to reach 1,242,129 (3233 per 100,000 population) in 2018 with significantly greater increase in females and HF-IE (both p&lt;0.0001, Fig. 1C and D, respectively). The HF prevalence per 100,000 population increased across all age groups except for the 70–79 years old. (Table 1).

Mortality increased by 28.5% to reach 142,379 cases (370 per 100,000 population) in 2018. The rise was more pronounced among females (p=0.015, Fig. 1E) and in HF-IE (p&lt;0.001, Fig. 1F). The HF mortality per 100 000 population increased across all age groups, except for the 50–59 subgroup (Table 1).

Conclusions

Heart failure incidence plummeted in years 2013–2018 in Poland due to drop in newly diagnosed HF-IE. Despite that fact, the prevalence and mortality increased with rising trends in HF-IE.

Figure 1. Incidence, prevalence, mortality trends

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): The project is co-financed by the European Union from the European Social Fund under the Operational Programme Knowledge Education Development and it is being carried out by the Analyses and Strategies Department of the Polish Ministry of Health

On-Pump vs Off-Pump coronary artery bypass surgery in atrial fibrillation. Analysis from the polish national registry of cardiac surgery procedures (KROK)

Background

No single randomized study has ever before addressed the safety of On-Pump coronary artery bypass grafting (CABG) vs Off-Pump CABG in the setting of atrial fibrillation (AF) and data from small observational samples remain inconclusive.

Methods and findings

Procedural data from KROK (Polish National Registry of Cardiac Surgery Procedures) were retrospectively collected. Of initial 188,972 patients undergoing CABG, 7,913 presented with baseline AF (76.0% men, mean age 69.1±8.2) and underwent CABG without concomitant valve surgery between 2006–2019 in 37 reference centers across Poland. Mean follow-up was 4.7±3.5 years (median 4.3 IQR 1.7–7.4). Cox proportional hazards models were used for computations. Of included patients, 3,681 underwent On-Pump- (46.52%) as compared to 4,232 (53.48%) who underwent Off-Pump CABG. Patients in the latter group less frequently were candidates for complete revascularization (P<0.001). In an unadjusted comparison, On-Pump surgery was associated with significantly worse survival at 30 days: HR: 1.28; 95%CIs: (1.07–1.53); P = 0.007. Along the 13-year study period, the trend shifted in favor of On-Pump CABG: HR: 0.92; 95%CIs: (0.83–0.99); P = 0.005. After rigorous propensity matching, 636 pairs were identified. The direction and magnitude of treatment effects was sustained with HRs of 3.58; (95%CIs: 1.34–9.61); p = 0.001 and 0.74; [95%CIs: 0.56–0.98]; p = 0.036) for 30-day and late mortality respectively.

Conclusions

Off-Pump CABG offered 30-day survival benefit to patients undergoing CABG surgery and presenting with underlying AF. On-Pump CABG was associated with significantly improved survival at long term.

Air embolization of a left ventricular assist device in a child: an unusual case of a tension pneumothorax resulting in a fatal complication

Our goal was to describe a fatal air embolization that probably occurred through an inflow cannula implantation site as a result of a tension pneumothorax in a child with a left ventricular assist device. This is the first case that highlights the possibility of a left ventricular assist device air embolism in a child with a pneumothorax, especially a tension pneumothorax. The risk of air embolism increases with positive pressure in the pleural and pericardial cavities.

Trends in isolated aortic valve replacement in middle‑aged patients over the last 10 years: epidemiology, risk factors, valve pathology, valve types, and outcomes

BACKGROUND

Valve prosthesis selection in aortic valve replacement (AVR) is particularly difficult in middle‑aged patients (60-70 years old).

AIMS

We described changes in trends and outcomes of AVR in middle‑aged patients over the last 10 years, based on the real‑life single‑center data from the Polish National Registry.

METHODS

A total of 4912 consecutive adult patients who underwent any type of isolated aortic valve surgery between 2006 to 2016 were included. The main outcome measures were changes in the number of procedures, characteristics, surgical details, and in‑hospital mortality.

RESULTS

Out of all 4912 AVR procedures performed, 1531 patients (31.2%) were between 60 and 70 years of age. The share of aortic valve prosthesis in the overall number of replacements changed between 2006 and 2016 for mechanical valves (MV) from 98.3% to 15.2% and for biological valves (BV) from 0% to 81.8% (P <0.001 for both comparisons). In the BV group, stented valves were implanted in 92.6%. The most common MV was the St. Jude Medical Mechanical Heart Valve (St. Jude Medical, Saint Paul, Minnesota, United States) and most common BV was the Carpentier‑Edwards Perimount Magna (Edwards Lifesciences, Irvine, California, United States). The most common prosthesis size was 23 mm. There were no significant differences in body mass index and comorbidities between the patients with MV and BV. The overall in‑hospital mortality was 3.46% (3.33% in the MV group and 3.69% in the BV group; P = 0.85).

CONCLUSIONS

In the last 10 years, one‑third of aortic valve replacements were performed in patients between 60 and 70 years of age. We observed rapidly changing trends in the type of implanted valve prostheses.

In-hospital and mid-term outcomes in patients reoperated on due to bleeding following coronary artery surgery (from the KROK Registry)

OBJECTIVES

Surgical re-exploration due to postoperative bleeding that follows coronary artery surgery is associated with significant morbidity and mortality. The aim of this study was to assess a relationship between re-exploration, major postoperative complications, in-hospital mortality and mid-term outcomes in patients following coronary surgery, on the basis of nationwide registry data.

METHODS

We identified all consecutive patients enrolled in Polish National Registry of Cardiac Surgical Procedures (KROK Registry) who underwent isolated coronary surgery between January 2012 and December 2014. Preoperative data, major postoperative complications, hospital mortality and mid-term all-cause mortality were, respectively, analysed. Comparisons were performed in all patients, low-risk patients (EuroSCORE II < 2%, males, aged 60-70 years) and propensity-matched patients. The starting point for follow-up was the date of hospital discharge.

RESULTS

Among 41 353 analysed patients, 1406 (3.4%) underwent re-exploration. Reoperated patients had more comorbidities, more frequent major postoperative complications, higher in-hospital mortality (13.2% vs 1.8%, P < 0.001) and higher mid-term mortality in survivors (P < 0.001). In the low-risk population, 3.0% of patients underwent re-exploration. Reoperated low-risk patients and propensity-matched patients also had more frequent major postoperative complications and higher in-hospital mortality, but mid-term mortality in survivors was similar. In a multivariable analysis, re-exploration was an independent predictor of death and all major postoperative complications.

CONCLUSIONS

Surgical re-exploration due to postoperative bleeding following coronary artery surgery carries a high risk of perioperative mortality and is linked to major postoperative complications. Among patients who survive to hospital discharge, mid-term mortality is associated primarily with preoperative comorbidities.

Changing trends in aortic valve procedures over the past ten years-from mechanical prosthesis via stented bioprosthesis to TAVI procedures-analysis of 50,846 aortic valve cases based on a Polish National Cardiac Surgery Database

Background

Aortic valve replacement (AVR) is one of the most common surgeries performed in cardiac surgery operating rooms. We present actual, real life trends from the last 10 years for AVR interventions based on a multicentre National Registry of Cardiac Surgery Database.

Methods

The study population consisted of all 50,846 consecutive adult patients who underwent AVR between January 2006 and August 2016 in all cardiac surgery units in Poland. The main outcome measures were changes in the number of valves, characteristics of valves, operative details, and in-hospital mortality. Analysis consisted of all aortic valve (AV) procedures, including isolated AV surgery, combination procedures and patients who had a prior valve operation.

Results

In last 10 years, the number of procedures increased by 46%. Isolated surgical AVR was performed in 61.2%, AVR + coronary artery bypass grafting (CABG) in 23.9%, AVR + mitral valve replacement (MVR) in 7%, and transcatheter aortic valve implantation (TAVI) in 2.3% of patients. The mean patient age increased significantly from 61.4 years in 2006 to 66.1 years in 2016. Aortic stenosis was diagnosed in 73.4%, severe aortic insufficiency in 15.8% of cases. The most common valve pathology was calcification. Congenital valve dysfunction was diagnosed in 3.7% of cases. There was a 33.7% increase of bioprosthesis, and the most common implanted bioprosthesis was the Hancock II. The most common implanted mechanical prosthesis was the St. Jude Medical Mechanical Valve. In-hospital mortality decreased significantly over the 10-year period in all AV procedures from 10.9% in 2006 to 8.3% in 2016. Mean in-hospital mortality was: 4.0% in isolated surgical AVR, 5.4% in TAVI, 6.8% in AVR + CABG, 9.8% in AVR + MVR, 17.2% in AVR + MVR + CABG.

Conclusions

In the last ten years, the number of AV procedure has doubled. Mortality was significantly lower with all types of AV procedure despite very rapid aging of AVR patients. TAVI procedure rapidly grew in popularity. There is significant increase in the use of bioprosthesis.

History of the World Society for Pediatric and Congenital Heart Surgery: The First Decade

The World Society for Pediatric and Congenital Heart Surgery (WSPCHS) is the largest professional organization in the world dedicated to pediatric and congenital heart surgery. The purpose of this article is to document the first decade of the history of WSPCHS from its formation in 2006, to summarize the current status of WSPCHS, and to consider the future of WSPCHS. The WSPCHS was incorporated in Canada on April 7, 2011, with a head office in Montreal, Canada. The vision of the WSPCHS is that every child born anywhere in the world with a congenital heart defect should have access to appropriate medical and surgical care. The mission of the WSPCHS is to promote the highest quality comprehensive cardiac care to all patients with congenital heart disease, from the fetus to the adult, regardless of the patient's economic means, with an emphasis on excellence in teaching, research, and community service.

The European Registry for Patients with Mechanical Circulatory Support (EUROMACS): first EUROMACS Paediatric (Paedi-EUROMACS) report

OBJECTIVES:

EUROMACS is a registry of the European Association for Cardio-Thoracic Surgery (EACTS) whose purpose is to gather clinical data related to durable mechanical circulatory support for scientific purposes and to publish annual reports. Because the treatment of children with end-stage heart failure has several significantly different characteristics than the treatment of adults, data and outcomes of interventions are analysed in this dedicated paediatric report.

METHODS:

Participating hospitals contributed pre-, peri- and long-term postoperative data on mechanical circulatory support implants to the registry. Data for all implants in paediatric patients (≤19 years of age) performed from 1 January 2000 to 31 December 2017 were analysed. This report includes updates of patient characteristics, implant frequency, outcome (including mortality rates, transplants and recovery rates) as well as adverse events.

RESULTS:

Twenty-five hospitals contributed 237 registered implants in 210 patients (81 ♀, 129 ♂) to the registry. The most frequent diagnosis was any form of cardiomyopathy (71.4%) followed by congenital heart disease (18.6%). Overall mean support time on a device was 11.6 months (±16.5 standard deviation). A total of 173 children (82.4%) survived to transplant, recovery or are ongoing; 37 patients (17.6%) died while on support within the observed follow-up time. At 12 months 38% of patients received transplants, 7% were weaned from their device and 15% died. At 24 months, 51% of patients received transplants, 17% died while on support, 22% were on a device and 9% were explanted due to myocardial recovery. The adverse events rate per 100 patient-months was 11.97 for device malfunction, 2.83 for major bleeding, 2.83 for major infection and 1.52 for neurological events within the first 3 months after implantation.

CONCLUSIONS:

The first paediatric EUROMACS report reveals a low transplant rate in European countries within the first 2 years of implantation compared to US data. The 1-year survival rate seems to be satisfactory. Device malfunction including pump chamber changes due to thrombosis was the most frequent adverse event.

Antithrombotic therapy in pediatric ventricular assist devices: Multicenter survey of the European EXCOR Pediatric Investigator Group

Objectives:

Mechanical circulatory support for pediatric heart failure patients with the Berlin Heart EXCOR ventricular assist system is the only approved and established bridging strategy for recovery or heart transplantation. In recent years, the burden of thromboembolic events has led to modifications of the recommended antithrombotic therapy. Therefore, we aimed to assess modifications of antithrombotic practice among the European EXCOR Pediatric Investigator Group members.

Methods:

We sent a questionnaire assessing seven aspects of antithrombotic therapy to 18 European hospitals using the EXCOR device for children. Returned questionnaires were analyzed and identified antithrombotic strategies were descriptively compared to “Edmonton protocol” recommendations developed for the US EXCOR pediatric approval study.

Results:

Analysis of 18 received surveys revealed substantial deviations from the Edmonton protocol, including earlier start of heparin therapy at 6–12 h postoperatively and in 50% of surveyed centers, monitoring of heparin effectiveness with aPTT assay, administering vitamin K antagonists before 12 months of age. About 39% of centers use higher international normalized ratio targets, and platelet inhibition is changed in 56% including the use of clopidogrel instead of dipyridamole. Significant inter-center variability with multiple deviations from the Edmonton protocol was discovered with only one center following the Edmonton protocol completely.

Conclusion:

Current antithrombotic practice among European EXCOR users representing the treatment of more than 600 pediatric patients has changed over time with a trend toward a more aggressive therapy. There is a need for systematic evidence-based evaluation and harmonization of developmentally adjusted antithrombotic management practices in prospective studies toward revised recommendations.

Left-Sided Reoperations After Arterial Switch Operation: A European Multicenter Study

BACKGROUND

We sought to report the frequency, types, and outcomes of left-sided reoperations (LSRs) after an arterial switch operation (ASO) for patients with D-transposition of the great arteries (D-TGA) and double-outlet right ventricle (DORV) TGA-type.

METHODS

Seventeen centers belonging to the European Congenital Heart Surgeons Association (ECHSA) contributed to data collection. We included 111 patients who underwent LSRs after 7,951 ASOs (1.4%) between January 1975 and December 2010. Original diagnoses included D-TGA (n = 99) and DORV TGA-type (n = 12). Main indications for LSR were neoaortic valve insufficiency (n = 52 [47%]) and coronary artery problems (CAPs) (n = 21 [19%]).

RESULTS

Median age at reoperation was 8.2 years (interquartile range [IQR], 2.9-14 years). Seven patients died early after LSRs (6.3%); 4 patients with D-TGA (5.9%) and 3 patients with DORV TGA-type (25%) (p = 0.02). Median age at last follow-up was 16.1 years (IQR, 9.9-21.8 years). Seventeen patients (16%) required another reoperation, which was more frequent in patients with DORV- TGA type (4 of 9 [45%]) than in patients with D-TGA (13 of 95 [14%]). Late death occurred in 4 patients (4 of 104 [3.8%]). The majority of survivors were asymptomatic at last clinical examination (84 of 100 [84%]).

CONCLUSIONS

Reoperations for residual LSRs are infrequent but may become necessary late after an ASO, predominantly for neoaortic valve insufficiency and CAPs. Risk at reoperation is not negligible, and DORV TGA-type anatomy, as well as procedures on the coronary arteries, were significantly associated with a higher morbidity and a lower overall survival. Recurrent reoperations after LSRs may be required.