Objectives Analyses of mechanical circulatory support (MCS) in pediatric heart surgery have primarily focused on single-center outcomes or narrow applications. We describe the patterns of use, ...patient characteristics, and MCS-associated outcomes across a large multicenter cohort. Methods Patients (aged <18 years) in the Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database (2000-2010) were included. The characteristics and outcomes of those receiving postoperative MCS were described, and bayesian hierarchical models were used to examine variations in the adjusted MCS rates across institutions. Results Of 96,596 operations (80 centers), MCS was used in 2.4%. The MCS patients were younger (13 vs 195 days, P < .0001) and more often had STS-defined preoperative risk factors (57.2% vs 32.7%, P < .0001). The operations with the greatest MCS rates included the Norwood procedure (17%) and complex biventricular repairs (arterial switch, ventricular septal defect, and arch repair 14%). More than one half of the MCS patients did not survive to hospital discharge (53.2% vs 2.9% of non-MCS patients; P < .0001). MCS-associated mortality was greatest for truncus arteriosus and Ross-Konno operations (both 71%). The hospital-level MCS rates adjusted for patient characteristics and case mix varied by 15-fold across institutions, with both high- and low-volume hospitals having substantial variation in MCS rates. Conclusions Perioperative MCS use varied widely across centers. The MCS rates were greatest overall for the Norwood procedure and complex biventricular repairs. Although MCS can be a life-saving therapy, more than one half of MCS patients will not survive to hospital discharge, with mortality >70% for some operations. Future studies aimed at better understanding the appropriate indications, optimal timing, and management of MCS could help to reduce the variation in MCS use across hospitals and improve outcomes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Post-traumatic stress disorder (PTSD) is associated with adverse outcomes and increased mortality in cardiac patients. No studies have examined PTSD in the adult congenital heart disease (ACHD) ...population. The objectives of this study were to assess the prevalence of self-reported symptoms of PTSD in patients with ACHD and explore potential associated factors. Patients were enrolled from an outpatient ACHD clinic and completed several validated measures including the Impact of Event Scale-Revised, PTSD Checklist-Civilian Version, and the Hospital Anxiety and Depression Scale. Clinical data were abstracted through medical data review. A total of 134 participants (mean age 34.6 ± 10.6; 46% men) were enrolled. Of the 127 participants who completed the Impact of Event Scale-Revised, 14 (11%) met criteria for elevated PTSD symptoms specifically related to their congenital heart disease or treatment. Of the 134 patients who completed PTSD Checklist-Civilian Version, 27 (21%) met criteria for global PTSD symptoms. In univariate analyses, patients with congenital heart disease–specific PTSD had their most recent cardiac surgery at an earlier year (p = 0.008), were less likely to have attended college (p = 0.04), had higher rates of stroke or transient ischemic attack (p = 0.03), and reported greater depressive symptoms on the Hospital Anxiety and Depression Scale (7 vs 2, p <0.001). In multivariable analysis, the 2 factors most strongly associated with PTSD were depressive symptoms (p <0.001) and year of most recent cardiac surgery (p <0.03). In conclusion, PTSD is present in 11% to 21% of subjects seen at a tertiary referral center for ACHD. The high prevalence of PTSD in this complex group of patients has important implications for the medical and psychosocial management of this growing population.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Background Adjustment for case mix is critical to accurate outcomes analysis in congenital heart surgery. Established tools encompass all age groups and are not specific to the growing population of ...adults undergoing congenital heart operations. We derived an empirically based adult congenital heart surgery (ACHS) mortality score. Methods In-hospital mortality was analyzed for the 152 most common procedures/procedural groups in adults 18 years of age and older in The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) (2000–2013). Procedure-specific adult mortality rate estimates were calculated using Bayesian methods adjusting for small denominators for procedures with 30 cases or more (N = 52). Each procedural group was assigned an ACHS mortality score ranging from 0.1 to 3.0 based on the estimated mortality rate. Discrimination was assessed using the c-index in a separate validation sample. Results A total of 12,513 procedures (116 centers) were analyzed. Overall unadjusted mortality was 1.8%. Significant differences in mortality rates in adults compared with all ages were seen for several procedures, including Ebstein’s repair (0.7% versus 4.9%; p = 0.003) and Fontan operations (6.8% versus 1.4%; p < 0.01). The procedure with the lowest model-based estimate of mortality and accompanying ACHS mortality score was atrial septal defect repair (0.2%, 0.1), and the highest was Fontan revision (9.7%, 3.0). The c-index for the ACHS mortality score was 0.809 versus 0.777 for the “non–age-specific” Society of Thoracic Surgeons–European Association for Cardio-thoracic Surgery (STAT) mortality score applied to adults. Conclusions Risk estimation based on the aggregate of all age groups is suboptimal when analyzing outcomes specifically among adults. An empirically based ACHS mortality score can facilitate case-mix adjustment by providing accurate estimation of mortality risk for adults.
Objective Outcomes data for adults undergoing congenital heart surgery are limited. Previous analyses used administrative data or focused on single-center outcomes. We describe the most common ...operations, patient characteristics, and postoperative outcomes using a multicenter clinical database. Methods The study included adults (aged ≥ 18 years) listed in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2000–2009). We describe patient characteristics and morbidity and mortality, and examine congenital procedures in the Society of Thoracic Surgeons Adult Cardiac Surgery Database to permit consideration of the primary dataset within a broader context. Results A total of 5265 patients (68 centers) from the Society of Thoracic Surgeons Congenital Heart Surgery Database were included. Patients’ median age was 25 years (interquartile range, 20–35). Common preoperative risk factors included noncardiac abnormalities (17%) and arrhythmia (14%). Overall, in-hospital mortality was 2.1%, 27% had 1 or more complication, and median length of stay was 5 days. Common operations included right ventricular outflow tract procedures (21%) and pacemaker/arrhythmia procedures (20%). We further evaluated cardiopulmonary bypass procedures in more than 100 patients. Mortality ranged from 0% (atrial septal defect repair) to 11% (Fontan revision/conversion). Separate evaluation of the Society of Thoracic Surgeons Adult Cardiac Surgery Database revealed 39,872 adults undergoing congenital heart operations. Conclusions Most adult congenital heart operations listed in the Society of Thoracic Surgeons Congenital Heart Surgery Database are performed in the third to fourth decades of life; approximately half are for right heart pathology or arrhythmia. Many patients have complications, but mortality is low with the exception of those undergoing Fontan revision/conversion. Many more adults undergoing congenital heart surgery are entered into the Society of Thoracic Surgeons Adult Cardiac Surgery Database.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background Understanding the seminal complications leading to death after pediatric cardiac surgical procedures may provide opportunities to reduce mortality. This study analyzed all deaths at two ...pediatric cardiac surgical programs and developed a method to identify the seminal complications and modes of death. Methods Trained nurses abstracted all cases of in-hospital mortality meeting inclusion criteria from each site over 5 years (2008 to 2012). Complication definitions were consistent with those of a multicenter clinical registry. An adjudication committee assigned a seminal complication in each case (the complication initiating the cascade of events leading to death). Seminal complications were grouped into categories to designate “mode of death.” The epidemiology of seminal complications and of mode of death was described. Results In 191 subjects, low cardiac output syndrome (71% of all subjects), cardiac arrest (52%), and arrhythmia (48%) were the most common complications. The committee assigned low cardiac output syndrome (30%), failure to separate from bypass (16%), and cardiac arrest (12%) most frequently as seminal complications. Seminal complications occurred a median 2 hours (interquartile range IQR, 0 to 35 hours) postoperatively. Patients experienced a median of seven (IQR, 3 to 12) additional complications before death at a median of 15 days (IQR, 4 to 46). Systemic circulatory failure was the most common mode of death (51%), followed by inadequate pulmonary blood flow (13%) and cardiac arrest (12%). Conclusions Seminal complications occurred early postoperatively, and systemic circulatory failure was the most common mode of death. Our classification system is likely scalable for subsequent multicenter analysis to understand cause-specific mortality variation across hospitals and to drive quality improvement.
The use of a right ventricle–to–pulmonary artery (RV-PA) conduit for stage 1 palliation of hypoplastic left heart syndrome is common. A prospective randomized multiinstitutional study revealed that ...approximately 40% of those receiving this shunt required intervention on the shunt or pulmonary arteries, or both. A technique has been developed to help ameliorate proximal conduit stenosis. We present a new technique to improve distal conduit stenosis and decrease anastomotic bleeding from this site. The technique involves dunking a segment of the shunt into the pulmonary arteries and suture placement in the shunt rings and not in the polytetrafluoroethylene (PTFE).
Aneurysm formation after the Norwood procedure: Case report and review of the literature Herrmann, Jeremy L., MD; Lewis, Michael J., MD; Fuller, Stephanie, MD ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
04/2014, Volume:
147, Issue:
4
Journal Article
Peer reviewed
Open access
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Surgery for congenital heart disease at The Children’s Hospital of Philadelphia began in the earliest days of cardiac surgery. In a rapidly advancing field, surgeons at Children’s Hospital of ...Philadelphia are recognized as innovators in the field. The Division of Cardiac Surgery is dedicated to providing outstanding clinical care, educating the next generation of congenital cardiac surgeons, and advancing the specialty through clinical and translational research.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Background Porcine bioprosthesis (bioroots) are an attractive surgical strategy for ascending aorta and arch replacement. This study evaluated the perioperative and late outcomes using this strategy ...for proximal aortic aneurysmal disease. Methods Between March 1998 and November 2009, 170 patients (40% women; median age, 70 years) underwent proximal thoracic aortic replacement using the Freestyle (Medtronics Inc, Minneapolis, MN) bioroot, with graft extension in 149 (87.6%). Aneurysmal etiology included degenerative-atherosclerotic (91.2%), acute dissection (5.3%), and chronic dissection (3.5%); 78% had greater than moderate aortic insufficiency. Surgical procedures were bioroot alone or with aortoplasty (12.3%), bioroot with ascending aortic graft (38.2%), bioroot with hemiarch graft (44.1%), and bioroot with total arch (5.3%). Hypothermic circulatory arrest was required in 49%. Results The 30-day mortality was 4.7% (n = 8). The overall complication rate was 58% (n = 100), including stroke (6.5%), renal failure (9.2%), respiratory failure (25.9%), and postoperative bleeding (7.6%). Mean hospitalization was 10.5 ± 7.3 days; 38 were discharged to a rehabilitation facility (23.5%). Predictors of 30-day/hospital death were coronary artery disease ( p = 0.0003), renal insufficiency ( p < 0.0001), emergent/urgent procedure ( p = 0.02), and hypothermic circulatory arrest ( p = 0.002). The 1-year, 5-year, and 10-year survivals were 90%, 80%, and 35% respectively. Freedom from endocarditis and reoperation was 96% at 1 year and 94% and 95% at 5 years, respectively. Conclusions Proximal thoracic aortic replacement using a porcine bioroot as part of the repair can be achieved with low perioperative mortality and acceptable late survival in a predominantly elderly population.
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