Objectives To assess variation in outcome measures and their associations with shunt thrombosis prophylaxis regimens after systemic-to-pulmonary artery shunt surgery across centers in the United ...States participating in the Pediatric Health Information System database. Methods We reviewed data on neonates who underwent an off-pump shunt procedure at 39 centers between 2000 and 2011. The overall variation in rates of discharge mortality and shunt-related complications were assessed by funnel plots. Complications were defined as revision/repeat of the shunt procedure during the same admission, institution of extracorporeal membrane oxygenation after surgery, and catheter interventions after shunt surgery. Bayesian hierarchical modeling was used to identify outliers. Shunt thrombosis prophylaxis regimens including the time of initiation of aspirin were compared between high and low outliers. Results A total of 2058 index operations were identified. Funnel plots highlighting the outcomes from various centers allowed discrimination of discharge mortality and complication rates around an aggregate of 6.7% and 12.3%, respectively. Bayesian modeling showed the presence of substantial variation in complication rates between centers; 20% of them were identified as outliers. Aspirin was initiated significantly earlier during the hospital course in centers with a lower composite rate of complications than those with higher rates (median initiation day of 2 interquartile range (IQR), 1-3 in low outliers vs 4 IQR, 3-6 in high outliers; P < .001). Conclusions A substantial variation was found between hospitals in the rate of shunt-related complications. Centers with best outcomes implement aspirin earlier in their postoperative shunt thrombosis prophylaxis regimen.
Myocardial function after fetal cardiac bypass in an ovine model Duffy, Jodie Y., PhD; Petrucci, Orlando, MD, PhD; Baker, R. Scott, BS ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
04/2011, Letnik:
141, Številka:
4
Journal Article
Recenzirano
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Objective Fetal cardiac surgery might improve the prognosis of certain complex congenital heart defects that have significant associated mortality and morbidity in utero or after birth. An important ...step in translating fetal cardiac surgery is identifying potential mechanisms leading to myocardial dysfunction after bypass. The hypothesis was that fetal cardiac bypass results in myocardial dysfunction, possibly because of perturbation of calcium cycling and contractile proteins. Methods Midterm sheep fetuses (n = 6) underwent 30 minutes of cardiac bypass and 120 minutes of monitoring after bypass. Sonomicrometric and pressure catheters inserted in the left and right ventricles measured myocardial function. Cardiac contractile and calcium cycling proteins, along with calpain, were analyzed by means of immunoblotting. Results Preload recruitable stroke work (slope of the regression line) was reduced at 120 minutes after bypass (right ventricle: baseline vs 120 minutes after bypass, 38.6 ± 6.8 vs 20.4 ± 4.8 P = .01; left ventricle: 37 ± 7.3 vs 20.6 ± 3.9, respectively P = .01). Tau (in milliseconds), a measure of diastolic relaxation, was increased in both ventricles (right ventricle: baseline vs 120 minutes after bypass, 32.7 ± 4.5 vs 67.8 ± 9.4 P < .01); left ventricle: 26.1 ± 3.2 vs 63.2 ± 11.2, respectively P = .01). Cardiac output was lower and end-diastolic pressures were higher in the right ventricle, but not in the left ventricle, after bypass compared with baseline values. Right ventricular troponin I was degraded by increased calpain activity, and protein levels of sarco(endo)plasmic reticulum calcium ATPase were reduced in both ventricles. Conclusions Fetal cardiac bypass was associated with myocardial dysfunction and disruption of calcium cycling and contractile proteins. Minimizing myocardial dysfunction after cardiac bypass is important for successful fetal surgery to repair complex congenital heart defects.
Prioritizing quality improvement in pediatric cardiac surgery Eghtesady, Pirooz, MD, PhD; Brar, Anoop K., PhD; Hall, Matthew, PhD
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
03/2013, Letnik:
145, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Background Several efforts are under way to conduct quality-improvement initiatives in pediatric cardiology and cardiac surgery. Our goal was to develop an objective prioritization scheme for such ...initiatives based on encounter frequency and relative contribution of quality measures of morbidity (and associated variances), particularly in the setting of low mortality. Methods We identified patients in the Pediatric Health Information System in Risk Adjustment for Congenital Heart Surgery 1 category 1 to 6 for 32 pediatric cardiac surgical procedures conducted between 2003 and 2011 (n = 67,550). These were examined for their overall contribution to mortality, intensive care unit and hospital lengths of stay (coefficient of variation and excess days), adverse events, and readmission rates. A ranking scheme was created on the basis of the outcome measures. Then we ordered the procedures across metrics to develop a prioritization scheme. Results Observed mortality rates were consistent with published rates. A few procedures accounted for significant variation in hospital and intensive care length of stay across the hospitals. Likewise, a few procedures accounted for most excess days of stay and readmission rates. Up to 60% of the hospital stay was accounted for by intensive care unit stay. Although there was a linear relationship between adverse event rates and Risk Adjustment for Congenital Heart Surgery 1 categories, a few procedures once again accounted for disproportionate event rates within and across their respective Risk Adjustment for Congenital Heart Surgery 1 categories. Conclusions A small number of procedures account for a substantial burden of morbidity, even among low mortality risk groups. Consideration should be given to using such objective prioritization schemes to develop targeted quality-improvement measures.
Background Protection and preservation of fetal myocardial function are important for successful fetal intracardiac repair. Our objective was to determine fetal biventricular cardiac performance ...after two cardiac-arrest techniques. Methods Three groups of midterm ovine fetuses underwent 90-minute bypass. A control group (no arrest shams, n = 3), and two groups that included 20 minutes of arrest, using fibrillatory (n = 3) or blood cardioplegia (n = 3), were compared. Blood cardioplegia consisted of 4:1 cold blood to crystalloid solution induction every 10 minutes, followed by a warm shot terminal dose before clamp removal. Myocardial function variables from biventricular intracardiac pressure catheters, and 3-axes cardiac sonomicrometry, fetal hemodynamics, and arterial blood gases were continuously recorded. Fetal myocardium was collected for troponin-I analysis at 90 minutes. Statistical analysis was by two-way analysis of variance for repeated measures. Results Compared with sham, right ventricular myocardial contractility was reduced with plegia but not fibrillation at 90 minutes after arrest: dP/dt max (511 ± 347 vs 1208 ± 239, p < 0.01) and preload-recruitable stroke work (7.2 ± 8.5 vs 32.3 ± 14.6, p < 0.01). Right ventricular end diastolic pressure-volume relationship (ventricular stiffness) worsened by 90 minutes for plegia vs fibrillation (0.84 ± 0.18 vs 0.25 ± 0.16, p < 0.05). There were no differences in left ventricle performance between groups. Fetal heart rate increased in shams by 30 minutes after arrest compared with both arrest groups ( p < 0.05). Right ventricular troponin-I degradation increased with plegia, but not fibrillation, compared with sham ( p < 0.05). Conclusions In vivo, fetal right ventricular contractile function deteriorates with a common blood-plegia regimen. Fibrillatory arrest better preserves right ventricular function, the dominant ventricle in fetal life, for short arrest periods.
Objective To assess growth from the time of neonatal discharge to the time of performance of the bidirectional Glenn (BDG) procedure in infants with a single ventricle and determine predictors of ...poor growth. Study design We performed a retrospective case series of infants who underwent the BDG procedure at our institution between January 2001 and December 2007 (n = 102). Anthropometric and clinical data were recorded during neonatal hospitalization and before BDG. Outcome variables included weight-for-age z -score (WAZ) at the time of BDG and average daily weight gain between neonatal discharge and BDG. Results Median age at the time of BDG was 5.1 months (range, 2.4-10 months), and median WAZ was -0.4 (range, -2.6 to 3.2) at neonatal admission and -1.3 (range, -3.9 to 0.6) at the time of BDG. Non-Caucasian infants ( P = .03) and those with lower WAZ at neonatal discharge ( P <.0001) had a lower WAZ at BDG. Being formula-fed at neonatal discharge ( P = .04), and having higher mean pulmonary arterial pressure ( P = .04) and systemic oxygen saturation ( P = .006) were associated with lower average daily weight gain between neonatal discharge and BDG. Conclusions Infants with a single ventricle have poor weight gain between neonatal discharge and BDG. Non-Caucasian infants and those with evidence of increased pulmonary blood flow are at particular risk for growth failure.
Objective Hypoplastic left heart syndrome is a major congenital heart defect and is associated with significant morbidity and mortality. Its etiology remains unknown although genetic studies imply ...complex inheritance. Anecdotal reports of cluster presentations suggest the possible involvement of an environmental component, although previous epidemiologic studies have been of limited scope. The objective of this study was to examine seasonal and temporal patterns of hypoplastic left heart syndrome births compared with other left-sided heart defects in the United States. Methods We conducted a retrospective analysis of the Pediatric Health Information System inpatient database from pediatric hospitals across the country from 1996 to 2006. Population and index case patterns were analyzed for each diagnostic category. An epidemiologic survey was performed through time–series analyses using Fisher's Kappa test and the Bartlett Kolmogorov–Smirnov test. The existence and strength of seasonality for the left-sided heart defects was quantified by the autoregression R2. Results A seasonal occurrence was found in hypoplastic left heart syndrome but not other left-sided heart diseases. Significant seasonal differences occurred each year, with peaks in summer months and troughs in winter months. The seasonality inversely correlated with the incidence of chromosomal and extracardiac anomalies; such anomalies were highest in interrupted aortic arch, which had a random pattern of presentation. Conclusions There is a significant seasonal pattern in the presentation of hypoplastic left heart syndrome, with preponderance in summer months, in contrast to the random pattern in other left-sided heart diseases. Further studies are warranted to identify the influence of potential environmental factor(s) in hypoplastic left heart syndrome, as seen in diseases with seasonal patterns.
Background Cardiac surgical procedures are complex and require the coordinated action of many. This creates the potential for small failures that could be the substrate for subsequent morbidity or ...mortality. High-reliability science suggests that preoccupation with small failures can lead to improved outcomes. Study Design Failures of all magnitudes (ie, events) were captured within the pediatric cardiac operating room starting with a single surgeon in April 2008. As the surgical team became more familiar with the process, failure recording was extended to all surgeons and all surgical procedures performed until the conclusion of the study in December 2010. New recording processes were developed and used on a rolling basis during this study. Results With systematic capture, event rates increased (from occurring within 20% to 50% of operative procedures). Although we identified 9 recurrent patterns, 2 categories (ie, Equipment and Patient Instability) accounted for almost half of the events (45%). The greatest number of events occurred during the prebypass period (40.2%), compared with bypass (20.1%) and postbypass (32.3%) periods. These events were mainly difficulties in access (31.8%), equipment (42.4%), and patient instability (33.3%) in each of the epochs, respectively. Of all events, 7.3% occurred during nonbypass cases, 30.6% of these were communication events. Implementation of this initiative led to recognition of major system-wide issues (eg, need for change in the blood-product acquisition process). Conclusions Preoccupation with all failures in the operating room can reveal important information about the operating room and perioperative microenvironment that can prompt substantive process changes both locally and within the larger health system.
Abstract Children with severe pulmonary hypertension have limited therapeutic options. To avert the consequences of right heart failure, the Potts shunt has been proposed as a means to off load the ...right ventricle, improving overall cardiac output at the expense of lower saturation and oxygen delivery to lower extremities. In the following, the details of the procedure are described along with a modification (with interposition graft) that could perhaps facilitate the performance of the procedure for patients as an alternative palliative intervention to lung transplantation.
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