Abstract
Introduction: Tetralogy of Fallot (TOF) repair is associated with excellent operative survival. However, a subset of patients experiences post-operative complications, which can significantly alter the early and late post-operative course. We utilized a machine learning approach to identify risk factors for post-operative complications after TOF repair.Methods: We conducted a single-center prospective cohort study of children <2 years of age with TOF undergoing surgical repair. The outcome was occurrence of post-operative cardiac complications, measured between TOF repair and hospital discharge or death. Predictors included patient, operative, and echocardiographic variables, including pre-operative right ventricular strain and fractional area change as measures of right ventricular function. Gradient-boosted quantile regression models (GBM) determined predictors of post-operative complications. Cross-validated GBMs were implemented with and without a filtering stage non-parametric regression model to select a subset of clinically meaningful predictors. Sensitivity analysis with gradient-boosted Poisson regression models was used to examine if the same predictors were identified in the subset of patients with at least one complication.Results: Of the 162 subjects enrolled between March 2012 and May 2018, 43 (26.5%) had at least one post-operative cardiac complication. The most frequent complications were arrhythmia requiring treatment (N = 22, 13.6%), cardiac catheterization (N = 17, 10.5%), and extracorporeal membrane oxygenation (ECMO) (N = 11, 6.8%). Fifty-six variables were used in the machine learning analysis, of which there were 21 predictors that were already identified from the first-stage regression. Duration of cardiopulmonary bypass (CPB) was the highest ranked predictor in all models. Other predictors included gestational age, pre-operative right ventricular (RV) global longitudinal strain, pulmonary valve Z-score, and immediate post-operative arterial oxygen level. Sensitivity analysis identified similar predictors, confirming the robustness of these findings across models.Conclusions: Cardiac complications after TOF repair are prevalent in a quarter of patients. A prolonged surgery remains an important predictor of post-operative complications; however, other perioperative factors are likewise important, including pre-operative right ventricular remodeling. This study identifies potential opportunities to optimize the surgical repair for TOF to diminish post-operative complications and secure improved clinical outcomes. Efforts toward optimizing pre-operative ventricular remodeling might mitigate post-operative complications and help reduce future morbidity.
Highlights
Tetralogy of Fallot (TOF) repair is associated with excellent operative survival
Inclusion criteria included TOF repair performed in a single stage or preceded by a palliative procedure
We identified the number of postoperative cardiac complications that occurred between TOF repair and hospital discharge or death, including the following: mediastinal exploration, delayed sternal closure, pleural effusion requiring chest tube, pericardial effusion requiring drainage, arrhythmia requiring treatment, cardiac catheterization, cardiac reoperation, cardiac arrest, and cardiopulmonary resuscitation, need for ECMO, unanticipated cardiac procedures, and pacemaker placement
Summary
Tetralogy of Fallot (TOF) repair is associated with excellent operative survival. We utilized a machine learning approach to identify risk factors for post-operative complications after TOF repair. Surgical reconstruction for Tetralogy of Fallot (TOF) is associated with low mortality but with significant long-term morbidity resulting from residual lesions and need for reinterventions [1,2,3,4,5,6,7,8,9,10,11,12,13,14]. Studying risk factors for post-operative complications using a machine learning approach might unveil risk factors not previously considered, or combinations of factors without the limitation of collinearity in classic multivariable regression models. Identifying patients at high risk for complications will allow for strategies that might improve outcomes. We hypothesized that post-operative complications are not infrequent after TOF surgery and sought to investigate risk factors for such complications using a machine learning method. Prediction of post-operative cardiac complications is important, as mitigating complications could improve overall outcomes
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