Regional sharing optimizes arterial switch outcomes

Abstract

Objective Although the arterial switch operation has been performed with very low mortality and morbidity in large pediatric cardiac surgical centers, we sought to determine if similar arterial switch results could be achieved in two medium-sized pediatric cardiac surgical centers that share one full-time surgeon who implements a comprehensive management protocol for both centers. Methods Patients with D-transposition of the great arteries undergoing arterial switch operations at two medium-sized pediatric cardiac surgery centers were evaluated for 30-day mortality and morbidity during three time periods: Period 1, before protocol was implemented at either center (Center 1: 11/1982–8/1995, Center 2: 3/1992–11/1999); Period 2, protocol implemented only at Center 1 (9/1995–11/1999); Period 3, protocol implemented at both centers with regional sharing of one surgeon (12/1999–1/2003). Results Ninety-six consecutive patients undergoing an arterial switch operation were reviewed. Mortality data were available for all cases. Mortality was 0% and significantly lower in Periods 2 and 3 versus Period 1 ( p<0.001). Mortality in both centers during Period 1 did not differ. New York State morbidity data were available for 59 patients born after state reporting was instituted (Period 1, 16/43; Period 2, 13/23; Period 3, 30/30). In Period 1, there were significantly more pre-operative risk factors ( p<0.001) and post-operative complications ( p<0.002) than in Periods 2 and 3. There were no significant differences in performance between Centers 1 and 2 in any time period. There were significant performance improvements between Period 1 versus Periods 2 and 3. There was no significant degradation in performance between Periods 2 and 3. Conclusions Outstanding surgical results for the arterial switch operation, similar to those in the largest pediatric cardiac surgical centers, are obtainable in two medium-sized pediatric cardiac surgery centers that share one full-time congenital heart surgeon. This model may be applicable in many other regions of the United States, where several medium-sized pediatric cardiac centers are within acceptable driving distance.