Aristotle Score Research Articles

Novel catheter‐interventional strategy for intracardiac connecting of total anomalous pulmonary venous return in newborns with hypoplastic left heart‐syndrome prior to hybrid approach

Total anomalous pulmonary venous return (TAPVR) associated with hypoplastic left heart-syndrome (HLHS) is a rare condition, and from the therapeutical point of view associated with a high Aristotle score and thus increased mortality. We report two newborns with HLHS, one with a supracardiac type of TAPVR and mildly obstructed left vertical vein, and the other with a supracardiac type of TAPVR in association with cor triatriatum and severely obstructed left-sided vertical vein. In both patients, radio frequency perforation from the pulmonary venous confluence to the systemic venous atrium was performed with consecutive gradual balloon dilatation, followed by stent placement in one. Hybrid stage I, and comprehensive stage II were successfully performed thereafter. Currently, both are awaiting their Fontan completion. Transcatheter intracardiac connecting of supracardiac type of TAPVR in newborns with HLHS is feasible and might render these children suitable candidates for further hybrid approach.

QTc Prolongation after Ventricular Septal Defect Repair in Infants

Background and ObjectivesProlonging of the corrected QT interval (QTc) has been reported after cardiac surgery in some studies. However, there have not been many studies on infant open cardiac surgery for ventricular septal defect (VSD) repair. This study was performed to define the changes in QTc and to find related post-surgery factors in this patient group.Subjects and MethodsFrom 2008 to 2012, 154 infants underwent VSD repair at the Severance Cardiovascular Hospital. This study includes 105 of these cases. QTc was measured in these patients retrospectively. Demographic data and peri-procedural data, such as Aristotle score, cross-clamp time and bypass time, were analyzed. The exclusion criteria included multiple and small VSDs that underwent direct closure.ResultsMean post-operative QTc was increased compared to the pre-operative measurements (from 413.6±2.3 to 444.9±2.5, p<0.001). In multiple linear regression, the comprehensive Aristotle score was associated with increasing QTc (p=0.047). The incidence of transient arrhythmia, such as atrial tachycardia, junctional ectopic tachycardia, premature atrial contraction, or premature ventricular contraction, was associated with QTc prolongation (p=0.005). Prolonged QTc was also associated with cross-clamp time (p=0.008) and low weight (p=0.042). Total length of stay at the intensive care unit and intubation time after surgery were not associated with QTc prolongation.ConclusionProlonged QTc could be seen after VSD repair in infants. This phenomenon was associated with peri-procedural factors such as the Aristotle score and cross-clamp time. Patients with QTc prolongation after cardiac surgery had an increased tendency towards arrhythmogenicity in the post-operative period.

Thyroid and Brain Natriuretic Peptide Response in Children Undergoing Cardiac Surgery for Congenital Heart Disease

Interest in hormonal response after pediatric cardiac surgery is growing, but many aspects remain unclear. The aim of this study was to test age-related variations and prognostic values of thyroid hormones, and brain natriuretic peptide (BNP) levels before and after surgery. A total of 162 children undergoing cardiac surgery were divided into 3 age groups (group 1, n=57 neonates; group 2, n=58 infants; group 3, n=47 toddlers). Free thyroid hormones (fT3 and fT4), thyrotropin (thyroid-stimulating hormone [TSH]) and BNP were measured preoperatively, daily postoperatively in the intensive care unit and after 15 days. The primary outcome was time to extubation (TTE; variable used as time to event by survival analysis). The hormonal response differed among age groups. In older children the TSH nadir occurred at 6-12h after surgery (0.42 mIU/L, P<0.001), with a progressive recovery thereafter, while in neonates the TSH nadir occurred later, at 36-60 h (0.14 mIU/L, P<0.001), followed by a much slower recovery. In neonates, BNP also dropped after surgery (from 2,899 to 824.0 ng/L, P<0.001) while increased in older children (from 71.00 to 527.00 ng/L, P<0.001). On multivariate analysis independent predictors of TTE were fT3 nadir in all age groups, together with TSH nadir and Aristotle score in neonates, and body surface area and BNP peak in older children. BNP and thyroid response after pediatric cardiac surgery differs widely according to age. Beside Aristotle score, combined measurement of fT3 and TSH are the strongest predictors of TTE, especially in neonates.

Copeptin as a marker of relative arginine vasopressin deficiency after pediatric cardiac surgery

Relative arginine vasopressin (AVP) deficiency after pediatric cardiac surgery has recently been described. Copeptin, a more stable and easily measured product of pro-AVP processing, may be a means of identifying these patients. We aimed to determine if copeptin was correlated with AVP in these children and whether it can be a surrogate marker of relative AVP deficiency. Patients <6 years of age with basic Aristotle scores ≥7 requiring surgery with cardiopulmonary bypass were prospectively enrolled. Plasma AVP and copeptin concentrations were measured pre-cardiopulmonary bypass and 4 and 24 h post-cardiopulmonary bypass. Relative AVP deficiency was defined a priori based on our previous work as AVP <9.2 pg/ml at 4 h post-cardiopulmonary bypass. Of 41 children enrolled, relative AVP deficiency was present in 13 (32 %). AVP and copeptin concentrations were significantly lower in these 13 children at 4 h post-cardiopulmonary bypass as compared to the other 28 patients. A significant positive association between plasma AVP and copeptin concentrations over time was determined. Based on log-transformed analyses, a 1 % increase in plasma AVP led to a 0.19 % increase in copeptin. Further, copeptin <1.12 ng/ml at 4 h post-cardiopulmonary bypass had a sensitivity of 92 % and a negative predictive value of 95 % for relative AVP deficiency. Plasma AVP and copeptin are positively associated in children undergoing cardiac surgery. Copeptin may represent a useful means of identifying relative AVP deficiency in these patients.

The impact of intraoperative vasopressin infusion in complex neonatal cardiac surgery

Although recent advances have led to a better understanding of the beneficial effects of vasopressin on haemodynamics in paediatric cardiac surgery, not much information is available on the adverse effects. The objective of this study was to assess the impact of intraoperative vasopressin infusion on postoperative liver, renal and haemostatic function and lactate levels in neonates undergoing cardiac surgery. We reviewed data from 34 consecutive neonates who had undergone complex cardiac surgery. The cohort was divided into two groups according to the use of vasopressin. Seventeen patients received vasopressin [vasopressin (+) group], and 17 patients did not [vasopressin (-) group]. No differences between the groups in terms of age, weight, cardiopulmonary bypass time, Risk Adjustment for Congenital Heart Surgery-1 score or the comprehensive Aristotle score were seen. No differences in the systolic or diastolic arterial blood pressures, heart rate or inotropic score upon admission to the intensive care unit were observed between the groups. No adverse effects on the aminotransferase levels were seen. The vasopressin (+) group had higher urea and creatinine levels. All the patients except one received peritoneal dialysis on the day of surgery. Thirteen patients in the vasopressin (+) group and 7 patients in the vasopressin (-) group continued to require peritoneal dialysis on postoperative day 5 (POD 5) (P = 0.04). The platelet count had decreased to a significantly lower level in the vasopressin (+) group on POD 5 [97 x 10(3)/mm(3) (range: 40-132 x 10(3)/mm(3))]. A tendency toward a high lactate concentration was seen in the vasopressin (+) group. In comparison with the vasopressin (-) group, the number of patients whose lactate level remained above 2.0 mmol/l was higher in the vasopressin (+) group on PODs 2 and 3 (17 patients vs 8 patients, P < 0.01 and 15 patients vs 7 patients, P = 0.01, respectively). These findings suggest that the intraoperative use of vasopressin extends the period of peritoneal dialysis, reduces platelet counts and delays the recovery of the lactate concentration. Intraoperative vasopressin infusion should not be used routinely, but only in catecholamine-refractory shock.

100 Comparison of the Aristotle and RACHS Scores to Predict Morbidity in Congenital Cardiac Surgery

automation were similar in terms of mean age, proportion female, heart failure, and diabetes (all p 0.05). Rates of referral increased from 41.9% prior to automated referral to 75.7% post-automation (p 0.0001). Of the 2390 subjects referred to CR, 1497 (62.6%) attended however, attendance rates were significantly lower after automation than before, 48.2 vs 65.7% (p 0.0001). Referral to CR, regardless of attendance status, was associated with reduced mortality (unadjusted hazard ratio, 0.54, 95%CI 0.48, 0.61; adjusted for all clinical comorbidities, 0.74, 95% CI 0.66, 0.84). CONCLUSION: Automated referral to CR in CABG patients results in higher rates of referral. However, there is a commensurate decline in CR attendance. Automated referral to CR is insufficient to increase attendance; when CR referral is automated, care must still be made to emphasize the benefits of CR to patients.

Editorial Comment: Does the shunt type determine midterm outcomes after a Norwood operation?

Dr Gaynor: So what shunt, what operation would you do for that patient? Dr Photiadis: Right now I think there is no data. Our data do not show it, and there are no other data, so we would still use the B-T shunt. Dr. S. Sano (Okayama, Japan): Yes, a Sano would be probably a reasonable alternative. Dr Gaynor: That is the one finding that did come out in your studies. Dr E. Bove (Ann Arbor, MI, USA): I enjoyed your paper, and I agree with your conclusion, but I rise to support what Dr. Gaynor said, and I think that we have to be very careful how we interpret data. It is a retrospective study, and if I understood from your abstract, it was surgeon preference which was not very clear. Does that mean one surgeon did one technique, another surgeon did a different one so that each surgeon decided preoperatively what he felt would be the best shunt? Additionally, looking at postoperative risk factors and showing that the Aristotle scores are equal does not have the same validity as a prospective randomized trial to reach the conclusion as you have reached. So even though I would like to agree with your conclusion, I think we have to be very careful how we interpret these data. Dr Photiadis: You are absolutely right, but again, randomisation may not give you the whole answer. If we have a patient, say aortic atresia, mitral atresia, who is stable preoperatively and whom you randomly assign to the Sano shunt, and then you have another patient with aortic atresia and mitral atresia, same anatomic type, was not prenatally diagnosed, decompensation without closure of the duct and cannot be stabilised, if you look on just the anatomic type, they are the same, but with respect to preoperative risk in fact they are not. By means of the Aristotle score these differences can be detected, with one patient being assigned to the low-risk and the other one to the high-risk group.

The combined use of neutrophil gelatinase-associated lipocalin and brain natriuretic peptide improves risk stratification in pediatric cardiac surgery

The aim of this study is to test the hypothesis whether the combined use of a cardio-specific biomarker, the brain natriuretic peptide (BNP) and a marker of early renal damage, the assay of urinary neutrophil gelatinase-associated lipocalin (uNGAL), may improve risk stratification in pediatric cardiac surgery. We prospectively enrolled 135 children [median age 7 (interquartile range 1-49) months] undergoing to cardiac surgery for congenital heart disease. All biomarkers were evaluated pre- and post-operatively at different times after cardiopulmonary-bypass (CPB): uNGAL at 2, 6 and 12 h; BNP at 12 and 36 h; serum creatinine at 2, 6, 12, and 36 h. Primary endpoints were development of acute kidney injury (AKI) (defined as 1.5 serum creatinine increase) and intubation time. AKI occurred in 39% of patients (65% neonates and 32% older children, p=0.004). The peak of uNGAL values occurred more frequently at 2 h. uNGAL values at 2 h [median 28.2 (interquartile range 7.0-124.6) ng/L] had a good diagnostic accuracy for early diagnosis of AKI with an AUC (area under the curve) ROC (receiver operating characteristic) curve of 0.85 (SE 0.034). Using multivariable logistic regression analysis, development of AKI was significantly associated with uNGAL values at 2 h after CPB [OR=1.88 (1.30-2.72, p=0.001)], together with the CPB time and Aristotle score, as an index of complexity of the surgical procedure, while pre-operative BNP values were not. Furthermore, uNGAL and pre-operative BNP values (together with Aristotle score) were significantly associated with adverse outcome (longer intubation time and mortality). Pre-operative BNP and uNGAL values after surgery (together with the Aristotle score) were independently associated with a more severe course and worse outcome in children undergoing cardiac surgery for congenital heart disease.

Editorial Comment: Re: Evaluation of the Aristotle complexity models in adult patients with congenital heart disease

With an increasing number of adult congenital heart (GUCH) surgery patients, a suitable risk stratification model should be available for outcome evaluation, but it would tend to be incomplete due to the very heterogeneous and often complex patient groups with multiple measured as well as unmeasured risk factors. The paper by Horer et al .[ 1] contained valuable data concerning the procedural factors associated with early death and the complications following GUCH surgery. In addition to identifying the associations between early death and procedural factors, the authors looked for associations between items contained within the Aristotle comprehensive complexity (ACC) score. They commented that some of the items in the ACC ‘did not achieve statistical significance’ in terms of an association with early death, putting this down to the low prevalence of these factors within the dataset or to the small number of deaths. However, the lack of inclusion of complex patients who were not offered high-risk surgical options might skew the analysis. A third possibility is the lack of an association between all items in the ACC (developed primarily for paediatric cardiac patients) and early death in adult patients. Having found that the ACC score had a fairly good discrimination in the GUCH patient population, the authors discussed the appropriateness of the ACC for predicting outcome. Some care is required here. The authors talked of predictive accuracy, but no assessment of the accuracy of ACC was presented. To be very clear, discrimination (the extent to which a model can discern between low-risk and high-risk cases) is not a measure of predictive accuracy for individual patients or patient sub-groups. As we may remember, the Aristotle score was not created to predict mortality [2]. The score would give an average value of mortality for a given paediatric cardiac procedure which every centre or surgeon could use for performance evaluation. The authors also commented on the potential utility of adding diagnostic information such as ‘univentricular status’ to augment procedural information in risk stratification schemes such as the ACC. We certainly see the value in this and have recently completed an analysis of the UK Central Cardiac Audit Database (CCAD) to develop a risk model for paediatric cardiac surgery that incorporates such information on diagnosis [3]. In risk modelling for paediatric cardiac surgery, the trend is towards systems based on the analysis of data rather than expert opinion [4]. Nevertheless, the authors’ vision of their work stimulating the collection and publication of larger series of data is one we fully endorse.

Prenatal diagnosis of cardiac defects: accuracy and benefit

The prenatal diagnosis of cardiac defects can potentially reduce postnatal morbidity and mortality. We wanted to evaluate prenatal cardiac diagnosis accuracy in a population referred for echocardiography. Single centre retrospective study of echocardiography referrals between April 1999 and December 2008. We compared the prenatal and postnatal cardiac diagnoses, the modified Aristotle and Wald scores. The final diagnosis Wald score was used to evaluate benefit. Six hundred fetuses were included. Diagnoses included: normal heart (312, 52%); congenital heart defect (CHD) (231, 38.5%); primary arrhythmia (39, 6.5%); or cardiomyopathy, myocarditis or cardiac tumor (18, 3%). The prenatal and postnatal Aristotle and Wald scores correlated in 81% and 86%, respectively, each with significant differences in 22 cases. Four significant CHDs were misdiagnosed, the surgical prediction was incorrect in 7 and 13 false positive diagnoses of aortic coarctation were made. In 76% (455/600) fetuses prenatal diagnosis was considered beneficial. The average CHD Aristotle score was 9.5 ± 5.0. In babies with CHDs and normal karyotype the score was either 6.5 ± 5.0, 12.9 ± 3.1 or 13.2 ± 2.9, in survivors, cases of postnatal demise and cases of pregnancy termination, respectively. Prenatal diagnosis was accurate and the counselling appropriate in most cases; however, a few errors were made. The diagnosis of aortic coarctation remains challenging.

Evaluation of the Aristotle complexity models in adult patients with congenital heart disease†

The adult congenital heart disease (CHD) population has surpassed the paediatric CHD population. Half of all mortality caused by CHD occurs in adulthood; in some patients, it occurs during surgery. We sought to assess the potential risk factors for adverse outcome after cardiac operations in adults with CHD, and to evaluate the predictive power of the Aristotle score models for hospital mortality. Procedure-dependent and independent factors, as well as the outcome factors of all consecutive patients aged 16 or more who underwent surgery for CHD between 2005 and 2008 at our institution were evaluated according to the European Association for Cardio-Thoracic Surgery Congenital Database nomenclature. An Aristotle basic complexity (ABC) and an Aristotle comprehensive complexity (ACC) score were assigned to each operation. The discriminatory power of the scores was assessed using the area under the receiver operating characteristics (AuROC) curve. During 542 operations, 773 procedures were performed. The early mortality rate was 2.4%, and the early complication rate was 53.7%. Tricuspid valve replacement (P = 0.009), mitral valve replacement (P < 0.001), elevated lung resistances (P = 0.002), hypothyroidism (P = 0.002) and redosternotomy (P = 0.003) emerged as risk factors for 30-day mortality. Tricuspid valve replacement (P < 0.001), tricuspid valvuloplasty (P = 0.006), mitral valve replacement (P = 0.003), shunt implantation (P = 0.009), surgical ablation (P = 0.024), myocardial dysfunction (P = 0.014), elevated lung resistances (P = 0.004), hypothyroidism (P = 0.002) and redosternotomy (P < 0.001) emerged as risk factors for complications. Mean ABC and ACC scores were 6.6 ± 2.3, and 9.0 ± 3.7, respectively. The AuROCs of the ABC and the ACC scores for 30-day mortality were 0.663 (P = 0.044), and 0.755 (P = 0.002), respectively. The AuROCs of the ABC and the ACC scores for complications were 0.634 (P < 0.001), and 0.670 (P < 0.001), respectively. Surgery for adults with CHD can be performed with low early mortality. However, complications are frequent, especially in patients who require repeat operations for atrioventricular valve incompetence. The ACC score may be helpful to estimate the risk of early mortality.

Congenital heart surgeon's technical proficiency affects neonatal hospital survival

Risk factors for mortality after neonatal cardiac surgery have been seldom studied. We sought to identify contemporary risk factors for mortality and the impact of surgical technical performance on surgical outcomes after neonatal cardiac surgery. We conducted a matched case-control study comparing 56 neonates who died after cardiac surgery (2002-2008) with 56 survivors matched by surgical procedure and year of surgery. Surgical efficacy for repair or palliation was graded using a reliable simple surgical technical score. Patient and surgical characteristics were compared for the survivors and nonsurvivors using paired analyses. There was no significant difference between patients who died and their matched controls in terms of age, Aristotle score, Risk Adjustment in Congenital Heart Surgery-1 category, and single versus biventricular repair. When compared with survivors, patients who died were more likely to be premature (41% vs 5%, P < .001), to weigh less than 2.5 kg (25% vs 9%, P = .05), and to have inadequate surgical repair or palliation (55% vs 9%, P < .001). Cardiopulmonary bypass time was longer for the patients who died (median, 159 vs 133 minutes, P = .002). Highest postoperative lactate (median, 9.0 vs 6.0, P < .001), use of extracorporeal membrane oxygenation (71% vs 13%, P < .001), and reoperation during the same admission (75% vs 2%, P < .001) were also associated with death. In multivariable analysis, inadequate surgical repair or palliation (odds ratio, 11, P = .02) and need for postoperative extracorporeal membrane oxygenation (odds ratio, 5.1, P = .009) were the only risk factors associated with hospital death. Our study highlights the need for optimal technical performance to minimize neonatal deaths. This has important implications when sustaining or developing a pediatric cardiac program.

Invited Commentary

The systemic inflammatory response syndrome is, at least partly, responsible for complications in children undergoing cardiac surgery with cardiopulmonary bypass (CPB), and has been the target of the prophylactic use of corticosteroids. The potential benefits and risks of corticosteroids remain controversial despite a widespread use for more than 30 years. Even though several trials demonstrated the ability of corticosteroids to modulate the inflammatory response related to CPB in children [1Schroeder V.A. Pearl J.M. Schwartz S.M. Shanley T.P. Manning P.B. Nelson D.P. Combined steroid treatment for congenital heart surgery improves oxygen delivery and reduces postbypass inflammatory mediator expression.Circulation. 2003; 107: 2823-2828Crossref PubMed Scopus (135) Google Scholar, 2Bronicki R.A. Backer C.L. Baden H.P. Mavroudis C. Crawford S.E. Green T.P. Dexamethasone reduces the inflammatory response to cardiopulmonary bypass in children.Ann Thorac Surg. 2000; 69: 1490-1495Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar], a pediatric meta-analysis published in 2007 [3Robertson-Malt S. El Barbary M. Prophylactic steroids for paediatric open-heart surgery: a systematic review.Int J Evid Based Healthc. 2008; 6: 391-395Crossref PubMed Scopus (7) Google Scholar] found no clinical benefit, and highlighted the paucity of data on adverse events, in particular sepsis and bleeding. A very recent publication by Clarizia and associates [4Clarizia N.A. Manlhiot C. Schwartz S.M. et al.Improved outcomes associated with intraoperative steroid use in high-risk pediatric cardiac surgery.Ann Thorac Surg. 2011; 91: 1222-1227Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar] has reported a significant reduction in length of stay when 30 mg/kg methylprednisolone was given intraoperatively, and a further reduction in the duration of mechanical ventilation when additional corticosteroids were given preoperatively. These were consistent with previous reports in children [1Schroeder V.A. Pearl J.M. Schwartz S.M. Shanley T.P. Manning P.B. Nelson D.P. Combined steroid treatment for congenital heart surgery improves oxygen delivery and reduces postbypass inflammatory mediator expression.Circulation. 2003; 107: 2823-2828Crossref PubMed Scopus (135) Google Scholar], but what was new in the publication by Clarizia and colleagues [4Clarizia N.A. Manlhiot C. Schwartz S.M. et al.Improved outcomes associated with intraoperative steroid use in high-risk pediatric cardiac surgery.Ann Thorac Surg. 2011; 91: 1222-1227Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar] was the targeted use of steroids in younger and more complex patients (Aristotle score above 10), suggesting steroids would provide the most spectacular effect in young patients subjected to considerable inflammatory responses. The present study of Heying and colleagues [5Heying R. Wehage E. Schumacher K. et al.Dexamethasone pretreatment provides antiinflammatory and myocardial protection in neonatal arterial switch operation.Ann Thorac Surg. 2012; 93: 869-877Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar] highlights a new aspect of the prophylactic use of corticosteroids in neonatal cardiac surgery: the protective myocardial effect. By showing lesser inflammation and lower cardiac troponin concentrations with the use of methylprednisolone, the present study directly relates post-CPB inflammation to myocardial protection. The present authors demonstrate the myocardial downregulation and upregulation of proinflammatory and antiinflammatory cytokines, respectively, with the prophylactic use of 1 mg/kg methylprednisolone given before CPB, and show effectiveness starting before onset of CPB and lasting throughout the procedure and the early postoperative period. We still have to answer the following questions: “What?,” “When?,” and “How much?,” especially as an international survey of 36 cardiac surgery centers revealed that despite the widespread use of corticosteroids in pediatrics, administration practices and dosing regimens are still the result of provider preferences [6Checchia P.A. Bronicki R.A. Costello J.M. Nelson D.P. Steroid use before pediatric cardiac operations using cardiopulmonary bypass: an international survey of 36 centers.Pediatr Crit Care Med. 2005; 6: 441-444Crossref PubMed Scopus (118) Google Scholar]. The steroid preparation responsible for fewer side effects, the best dosing regimen, and the best timing are still debated in pediatric cardiac surgery. Dexamethasone Pretreatment Provides Antiinflammatory and Myocardial Protection in Neonatal Arterial Switch OperationThe Annals of Thoracic SurgeryVol. 93Issue 3PreviewThis prospective double-blinded randomized study tested the hypothesis that preoperative treatment with dexamethasone would attenuate inflammatory priming of the myocardium, reduce the systemic inflammatory reaction upon cardiac operation, and provide organ protection in neonates. Full-Text PDF

Morbidity of the Arterial Switch Operation

The arterial switch operation (ASO) has become a safe, reproducible surgical procedure with low mortality in experienced centers. We examined morbidity, which remains significant, particularly for complex ASO. From 2003 to 2011, 101 consecutive patients underwent ASO, arbitrarily classified as "simple" (n=52) or "complex" (n=49). Morbidity was measured in selected complications and postoperative hospitalization. Three outcomes were analyzed: ventilation time, postextubation hospital length of stay, and a composite morbidity index, defined as ventilation time+postextubation hospital length of stay+occurrence of selected major complications. Complexity was measured with the comprehensive Aristotle score. The operative mortality was zero. Twenty-five major complications occurred in 23 patients: 6 of 25 (12%) in simple ASO and 19 of 49 (39%) in complex ASO (p=0.002). The most frequent complication was unplanned reoperation (15 vs 6, p=0.03). No patients required permanent pacing. The complex group had a significantly higher morbidity index and longer ventilation time and postextubation hospital length of stay. In multivariate analysis, factors independently predicting higher morbidity were the comprehensive Aristotle score, arch repair, bypass time, and malaligned commissures. Myocardial infarction caused one sudden late death at 3 months. Late coronary failure was 2%. Overall survival was 99% at a mean follow-up of 49±27 months. In this consecutive series without operative mortality, morbidity was significantly higher in complex ASO. The only anatomic incremental risk factors for morbidity were aortic arch repair and malaligned commissures, but not primary diagnosis, weight less than 2.5 kg, or coronary patterns.

Does the shunt type determine mid-term outcome after Norwood operation?

With improved short-term outcomes the right ventricular to pulmonary artery shunt (Sano) has become the preferred pulmonary blood source in the Norwood procedure in many centres. However, most studies analysed consecutive cohorts, with a first modified Blalock-Taussig shunt (BT) followed by the Sano cohort. Besides, neither comprehensive preoperative risk analysis nor outcome beyond 1 year of age was investigated. This study reviews 109 neonates undergoing the Norwood procedure in the same interval between October 2002 and December 2009. The Sano (38) or BT shunt (71) was assigned according to the surgeon's preference. Two neonates subsequently underwent successful biventricular repair and were excluded. The Aristotle comprehensive score (ACS) was used to evaluate preoperative risk, with high-risk patients (n = 39) classified as having an ACS ≥ 20, and low-risk patients (n = 68) given an ACS <20. Mean Aristotle score at the Norwood operation was 18.8 ± 0.4 and 18.9 ± 0.3 (P = 0.9) in Sano and BT, respectively. Mean follow-up interval was 4.1 ± 2.1 years (range: 1.7-8.9 years). Actuarial survival was similar, stabilizing from the 8th postoperative month onwards at 78.6 ± 4.9% (95% CI: 67.0-86.5%) for Sano and 78.4 ± 6.8% (95% CI: 61.4-88.6%) for BT; P = 0.95. Midterm actuarial survival was higher in low-risk patients, 88.2 ± 3.9% (95% CI: 77.8-93.9%) than in high-risk patients: 61.5 ± 7.8% (95% CI: 44.5-74.7%, P = 0.0003). No survival benefit was detected in low- or high-risk cases for either shunt type. Risk factors for midterm mortality were cardiorespiratory failure requiring ventilation (13/34, P = 0.004), and ACS ≥ 20 (15/39, P = 0.001), but not shunt type (8/37, P = 0.95). Increased number of shunt-related interventions before the Glenn procedure were noted with Sano (32.4 versus 6.5%, P = 0.002). Preoperative risk factors, regardless of shunt type, influence midterm survival after the Norwood procedure with an excellent outcome in low-risk patients, while high-risk cases still incur a significant mortality. Sano shunt interventions occurred with increased numbers. Although, Sano shunt may be the only feasible option in some instances, given the possible negative effects of ventriculotomy on right ventricle function, the widespread use of Sano shunt should be reconsidered.

A morbidity score for congenital heart surgery based on observed complications

The aim of this study was to develop a morbidity score based on observed postoperative complications after congenital heart surgery. Conditions or diseases that impair patients after congenital heart surgery or increase costs of hospital stay were called complications and attributed to scores ranging from 1 (mild) to 4 (severe) points, according to estimated severity or costliness. 'No complication' was assigned 0.5 points. From January to March 2011, scores for each observed 'complication' for every main (primary) surgical procedure were recorded and a morbidity score was calculated. In conformity with the Aristotle score methodology, if the sum of observed complication scores amounted to more than 5 points, a morbidity score of only 5 points was attributed. The estimated morbidity score was compared with the morbidity score attributed by the Aristotle basic complexity (ABC) score. One hundred and thirty-nine primary procedures were carried out. The mean ABC and Aristotle comprehensive complexity scores reached 8.31 ± 2.52 and 9.62 ± 3.47 points, respectively. Two patients died. No complication was detected after 46 procedures. Overall, there were 185 listed 'morbidity' conditions in connection with the other 93 surgical procedures, rendering a total score of 385 points. The most frequent event was 'mechanical ventilation 25-95 h': n = 39. The mean morbidity score was 2.14 ± 1.63. The morbidity scores ranged from 0.5 points (n = 46) to 5 points (n = 23) with a median of 2.0 points. The scores for 11 different procedures that were performed at least five times positively correlated with the corresponding Aristotle morbidity scores: Pearson's coefficient r = 0.75. But the morbidity score for bidirectional cavopulmonary anastomosis (3.14 ± 1.77) was higher than the corresponding Aristotle morbidity score (2.0). It was lower for 'conduit placement, right ventricle to pulmonary artery': 1.08 ± 0.97, versus 2.0, and for arterial switch operation: 2.08 ± 1.11, versus 3.0. The reported morbidity scores need to be tested on larger series and in different institutions. The introduced morbidity score has the potential to quantify postoperative complications accurately. Its estimation over time can facilitate the assessment of quality of congenital heart surgery. It will allow comparison of morbidity outcomes across institutions with different case-mixes.

Surgical Management of Congenital Heart Disease: Contribution of the Aristotle Complexity Score to Planning and Budgeting in the German Diagnosis-Related Groups System

Planning and budgeting for congenital heart surgery depend primarily on how closely reimbursement matches costs and on the number and complexity of the surgical procedures. Aristotle complexity scores for the year 2010 were correlated with hospital costs and with reimbursement according to the German diagnosis-related groups (DRG) system. Unit surgical performance was estimated as surgical performance (complexity score × hospital survival) times the number of primary procedures. This study investigated how this performance evolved during years 2006 to 2010. Hospital costs and reimbursements correlated highly with Aristotle comprehensive complexity levels (Spearman r = 1). Mean costs and reimbursement reached 35,050<euro> ± 32,665<euro> and 31,283<euro> ± 34,732<euro>, respectively, for an underfunding of 10.7%. Basic and comprehensive unit surgical performances were respectively 3036 ± 1009 and 3891 ± 1591 points in 2006. Both performances increased in sigmoid fashion to reach 3883 ± 1344 and 5335 ± 1314 points, respectively, in 2010. Top performances would be achieved in year 2011, and extrapolated costs would comprise about 19,434,094.92<euro> (95% confidence interval, 11,961,491.22-22,495,764.42<euro>). The current underfunding of congenital heart surgery needs correction. The Aristotle score can help to adjust reimbursement according to complexity of procedures. Unit surgical performance allows accurate budgeting in the current German DRG system.

Acute Kidney Injury After Cardiac Surgery in Infants and Children: Evaluation of the Role of Angiotensin-Converting Enzyme Inhibitors

Children with congenital heart disease who undergo cardiac surgery are vulnerable to acute kidney injury (AKI). This study sought to evaluate the role of angiotensin-converting enzyme (ACE) inhibitors and other nephrotoxic medications in the risk for the development of AKI in neonates and children undergoing cardiac surgery. A retrospective review of all patients younger than 2 years admitted to the cardiac intensive care unit after cardiac surgery from March 2007 to September 2008 was conducted. Patients were included in the review if they received furosemide alone or in combination with an ACE inhibitor. Creatinine clearance was calculated, and the patient's maximal degree of AKI was classified by pRIFLE. A P value less than 0.05 was considered significant. Of the 319 patients who met the inclusion criteria, 149 (47%) received furosemide therapy alone and 170 (53%) received a combination of furosemide and an ACE inhibitor. Patients in the furosemide-only group (age, 5 months) were older than the patients who received both furosemide and an ACE inhibitor (age, 3.8 months; P = 0.024). Despite statistically higher Aristotle scores in the ACE-inhibitor group, the intraoperative variables did not differ between the two groups. Postoperatively, the ACE-inhibitor group had a decreased creatinine clearance (55.3 ml/min/1.73 m(2)) compared with the furosemide group (64.4 ml/min/1.73 m(2); P = 0.015) and an increased incidence of a pRIFLE maximal score of "F" (odds ratio [OR], 1.75; P = 0.033). However, after adjustment for additional risk factors, no difference in the occurrence of AKI resulted (OR, 0.939; P = 0.85) when patients received an ACE inhibitor. More than half of the study population received ACE inhibitors, but this treatment was not associated with an increase in AKI.

Impact of Delayed Sternal Closure on Postoperative Infection or Wound Dehiscence in Patients With Congenital Heart Disease

We sought to determine whether longer duration before delayed sternal closure (DSC) increases the risk of mortality, postoperative infection, or wound dehiscence. A retrospective review was performed of 154 patients who underwent DSC between January 1999 and April 2009. Median body weight and age at operation were 3.6 kg (1.5 to 80 kg) and 25 days (2 days to 20 years), respectively. Palliative procedures were performed in 58 patients (58/154, 37.7%). Sternal wound problems were categorized according to the consensus-based definitions. Multivariate analysis was conducted encompassing various preoperative and intraoperative variables to identify risk factors for adverse surgical outcomes. The mean comprehensive Aristotle score (CAS) was 13.2±3.1. There were 28 hospital mortalities (28/154, 18.2%). Excluding patients who died before sternal closure (4/154, 2.6%), the median duration of sternal opening was 3.5 days (1 to 182 days). Postoperative infection (sternal wound infection or systemic infection) and sterile wound dehiscence (SWD) occurred in 17 and 14 patients, respectively. Multivariate analysis revealed that duration of ventilatory support increased the risk of mortality (p=0.004), and postoperative infection/SWD (p=0.001). CAS also correlated with postoperative infection/SWD (p=0.026). Duration of sternal opening however was associated with none of the outcome variables. Long ventilatory support and complexity of the cardiac anomaly increase the risk of adverse outcomes after procedures to repair congenital cardiac anomalies . After adjusting these variables, longer duration before DSC does not seem to be a risk factor for surgical mortality, postoperative infection, or wound dehiscence.

Congenital Heart Surgery: Expected Versus Observed Surgical Performance According to the Aristotle Complexity Score

The Aristotle score quantifies the complexity involved in congenital heart surgery. It defines surgical performance as complexity score times hospital survival. We studied how expected and observed surgical performance evolved over time. 2312 main procedures carried out between 2006 and 2010 were analyzed. The Aristotle basic score, corresponding hospital survival and related observed surgical performance were estimated. Expected survival was based on the mortality risks published by O'Brien and coauthors. Observed performance divided by expected performance was called the standardized ratio of performance. This should trend towards a figure above 100%. Survival rates and performance are given with 95% confidence intervals. The mean Aristotle basic score was 7.88 ± 2.68. 51 patients died: observed hospital survival was 97.8 % (97.1 %-98.3%). 115 deaths were anticipated: expected survival was 95.2% (93.5%-96.3%). Observed and expected surgical performance reached 7.71 (7.65-7.75) and 7.49 (7.37-7.59), respectively. Therefore the overall standardized ratio of performance was 102.94%. The ratio increased from 2006 (ratio = 101.60%) to 2009 (103.92%) and was 103.42% in 2010. Performance was high for the repair of congenital corrected transposition of the great arteries and ventricular septal defect (VSD) by atrial switch and Rastelli procedure, the Norwood procedure, repair of truncus arteriosus, aortic arch repair and VSD closure, and the Ross-Konno procedure, with corresponding standardized ratios of 123.30%, 116.83%, 112.99%, 110.86% and 110.38%, respectively. With a ratio of 82.87%, performance was low for repair of Ebstein's anomaly. The standardized ratio of surgical performance integrates three factors into a single value: procedure complexity, postoperative observed survival, and comparison with expected survival. It constitutes an excellent instrument for quality monitoring of congenital heart surgery programs over time. It allows an accurate comparison of surgical performance across institutions with different case mixes.