Cases Of Heart Surgery Research Articles

Right thoracotomy with central cannulation for valve surgery: 10 years of experience.

The aim of this study is to report the early outcomes of valvular heart surgeries performed via the right thoracotomy approach. While thoracotomy with femoro-femoral bypass is an established method for minimally invasive open-heart surgeries, thoracotomy with conventional cannulation is still being explored. In our center, we conducted 958 valvular heart surgery cases using the right anterolateral thoracotomy approach with central cannulation and data were analyzed. This is a retrospective observational study based on prospectively collected data from patients who underwent valvular heart surgery at our center spanning from April 2013 to April 2023. The data encompass demographics, procedures, operative techniques, post-operative morbidity, mortality, and a 1-month follow-up. Our study revealed no procedure-related mortality. No patient required conversion to median sternotomy. Smooth cannulation and satisfactory exposure were achieved in all patients. The study encompassed a wide age range, from 14 to 68 years, with 618 female patients (64.5%) and 340 male patients (35.5%). The average cross-clamp time ranged from 38 to 90min, the duration of cardio-pulmonary bypass ranged from 45 to 105min, post-operative extubation ranged from 3 to 8h, the average drain volume ranged from 100 to 350ml, and the incision size ranged from 5 to 7cm. Our data demonstrate that conventional cannulation via the right antero-lateral thoracotomy approach for valvular heart disease is a viable alternative to reduce the side effects associated with sternotomy and femoral cannulation. This procedure is safe, reproducible, and provides the same level of treatment quality.

The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2020 Update on Outcomes and Research

The Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database (CHSD) continues to be a highly regarded, comprehensive clinical outcomes database that captures more than 90% of all congenital heart surgery cases in the United States and has more than 90% of all congenital heart surgery centers as participants. This report includes aggregate information on clinical outcomes evaluated at the aggregate and The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category levels for the period July 1, 2015, through June 30, 2019. It also includes the published research activities that use data from the STS CHSD. Also included is information on the STS CHSD auditing function, a summary of the significant revisions to the data, which is collected on each patient, and an update on efforts to update the risk-adjustment methods for evaluation of the outcomes.

Prediction of temporary epicardial pacing wire use in cardiac surgery.

Placement of temporary epicardial pacing wires (TEPW) at the end of open heart surgery cases is routine but can be associated with complications. Identification of patients who are high risk for requiring pacing would be beneficial on guiding selective TEPW placement. The purpose of this study was to identify predictors of temporary pacing immediately post cardiac surgery. A retrospective analysis of patients undergoing cardiac surgery from 2005 to 2016 at the Maritime Heart Center was conducted. Analysis was performed of patients who require pacing on arrival to the cardiovascular intensive care unit (CVICU) compared with those who were not paced. Multivariable logistic regression was used to determine each variable's risk adjusted likelihood of pacing for the entire cohort. Subgroup analysis was performed in the isolated procedures. A total of 11 752 patient underwent surgery from the year 2005 to 2016. Two thousand and fifty-one (17.5%) required pacing on arrival to CVICU. Older age, female sex, preoperative renal failure, lower ejection fraction (EF), preoperative arrhythmia, preoperative use of calcium channel blockers, and longer cross-clamp times were risk factors for pacing. In the isolated coronary artery bypass grafting and aortic valve replacement groups, findings were similar to the overall cohort. Only age, obesity, and chronic obstructive pulmonary disease were risk factors for pacing in the isolatedmitral valve (MV) repair group and only preoperative arrhythmia in the isolated MV replacement group. We have identified risk factors for TEPW use following cardiac surgery and in isolated procedure subgroups. These risk factors may help guide selective TEPW placement.

Giant unruptured sinus of Valsalva aneurysm successfully managed with valve-sparing procedure \u2013 a case report

BackgroundSinus of Valsalva aneurysm (SVA) is an uncommon cardiac anomaly, with an incidence of less than 1% of open heart surgery cases. Its evolution is most frequently silent, being found incidentally or discovered in the event of its acute rupture. Non-ruptured giant SVAs may cause unusual clinical manifestations, as a consequence of their protrusion into the heart chambers or compression of the coronary vessels and are frequently associated with aortic insufficiency of various degrees of severity. The gold standard treatment for SVAs consists of complete replacement of the aortic root and valve. However, in certain cases, valve-sparing procedures may prove to be a more suitable alternative.Case presentationA 68-year-old male patient presented with dyspnea as symptom caused by a large (> 5 cm) right sinus of Valsalva aneurysm. The aneurysm was occupying most of the right ventricle and was associated with severe aortic regurgitation. The surgical treatment of the condition involved valve-sparing root reconstruction procedure (remodeling technique), completed with external stabilization of the aortic valve annulus via running suture annuloplasty. Following the uneventful intervention, the patient did well and his status improved. The follow-up transthoracic echocardiography obtained 1 month after surgery showed a fully competent aortic valve with no regurgitation.ConclusionsDespite complete aortic root and valve replacement being considered the safest approach to large SVAs complicated with aortic insufficiency, valve-sparing procedures should not be overlooked in case of a dilated aortic root with uncalcified aortic valve. Performing valve-sparing by applying a remodeling technique operation completed with annuloplasty reduces aortic valve insufficiency, avoiding side-effects related to implanted valves.

Atrioventricular block after congenital heart surgery: Analysis from the Pediatric Cardiac Critical Care Consortium

ObjectivesOur primary aims were to describe the contemporary epidemiology of postoperative high-grade atrioventricular block (AVB), the timing of recovery and permanent pacemaker (PPM) placement, and to determine predictors for development of and recovery from AVB. MethodsPatients who underwent congenital heart surgery from August 2014 to June 2017 were analyzed for AVB using the Pediatric Cardiac Critical Care Consortium registry. Predictors of AVB with or without PPM were identified using multinomial logistic regression. We used these predictors to model the probability of PPM for the subgroup of patients with intraoperative complete AVB. ResultsWe analyzed 15,901 surgical hospitalizations; 422 (2.7%) were complicated by AVB and 162 (1.0%) patients underwent PPM placement. In patients with transient AVB, 50% resolved by 2 days, and 94% resolved by 10 days. In patients who received a PPM, 50% were placed by 8 days and 62% were placed by 10 days. Independent risk factors associated with PPM compared with resolution of AVB were longer duration of cardiopulmonary bypass (relative risk ratio, 1.04; P = .023) and a high-risk operation (relative risk ratio, 2.59; P < .001). Among patients with complete AVB originating in the operating room, those with the highest predicted probability of PPM had a PPM placed only 77% of the time. ConclusionsIn this cohort, postoperative AVB complicated almost 3% of congenital heart surgery cases and 1% of patients underwent PPM placement. Because almost all patients (94%) with transient AVB had resolution by 10 days, our results suggest there is limited benefit to delaying PPM placement beyond that time frame.

Outcomes of with open and Seldinger-Guided Peripheral Cannulation Techniques in open heart surgery

Objective: In this study, we evaluated the results of open access and seldinger guided peripheral cannulation techniques in patients which underwent open heart surgery. Materials and Method: The results of heart surgery cases with peripheral artery and vein open access technique and seldinger guide technique between November 2010 and October 2017 were evaluated retrospectively. Edwards® Fem-Flex II and Medtronic Bio-Medicus™ NextGen percutaneous femoral artery and venous Cannulas were chosen. Peripheric cannulations were performed percutaneously with doppler ultrasonography via guided seldinger technique. Seldinger technique for peripheric cannulation was preferred even open exploration of the groin vessels were needed. Results: 65 patients (32 male, 33 female; mean age 43±37 years; range 3-81 years) were taken into the study that peripheral cannulation performed. In 18 (27.6%) patients minimally invasive technique was applied and 34 (52.3%) patients were redo cases. A mean flow of 4,108±0.6 m2 l/m2/m was achieved with vacuum application in only 6 patients (9.2%) for venous drainage. No hemothorax, pneumothorax or hematoma had occured in cannulation sites due to internal jugular vein or femoral cannulations. Surgical embolectomy was performed due to distal thrombus only in 4 patients (6.15%) to whom had conventional cannulation. In 4 patients (6.15%) femoral venous cannula couldnÂ’t reached up to the right atrium. Conclusion: In our opinion, seldinger technique either performed percutaneously or surgically is a faster, easier and superior technique in protecting distal limb perfusion when compared with open vasculotomy with proximal/distal clamping technique. Moreover, it can be safely applied in high risk redo cases as well as routine minimally invasive surgery.

Invited Commentary

Invited Commentary

Open heart surgery: Management of nonsurgical bleeding in the peri-operative period; 31/2-years institutional experience

BACKGROUND:Excessive perioperative bleeding remains a major complication following open heart surgery, resulting in increased morbidity and mortality of some patients in our institution.A study of the principal causes of excessive nonsurgical haemostatic perioperative bleeding,clinical evaluation,treatment and preventive strategies is justified.OBJECTIVE/AIM: To identify the causes of bleeding in patients with haemorrhage that did not require reexploration and assess the impact on the patient outcomes from different causes of nonsurgical bleeding perioperatively.MATERIALS AND METHOD: For a period of 31/2 years (March 2013 – February 2016), the National Cardiothoracic Center of Excellence,UNTH,Ituku/Ozalla,Enugu,Nigeria, partnered with different foreign cardiac missions (USA,UK and India) for the performance of open heart surgery.The case files of the patients managed in the envisaged period were retrieved and analyzed using SPSS, version 2.0(Chicago). The data analyzed were patients' demographics, the total number of open heart surgery cases, the number that had perioperative nonsurgical bleeding,clinical detection strategies,treatment and preventive modalities as well as the outcome.RESULTS: During the period,a total number of 78 cases of open heart surgery (OHS) were done.There were 43 males and 35 females, with a ratio of approximately 1.3:1.The youngest age was 5 months and the oldest was 74 years, with a mean of 11.1 +/-SD 0.05. Out of these 78 cases, a total of 7 patients had perioperative nonsurgical bleeding, giving a percentage of 9%.3 patients were noticed intraoperatively in the operating room (OR) while 4 were noticed postoperatively in the intensive care unit (ICU). Treatment included the use of tranexemic acid or aprotinin, fresh frozen plasma (FFP) or fresh whole blood, platelet concentrate and additional doses of protamine, when incomplete reversal of heparin was the cause.CONCLUSION: Detection of the cause(s) of nonsurgical bleeding without thromboelastography or platelet function analyzer can be quite challenging in our environment.Applying appropriate pharmacologic agents among other interventions can reduce allogenic blood requirements with their attendant complications.KEY WORDS:Perioperative,Open heart surgery (OHS),thromboelastography,platelet function analyzer.

Congenital Heart Surgery Case Mix Across North American Centers and Impact on Performance Assessment

Performance assessment in congenital heart surgery is challenging due to the wide heterogeneity of disease. We describe current case mix across centers, evaluate methodology inclusive of all cardiac operations versus the more homogeneous subset of Society of Thoracic Surgeons benchmark operations, and describe implications regarding performance assessment. Centers (n= 119) participating in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2010 through 2014) were included. Index operation type and frequency across centers were described. Center performance (risk-adjusted operative mortality) was evaluated and classified when including the benchmark versus all eligible operations. Overall, 207 types of operations were performed during the study period (112,140 total cases). Few operations were performed across all centers; only 25% were performed at least once by 75% or more of centers. There was 7.9-fold variation across centers in the proportion of total cases comprising high-complexity cases (STAT 5). In contrast, the benchmark operations made up 36% of cases, and all but 2 were performed by at least 90% of centers. When evaluating performance based on benchmark versus all operations, 15% of centers changed performance classification; 85% remained unchanged. Benchmark versus all operation methodology was associated with lower power, with 35% versus 78% of centers meeting sample size thresholds. There is wide variation in congenital heart surgery case mix across centers. Metrics based on benchmark versus all operations are associated with strengths (less heterogeneity) and weaknesses (lower power), and lead to differing performance classification for some centers. These findings have implications for ongoing efforts to optimize performance assessment, including choice of target population and appropriate interpretation of reported metrics.

Carbon dioxide insufflation and neurocognitive outcome of open heart surgery.

Neurocognitive dysfunction continues to be the bane of open heart surgery despite vast improvements in surgical, anesthetic, and postoperative management. This observational cohort study was carried out to evaluate the efficacy of intraoperative CO2 insufflation by the field flooding technique in reducing postoperative neurocognitive dysfunction. Three hundred randomly selected patients undergoing open heart surgery were observed: 150 (group A) were exposed to CO2 insufflation, and the other 150 (group B) were not exposed to CO2. Anesthetic, cardiopulmonary bypass, and myocardial protection techniques were standardized and similar in both groups. Neurocognitive function tests were performed preoperatively, 1 week postoperatively, and after 1 month. The analysis revealed that neurocognitive dysfunction occurred in 8 of 150 patients in group A (incidence p1 = 0.053) and 27 of 150 in group B (incidence p2 = 0.18). The relative risk of neurocognitive dysfunction was 0.30 (p = 0.001, 95% confidence interval 0.14-0.63), implying that CO2 insufflation is protective against neurocognitive dysfunction. The risk difference was 0.13 (p2-p1); this implies that 13% of patients can be prevented from developing neurocognitive dysfunction if exposed to CO2. This study confirms the known advantage of the relatively underutilized practice of CO2 insufflation. We recommend that CO2 insufflation be performed in all open heart surgery cases to bring down the incidence of neurocognitive dysfunction. This technique is simple to use without any major paraphernalia or additional cost.

Reducing Mortality and Infections After Congenital Heart Surgery in the Developing World

There is little information about congenital heart surgery outcomes in developing countries. The International Quality Improvement Collaborative for Congenital Heart Surgery in Developing World Countries uses a registry and quality improvement strategies with nongovernmental organization reinforcement to reduce mortality. Registry data were used to evaluate impact. Twenty-eight sites in 17 developing world countries submitted congenital heart surgery data to a registry, received annual benchmarking reports, and created quality improvement teams. Webinars targeted 3 key drivers: safe perioperative practice, infection reduction, and team-based practice. Registry data were audited annually; only verified data were included in analyses. Risk-adjusted standardized mortality ratios (SMRs) and standardized infection ratios among participating sites were calculated. Twenty-seven sites had verified data in at least 1 year, and 1 site withdrew. Among 15,049 cases of pediatric congenital heart surgery, unadjusted mortality was 6.3% and any major infection was 7.0%. SMRs for the overall International Quality Improvement Collaborative for Congenital Heart Surgery in Developing World Countries were 0.71 (95% confidence interval [CI] 0.62-0.81) in 2011 and 0.76 (95% CI 0.69-0.83) in 2012, compared with 2010 baseline. SMRs among 7 sites participating in all 3 years were 0.85 (95% CI 0.71-1.00) in 2011 and 0.80 (95% CI 0.66-0.96) in 2012; among 14 sites participating in 2011 and 2012, the SMR was 0.80 (95% CI 0.70-0.91) in 2012. Standardized infection ratios were similarly reduced. Congenital heart surgery risk-adjusted mortality and infections were reduced in developing world programs participating in the collaborative quality improvement project and registry. Similar strategies might allow rapid reduction in global health care disparities.

Society of Thoracic Surgeons 2008 cardiac risk models predict in-hospital mortality of heart valve surgery in a Chinese population: A multicenter study

The Society of Thoracic Surgeons 2008 cardiac surgery risk models have been developed for heart valve surgery with and without coronary artery bypass grafting. The aim of our study was to evaluate the performance of Society of Thoracic Surgeons 2008 cardiac risk models in Chinese patients undergoing single valve surgery and the predicted mortality rates of those undergoing multiple valve surgery derived from the Society of Thoracic Surgeons 2008 risk models. A total of 12,170 patients underwent heart valve surgery from January 2008 to December 2011. Combined congenital heart surgery and aortal surgery cases were excluded. A relatively small number of valve surgery combinations were excluded. The final research population included the following isolated heart valve surgery types: aortic valve replacement, mitral valve replacement, and mitral valve repair. The following combined valve surgery types were included: mitral valve replacement plus tricuspid valve repair, mitral valve replacement plus aortic valve replacement, and mitral valve replacement plus aortic valve replacement and tricuspid valve repair. Evaluation was performed by using the Hosmer-Lemeshow test and C-statistics. Data from 9846 patients were analyzed. The Society of Thoracic Surgeons 2008 cardiac risk models showed reasonable discrimination and poor calibration (C-statistic, 0.712; P = .00006 in Hosmer-Lemeshow test). Society of Thoracic Surgeons 2008 models had better discrimination (C-statistic, 0.734) and calibration (P = .5805) in patients undergoing isolated valve surgery than in patients undergoing multiple valve surgery (C-statistic, 0.694; P = .00002 in Hosmer-Lemeshow test). Estimates derived from the Society of Thoracic Surgeons 2008 models exceeded the mortality rates of multiple valve surgery (observed/expected ratios of 1.44 for multiple valve surgery and 1.17 for single valve surgery). The Society of Thoracic Surgeons 2008 cardiac surgery risk models performed well when predicting the mortality for Chinese patients undergoing valve surgery. The Society of Thoracic Surgeons 2008 models were suitable for single valve surgery in a Chinese population; estimates of mortality for multiple valve surgery derived from the Society of Thoracic Surgeons 2008 models were less accurate.

Invited Commentary

In the current health care environment, there is a seemingly endless amount of data with which one can assess performance, identify patterns, compare processes, and hopefully improve outcomes. We have powerful software and tools to help us use data in ways not imagined when the data were first collected. Yet, to use data wisely, one must remember the words of 19th century mathematician Charles Babbage [1Babbage C. Passages from the life of a philosopher. Longman and Company, London1864Google Scholar]:On two occasions I have been asked, “Pray, Mr. Babbage, if you put into the machine wrong figures, will the right answers come out?” I am not able rightly to apprehend the kind of confusion of ideas that could provoke such a question. In other words, as the old adage of computing goes garbage in, garbage out. In this article, Pasquali and colleagues [2Pasquali S.K. Peterson E.D. Jacobs J.P. et al.Differential case ascertainment in clinical registry versus administrative data and impact on outcomes assessment in pediatric cardiac operations.Ann Thorac Surg. 2013; 95: 197-203Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar] assess the quality of the figures we put into our machines, using an example in pediatric heart surgery. In a comparison of administrative data from the Pediatric Health Information Systems (PHIS) database with clinical data from the Society for Thoracic Surgeons Congenital Heart Surgery (STS-CHS) database, agreement between the two databases was poor. Furthermore, the administrative database had a rather low positive predictive value for identifying true cases of pediatric heart surgery. As the authors indicate, the finding that administrative data fare poorly as compared to clinical data with regards to accuracy of diagnosis and procedure is not novel. However, what is noteworthy about these findings is the effect that these inaccuracies may have on assessing and comparing outcomes. The administrative data substantially overestimated the mortality for some operations and underestimated the mortality for others. For a system in which hospitals are often compared based on outcomes determined by administrative data, these results should be eye-opening. Where should we go from here? Rather than focus on the inadequacies of administrative data demonstrated in this article, I believe that we should recognize the paradigm shift that these findings present. No database is perfect; each has its own set of strengths and weaknesses. By merging databases, however, we can maximize the strengths while minimizing the weaknesses. In the absence of global unique identifiers, this is not an easy task. Yet the opportunity (and challenge) before us lies in the ability to successfully link databases such as PHIS and STS-CHS with a myriad of other databases in critical care, anesthesia, catheterization, electrophysiology, federal agencies, and more. Only by taking advantage of the strengths that the various databases offer will we be able to put the right figures into the machine so that the right answers may come out. Differential Case Ascertainment in Clinical Registry Versus Administrative Data and Impact on Outcomes Assessment for Pediatric Cardiac OperationsThe Annals of Thoracic SurgeryVol. 95Issue 1PreviewAdministrative datasets are often used to assess outcomes and quality of pediatric cardiac programs; however their accuracy regarding case ascertainment is unclear. We linked patient data (2004–2010) from the Society of Thoracic Surgeons Congenital Heart Surgery (STS-CHS) Database (clinical registry) and the Pediatric Health Information Systems (PHIS) database (administrative database) from hospitals participating in both to evaluate differential coding/classification of operations between datasets and subsequent impact on outcomes assessment. Full-Text PDF

Our experience with pectoralis major flap for management of sternal dehiscence: A review of 25 cases

Objective:To report our experience of the pectoralis major flap as the treatment modality for post coronary artery bypass sternal wound dehiscence.Materials and Methods:A retrospective study of 25 open heart surgery cases, performed between January 2006 and December 2010 at Deenanath Mangeshkar Hospital, Pune, was carried out. Unilateral or bilateral pectoralis major muscle flap by the double breasting technique using rectus extension was used in the management of these patients. The outcome was assessed on the basis of efficacy of flap surgery in achieving wound healing and post-surgery shoulder joint movements to evaluate donor site morbidity. The follow-up ranged from 5 months to 3.5 years.Results:Twenty-three (92%) patients were discharged with complete wound closure. One patient (4%) had wound dehiscence after flap surgery. One patient (4%) died in the hospital in the immediate postoperative period due to mediastinitis. No recurrent sternum infection has occurred till date in 24 patients (96%). For one patient (4%) who had wound dehiscence, daily dressing was done and wound healing was achieved with secondary intension. At follow-up, shoulder joint movements were normal in all the patients.Conclusions:The double breasting technique of the pectoralis major muscle flaps with rectus sheath extension is efficient in covering the entire length of the defect and can reduce the morbidity, without affecting the function of the shoulder joint.

Cardiovascular surgery for congenital heart disease associated with trisomy 18

Trisomy 18 (T18) is the second most common autosomal trisomy after trisomy 21 (T21). More than 90% of patients with T18 have congenital heart disease (CHD). Patients with T18 also have multiple malformations and severe psychomotor retardation, and their 1-year survival rate is 5%–10%. No criteria for surgical treatment of CHD in patients with T18 have been established. The prognosis of patients with T21 has been signifi cantly improved as surgical treatment of CHD for these patients has become common. However, the prognosis of patients with T18 is still poor, and it has been believed that surgical treatment does not improve their survival. Thus, CHD in this patient population has been managed conservatively. However, since 1990s, cases of heart surgery in patients with T18 have been reported in and outside Japan, and Graham et al. have evaluated the outcome of surgery in many patients with T18 (Table 1). Recently, indications for surgical treatment of CHD in patients with T18 have been discussed more extensively. In patients with T18, the risk of complications associated with surgical treatment of CHD is high, as is the risk of early death due to causes other than CHD. Because no well-defi ned criteria for heart surgery are available for patients with T18, physicians often experience diffi culty when determining whether heart surgery should be performed. In reports advocating surgical treatment of CHD for patients with T18, including that by Kobayashi et al. in this issue, authors have suggested that surgical treatment, when performed with full understanding of the disease by the parents and with their hope for improving their children’s condition, may contribute to improving the life expectancy of patients, discharge from hospital, and improving the quality of life (QOL) of both patients and their family. Opinions supportive of aggressive surgical treatment of CHD for patients with T18 may be based on recent advances in neonatal care. Kosho et al. reported that mechanical ventilation, surgical correction of gastrointestinal and respiratory complications, and active medical treatment of CHD in 24 patients with T18 improved the 1-year survival to 25%. Although these 24 patients did not undergo heart surgery, the fi ndings suggest that multimodality therapy for complications related to T18 may improve at least short-term survival. However, such reports remain scanty. A larger number of cases must be accumulated, as in the above-mentioned report by Kobayashi et al, for development of guidelines for treating these patients. The Genetics & Epidemiology Committee of the Japan Society of Pediatric Cardiology and Cardiac Surgery, of which the author is the chairperson, developed a survey plan to investigate the conditions of patients with T18 in Japan. Some of the results obtained from 15 institutions by the end of 2008 are briefl y summarized as follows.

The contribution of complications to high resource utilization during congenital heart surgery admissions.

The Institutes of Medicine estimates that patient safety events cost the United States between $17 billion and $29 billion annually. Costs associated with patient safety events or complications among congenital heart surgery admissions are understudied. To determine the independent contribution of complications on increased resource utilization during congenital heart surgery admissions. Data were obtained from the Healthcare Cost and Utilization Project Kids' Inpatient Database year 2000. Cases of congenital heart surgery <18 years of age were identified. High resource use admissions were defined as admissions above the 90th percentile for total hospital charges. Complications were identified by a method published by the Agency for Healthcare Research Quality using ICD-9-CM codes. Multivariate analyses using generalized estimating equations adjusted for previously identified factors associated with high resource use to estimate the independent effect of a complication on high resource use. These factors include: Risk Adjustment for Congenital Heart Surgery risk categories, age, prematurity, major noncardiac structural anomalies, Medicaid, weekend admission, and state. The added explanatory power attributed to a complication diagnosis variable was measured by an increase in the area under the receiver operator characteristic curve (ROC). Among 10,602 congenital heart surgery admissions identified, the median total charges were $51,125. The threshold for high resource use was total charges >or=$192,272. High resource admissions accounted for >40% of the total charges for all admissions. Complications were identified in 3360 (32%) of congenital heart surgery admissions. Univariate analysis demonstrated that admissions with at least 1 complication diagnosis were more likely to be a high resource use admission (18% vs. 6%, OR 3.0, P < 0.001). Multivariate analyses revealed that admissions with a complication diagnosis were much more likely to exceed the threshold for high resource utilization (OR 3.2, P < 0.001). The addition of the complication variable to the multivariate model increased the area under the ROC curve from 0.837 to 0.863. Congenital heart surgery admissions with a complication diagnosis are 3 times more likely to exceed $192 272 in total charges despite adjusting for known risk factors for high resource use. Complication reduction may result in both an economic and clinical benefit.

Factors Associated With Increased Resource Utilization for Congenital Heart Disease

To identify patient, institutional, and regional factors that are associated with high resource utilization for congenital heart surgery. We used hospital discharge data from the Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID) year 2000 (data from 27 states). Patients who had congenital heart surgery and were younger than 18 years were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. High resource utilization admissions were defined as those in the highest decile for total hospital charges. Univariate and multivariate analyses with and without deaths were used to determine demographic and hospital predictors for cases of high resource use. Case-mix severity was approximated using Risk Adjustment for Congenital Heart Surgery risk groups. Regional and state differences were also examined. Among 10,569 cases of congenital heart surgery identified, median total hospital charges were 53,828 dollars. Statewide differences in the number of high resource use admissions were present; California, Colorado, Florida, Hawaii, Pennsylvania, and Texas were more likely to have high resource use cases, and Maine and South Carolina were less likely. Subsequent analyses were performed adjusting for baseline state effects. Multivariate analyses using generalized estimating equations models revealed Risk Adjustment for Congenital Heart Surgery risk category (odds ratio [OR]: 1.66-14.1), age (OR: 3.81), prematurity (OR: 4.85), the presence of other major noncardiac structural anomalies (OR: 2.53), Medicaid insurance (OR: 1.48), and admission during a weekend (OR: 1.62) to be independent predictors of a higher odds of high cost cases. Although some institutional differences were noted in univariate analyses, gender, race, bed size, teaching and children's hospital status, hospital ownership, and hospital volume of cardiac cases were not independently associated with greater odds of high resource utilization. States varied in the frequency of high resource utilization for congenital heart surgery. Patients who had greater disease complexity, younger age, prematurity, other anomalies, and Medicaid and were admitted during a weekend were more likely to result in high resource utilization. Institutions of various types did not differ in high cost admissions, regardless of children's hospital or teaching status.

68 Marked Statewide Variation in Risk-Adjusted Hospital Charges for Congenital Heart Surgery

Background: Selected referral to institutions with low mortality rates has been proposed as a strategy to improve outcomes for congenital heart surgery; the impact of such strategies in medical costs is not known. Objective: To examine whether total hospital charges for congenital heart surgery varies across geographic regions. Methods: Cases of congenital heart surgery (<18y) were identified from the Health Care Utilization Project KID 2000 database (27 states) using ICD-9-CM codes. To adjust for baseline case mix differences, patient characteristics independently associated with higher hospital charges were identified. Procedures were grouped into RACHS-1 risk categories. Reported total hospital charges were log transformed. Differences between observed and expected mean total hospital charges were examined for each state; predictors of these differences were explored. Proportions of state volume of congenital heart surgery, proportions of caseload at children's and teaching hospitals, and complexity of case mix by insurance were also examined. Results: Among the 9,406 cases of congenital heart surgery for which a RACHS-1 risk category could be assigned, mean total hospital charges were $54,725. RACHS-1 risk category, age, prematurity, major non-cardiac structural anomaly, multiple surgical procedures, chromosomal abnormality and weekend admisiion were associated with higher charges. Among the 27 states examined, charges varied by $51,912 ($24,020 to -$27,892). Institutional and case mix descriptors were not found to be associated with the average dollar charge differential. Conclusions: States vary considerably in risk adjusted total hospital charges for congenital heart surgery procedures. These variations could not be explained by state volume of congenital heart surgery cases per number of institutions performing congenital heart surgery, proportions of caseload at children's and teaching hospitals, and complexity of case mix by insurance.

Competence to practise and revalidation: all change for the PAMs

Professional fitness to practise is a major issue within the public arena. In light of the Bristol heart surgery cases, the main focus of interest has been the medical profession. This has lead to massive scrutiny of the methods by which the General Medical Council (GMC) regulates and assesses doctors' practice. The changes in the medical profession with which this has coincided have implications for the development of fitness to practise standards for the professions allied to medicine (PAMs).

開心手術症例におけるコイル加熱型連続心拍出量測定装置，混合静脈血酸素飽和度測定装置の有用性について

連続心拍出量測定(CCO),混合静脈血酸素飽和度(SvO2)の両方を連続表示するモニターリングシステム(Vigilance)を用い,人工心肺装着下の開心術例64例を対象とし検討を行った。Baxter社製CCOスワンガンツカテーテルを肺動脈内に挿入・留置し,CCOとSvO2を48時間にわたって持続的に測定した。開心術直後の血行動態は従来考えられていたように,SvO2とCCOの変化は必ずしも相関せず,様々な原因から解離した変化を示した。従来のスワンガンツカテーテルを用いた管理に比し,血行動態を迅速かつ的確な把握を可能とする点で有用性は高い。しかし,SvO2はCCOに比し迅速に反応するという報告はなされているものの,SvO2のみの変化による患者管理には注意を必要とすることが示された。Key words:CCO,SvO2,Vigilance