Major Residua Research Articles

Technical performance scores associate with early prognosis of tetralogy of Fallot repair.

This study aimed to investigate the relationship between technical performance scores (TPS) and the early prognosis of tetralogy of Fallot repair (TOF). A retrospective study was conducted on TOF repair patients at our center from Oct 2017 to Oct 2022. Patients were classified into Class 1 (no residua), Class 2 (minor residua), or Class 3 (major residua) based on TPS derived from predischarge echocardiograms and need for reintervention. Statistical methods were used to assess the association between TPS and early prognosis. A total of 75 TOF repair patients (40% female, 60% male) were analyzed and categorized into TPS1 (24%), TPS2 (53.3%), and TPS3 (22.6%) based on pre-discharge echocardiographic findings. The median follow-up time was 7.0 months. The multivariable Cox regression analysis indicated that TPS3 scores are associated with a 12.68-fold increase in risk compared to TPS1 and TPS2 scores [95% CI = 12.68 (0.9∼179.28), P = 0.06]. The Spearman rank correlation analysis revealed a weak positive correlation between TPS classification and low cardiac output syndrome (r = 0.26, P = 0.03). However, there were no significant differences in ICU stay or duration of mechanical ventilation among the groups. TPS3 after intracardiac TOF repair is associated with higher risk of early re-intervention, highlighting the importance of close follow-up and monitoring in this patient population. Patients who develop low cardiac output syndrome in the early postoperative period may have residual defects that require prompt identification.

Impact of Residual Lesion Severity on Neurodevelopmental Outcomes Following Congenital Heart Surgery in Infancy and Childhood.

Children with congenital heart disease are at increased risk of neurodevelopmental delay throughout their lifespan. This risk is exacerbated following congenital heart surgery (CHS) in infancy. However, there are few modifiable risk factors for postoperative neurodevelopmental delay. In this study, weassessed the Residual Lesion Score (RLS), a quality assessment metric that evaluates residual lesion severity following CHS, as a predictor of neurodevelopmental delay. This was a single-center, retrospective review of patients who underwent CHS from 01/2011 to 03/2021 and post-discharge neurodevelopmental evaluation from 12 to 42months of age using the Bayley Scales of Infant Development, 3rd Edition (BSID-III). RLS was assigned per published criteria: RLS 1, no residua; RLS 2, minor residua; and RLS 3, major residua or pre-discharge reintervention. Associations between RLS and BSID-III scores, as well as trends in neurodevelopmental outcomes over time, were evaluated. Of 517 patients with median age at neurodevelopmental testing of 20.0 (IQR 18.0-22.7) months, 304 (58.8%), 146 (28.2%), and 67 (13.0%) were RLS 1, 2, and 3, respectively. RLS 3 patients had significantly lower scaled scores in the cognitive, receptive, and expressive communication, and fine and gross motor domains, compared with RLS 1 patients. Multivariable models accounted for 21.5%-31.5% of the variation in the scaled scores, with RLS explaining 1.4-7.3% of the variation. In a subgroup analysis, RLS 3 patients demonstrated relatively fewer gains in cognitive, expressive communication, and gross motor scores over time (all p < 0.05). In conclusion,RLS 3 patients are at increased risk for neurodevelopmental delay, warranting closer follow-up and greater developmental support for cognitive, language, and motor skills soon after surgery.

Abstract 10403: Residual Lesion Severity is Associated With Adverse Neurodevelopmental Outcomes in Young Children With Congenital Heart Disease

Introduction: There are few modifiable risk factors for adverse neurodevelopmental (ND) outcomes in congenital heart disease. We assessed the Residual Lesion Score (RLS), a quality improvement metric that assesses residual lesion severity following congenital heart surgery (CHS), as a predictor of ND delay. Hypothesis: We hypothesized that RLS would be independently associated with ND outcomes. Methods: This was a single center, retrospective review of patients who underwent CHS from 01/2011-12/2019 and received post-discharge ND evaluation between the ages of 12 and 42 months using the Bayley Scales of Infant Development, 3 rd ed. (BSID-3). RLS was assigned at discharge per previously published criteria: Class 1, no residua; Class 2, minor residua; Class 3, major residua or in-hospital unplanned reintervention. Associations between RLS and BSID-3 scores (at the first ND evaluation) were evaluated using linear regression, adjusting for baseline patient risk, the Childhood Opportunity Index, and maternal education level. Linear mixed effects models assessed trends in ND outcomes over time. Results: Of 477 patients with mean age at ND testing of 21.2 ± 6.1 months, 282 (59.1%), 132 (27.7%), and 63 (13.2%) patients had RLS 1, 2, and 3 lesions, respectively. Table 1A shows BSID-3 outcomes by RLS. On multivariable analysis, Class 3 patients had significantly lower cognitive, receptive and expressive communication, and fine and gross motor scaled scores, compared to Class 1 patients, with the largest difference observed in the cognitive domain ( Table 1B ). In a subset of 191 patients with more than one ND evaluation, Class 3 patients made fewer gains in skills from the first to the last evaluation in the cognitive and language domains, compared to Class 1 patients (both p&lt;0.05). Conclusions: Patients with major residua (RLS 3) are at increased risk for ND delay, warranting closer ND follow-up and greater developmental support for cognitive, communication, and motor skills.

A Risk Prediction Model for Reintervention After Total Anomalous Pulmonary Venous Connection Repair

BackgroundOutcomes after total anomalous pulmonary venous connection (TAPVC) repair remain suboptimal due to recurrent pulmonary vein (PV) obstruction requiring reinterventions. We sought to develop a clinical prediction rule for PV reintervention after TAPVC repair. MethodsData from consecutive patients who underwent TAPVC repair at a single institution from January 1980 to January 2020 were retrospectively reviewed after Institutional Review Board approval. The primary outcome was postdischarge (late) unplanned PV surgical or transcatheter reintervention. Echocardiographic criteria were used to assess PV residual lesion severity at discharge (class 1: no residua; class 2: minor residua; class 3: major residua). Competing risk models were used to develop a weighted risk score for late reintervention. ResultsOf 437 patients who met entry criteria, there were 81 (18.5%) reinterventions at a median follow-up of 15.6 (interquartile range, 5.5-22.2) years. On univariable analysis, minor and major PV residua, age, single-ventricle physiology, infracardiac and mixed TAPVC, and preoperative obstruction were associated with late reintervention (all P < .05). The final risk prediction model included PV residua (class 2: subdistribution hazard ratio [SHR], 4.8; 95% CI, 2.8-8.1; P < .001; class 3: SHR, 6.4; 95% CI, 3.5-11.7; P < .001), age <1 year (SHR, 3.3; 95% CI, 1.3-8.5; P = .014), and preoperative obstruction (SHR, 1.8; 95% CI, 1.1-2.8; P = .015). A risk score comprising PV residua (class 2 or 3: 3 points), age (neonate or infant: 2 points), and obstruction (1 point) was formulated. Higher risk scores were significantly associated with worse freedom from reintervention (P < .001). ConclusionsA risk prediction model of late reintervention may guide prognostication of high-risk patients after TAPVC repair.

Intraoperative Technical Performance Score Predicts Outcomes After Congenital Cardiac Surgery

BackgroundThe utility of the intraoperative technical performance score (IO-TPS) in predicting outcomes after congenital cardiac surgery remains unknown. MethodsData from patients undergoing surgery for congenital heart disease from January 2011 to December 2019 at a single institution were retrospectively reviewed. Intraoperative echocardiograms were used to assign IO-TPS for each index operation (class 1, no residua; class 2, minor residua; class 3, major residua). The primary outcome was a composite of in-hospital mortality, transplant, unplanned reintervention in the anatomic area of repair, and new permanent pacemaker implantation. Secondary outcomes included postdischarge (late) mortality or transplant and unplanned reintervention. Associations between IO-TPS and outcomes were assessed using logistic (primary) and Cox or competing risk (secondary) models, adjusting for preoperative patient- and procedure-related covariates. ResultsThe primary outcome was observed in 784 (11.5%) of 6793 patients who met entry criteria. On multivariable analysis, IO-TPS was a significant predictor of the primary outcome (class 2: odds ratio, 1.7 [95% CI, 1.4-2.0; P < .001]; class 3: odds ratio, 6.0 [95% CI, 4.0-8.9; P < .001]). Among 6661 transplant-free survivors of hospital discharge observed for up to 10.5 years, there were 185 (2.8%) deaths or transplants and 1171 (17.6%) reinterventions. Class 3 patients had a greater adjusted risk of late mortality or transplant (hazard ratio, 2.2; 95% CI, 1.2-4.2; P = .012) and late reintervention (subdistribution hazard ratio, 2.5; 95% CI, 1.8-3.3; P < .001) vs class 1 patients. ConclusionsIO-TPS is significantly associated with adverse early and late outcomes after congenital heart surgery and may serve as an important adjunct for self-assessment and quality improvement.

How Good Is Good Enough?

The technical performance score (TPS) has been investigated across numerous studies as a tool to assess residual lesions after congenital heart surgery.1,2 TPS has been shown to be associated with both early and late outcomes and is defined by echocardiographic assessment, graded as class 1 (no residua), class 2 (minor residua), and class 3 (major residua). Traditionally TPS has been evaluated using the discharge echocardiogram (DC-TPS). However, this approach is limited in that it does not provide assessment at the time of the operation, nor allow for intervention at that time or during the hospital period.

Comparison of Intraoperative and Discharge Residual Lesion Severity in Congenital Heart Surgery

BackgroundWhile the predischarge technical performance score (DC-TPS) is significantly associated with outcomes after congenital cardiac surgery, the utility of the intraoperative TPS (IO-TPS) remains unknown. MethodsThis was a single-center retrospective review of consecutive patients who underwent congenital cardiac surgery from January 2011 to December 2019. Intraoperative and predischarge echocardiograms were used to assign IO-TPS and DC-TPS, respectively, for each index operation (class 1, no residua; class 2, minor residua; class 3, major residua). Anatomic modules identifying the principal residual lesion were assigned to all class 2/3 patients. Overall and module-specific TPS comparisons were made. Multivariable regression models with IO-TPS and DC-TPS as separate predictors of postoperative outcomes were compared. ResultsOf 6201 patients, overall agreement between IO-TPS and DC-TPS was observed in 4251 patients (68.6%); scores were likelier to be worse at discharge (P < .001). Paired comparative analyses revealed that among patients with at least class 2 atrioventricular and semilunar valve residua, IO-TPS was likelier to worsen than improve (both P < .001). Class 3 patients had a higher risk of in-hospital/early mortality (IO-TPS: odds ratio, 7.5; 95% CI, 2.4-23; DC-TPS: odds ratio, 6.6; 95% CI, 3.0-15), postdischarge/late mortality (IO-TPS: hazard ratio [HR], 3.1, 95% CI, 1.3-7.1; DC-TPS: HR, 2.3; 95% CI, 1.2-4.4), and late unplanned reintervention (IO-TPS: HR, 2.8; 95% CI, 1.9-4.0; DC-TPS: HR, 3.4; 95% CI, 2.8-4.2) vs class 1 (all P < .05). IO- and DC-TPS models were equivalent fits for predicting early and late mortality; the latter was a marginally better fit for late reintervention. ConclusionsIO-TPS and DC-TPS are both important adjuncts for quality improvement in congenital cardiac surgery.

Digital solution for follow-up in congenital cardiac surgery.

In this era of public scrutiny, there is an ongoing need for innovative methods for patient follow-up. As part of a quality initiative, we developed an automated post-operative follow-up system for patients following discharge after cardiac surgery at Boston Children's Hospital. Discharge Communication (DisCo) is a web-based system developed at Boston Children's Hospital. An automated text and e-mail with a link to a health status survey are sent at 30 days and 1 year post-discharge in English/Spanish. If there is no response, surveys are completed via phone calls to the patient/patient's physician or chart review. Responses are stored in the DisCo database and the patient's medical record. Patients who underwent cardiac surgery and survived to hospital discharge from October, 2016 received the surveys. Overall, 334530-day and 25631-year surveys were sent between October, 2016 and June, 2020. Of 334530-day surveys, there were 3191 responses (95%). Of 25631-year surveys, there were 1807 responses (71%). Most patients/families responded directly to the link at 30 days (65% for paediatrics/75% for adults) and at 1 year (72% for paediatrics/78% for adults). Multi-variable logistic regression revealed that higher complexity of cardiac lesion, presence of major non-cardiac anomalies and presence of major residua were associated with readmission and catheter/surgical reinterventions. Non-cardiac anomalies were associated with increased need for services for learning, development or behaviour. DisCo provides a successful web-based health status assessment of patients following congenital cardiac surgery. It helps to identify high-risk patients who need closer follow-up.

Technical Performance Score’s Association With Arterial Switch Operation Outcomes

Outcomes after the arterial switch operation (ASO) for dextro-transposition of the great arteries have improved significantly since its inception in the 1980s. This study reviews contemporaneous outcomes and predictors for late reinterventions after ASO. We retrospectively reviewed patients who underwent ASO for dextro-transposition of the great arteries from 1997 to 2017. Technical performance score (TPS) class (class 1, trivial or no residua; class 2, minor residua; class 3, major residua or reintervention) was assigned at discharge based on echocardiographic evaluation of components of the ASO. Multivariable Cox regression identified patient- and procedure-specific factors associated with postdischarge reinterventions. Among 598 patients, 410 (69%) underwent ASO and 188 (31%) underwent ASO with ventricular septal defect repair. Median age at surgery was 5 days (interquartile range, 3 to 7); median follow-up time was 8.2 years; 408 (68%) were male; 50 (8.3%) were premature; and 10 (1.7%) had noncardiac anomalies or syndromes. Survival to hospital discharge was 98% (n= 591). Among 349 patients with follow-up, freedom from unplanned reintervent2ion at 5 years was 99% for TPS class 1, compared with 84% for class 2 and 30% for class 3. On multivariable Cox regression, classes 2 and 3 had significantly higher hazard for reintervention (class 2 hazard ratio 10.6; 95% confidence interval, 2.5 to 44.2; P= .001; class 3 hazard ratio 58.2, 95% confidence interval, 13.1 to 259; P < .001). At our center, ASO was associated with relatively low mortality. Class 2 and class 3 TPS were the most important independent predictors of reinterventions after discharge. Therefore, TPS can serve as a tool for identifying high-risk patients who warrant closer follow-up.

Atrioventricular Valve Function Predicts Reintervention in Complete Atrioventricular Septal Defect.

Objective:Technical performance score (TPS) has been associated with both early and late outcomes across a wide range of congenital cardiac procedures. A previous study has shown that the presence of residual lesions before discharge, as measured by TPS, is accurately able to identify patients who required postdischarge reinterventions after complete atrioventricular septal defect (CAVSD) repair. The aim of this study is to determine which subcomponents of TPS best predict postdischarge reinterventions after CAVSD repair.Methods:This was a single-center retrospective review of patients with CAVSD after repair between January 2000 and March 2016. We assigned TPS (class 1, no residua; class 2, minor residua; class 3, major residua or reintervention before discharge for residua) based on subcomponent scores from discharge echocardiograms. Outcome of interest was postdischarge reintervention.Results:Among 344 patients, median age was 3.2 months (interquartile range [IQR], 2.4-4.2). There were 34 (10%) postdischarge reinterventions. Median follow-up was 2.6 years (IQR, 0.09-7.9). Trisomy 21 and concomitant procedure were associated with postdischarge reinterventions. After adjusting for these factors, among the subcomponents, left atrioventricular valve stenosis and regurgitation, right atrioventricular valve regurgitation, residual ventricular septal defect, and abnormal conduction at discharge were significantly associated with postdischarge reinterventions.Conclusions:We demonstrated the ability of TPS to predict postdischarge reinterventions in patients who underwent CAVSD repair. Residual left and right atrioventricular valve regurgitation and abnormal conduction at discharge were among the subcomponents strongly associated with postdischarge reinterventions. Thus, TPS may aid clinicians in identifying children at higher risk for reintervention.

The Pediatric Heart Network Residual Lesion Score Study: Design and objectives

ObjectivesThe Residual Lesion Score (RLS) was developed as a novel tool for assessing residual lesions after congenital heart operations based on widely available clinical and echocardiographic characteristics. The RLS ranks postoperative findings as follows: Class 1 (no/trivial residua), Class 2 (minor residua), or Class 3 (major residua or reintervention before discharge for residua). The multicenter prospective RLS study aims to analyze the influence of residual lesions on outcomes in common congenital cardiac operations. We hypothesize that RLS will predict postoperative adverse events, resource utilization, mortality, and reinterventions by 1 year postoperatively. MethodsThe study cohort consisted of infants aged ≤12 months undergoing definitive surgery for complete atrioventricular septal defect, tetralogy of Fallot, dextro-transposition of the great arteries with or without intact ventricular septum, single ventricle (Norwood procedure), and coarctation or interrupted/hypoplastic arch with ventricular septal defect. Children with major congenital or acquired extracardiac anomalies that could independently affect the primary end point, which was number of days alive and out of the hospital within 30 days of surgery (60 days for Norwood procedure), were excluded. Secondary outcomes included ≥1 early major postoperative adverse event; days of intensive care unit and hospital stay, and initial and total ventilator time; mortality/transplant after discharge; unplanned reinterventions after discharge; and cost. All analyses will be performed separately by surgical operation. ConclusionsThis is the first multicenter prospective validation of a tool for surgical outcome assessment and quality improvement specific to congenital heart surgery.

Technical Performance Score Predicts Partial/Transitional Atrioventricular Septal Defect Outcomes

Repair of partial or transitional atrioventricular septal defects (P/TAVSDs) has excellent outcomes; however, late reinterventions remain a concern. Technical performance score (TPS) measures residua after repair and has been associated with early/mid-term outcomes after congenital cardiac operation. Our studyinvestigates TPS as a predictor of outcomes after P/TAVSD repair. This was a single-center retrospective review of P/TAVSD repair from July 2000 to November 2015. Intraoperative and discharge TPS were assigned based on echocardiographic criteria: class 1, no residua; class 2, minor residua; and class 3, major residua or reintervention for major residua. Intensive care unit (ICU) hospital length of stay and reintervention after discharge were analyzed with Cox regression. In our cohort, 124 partial (68%) and 59 transitional (32%) AVSDs underwent repair. Median age was 1.5 years (interquartile range [IQR]: 0.6 to 3.8 years), median weight was 9.7 kg (IQR: 6.6 to 14.1 kg), and 96 (52%) were female. Twenty patients (11%) required reintervention after discharge. On multivariable modeling, patients with TPS class 3 spent more days in the ICU (hazard ratio [HR] 0.33, 95% confidence interval [CI]: 0.19 to 0.58, p < 0.001) and hospital (HR 0.33, 95% CI: 0.19 to 0.57, p < 0.001) and had shorter time to reintervention after discharge (HR 8.76, 95% CI: 1.03 to 74.7, p=0.047). Major residua, that is TPS class 3, were a predictor of in-hospital outcomes and unplanned reinterventions after discharge, with left atrioventricular valve regurgitation being the strongest predictor. Use of TPS as a tool for residual lesions may identify patients predisposed to prolonged ICU hospital stay and reinterventions after discharge, providing feedback on areas in need of improvement in technique and identification of patients who warrant closer follow-up.

Technical Performance Score: Predictor of Outcomes in Complete Atrioventricular Septal Defect Repair

Technical performance score (TPS) has been associated with both early and late outcomes across a wide range of congenital cardiac procedures. We sought to validate TPS as predictor of outcomes for complete atrioventricular septal defect (CAVSD) repair. This was a single-center retrospective review of patients after balanced CAVSD repair between January 1, 2000, and March 1, 2016. We assigned TPS (class 1, no residua; class 2, minor residua; class 3, major residua or reintervention before discharge for residua) based on summation of subcomponent scores from discharge echocardiograms. Outcomes of interest were in-hospital complications, postoperative days on ventilator, and postdischarge reintervention. Among 350 patients, median age was 3.2 months (interquartile range [IQR], 2.4 to 4.2 months). Fifty-four patients (16%) had class 1 TPS, 218 (62%) class 2, 63 (18%) class 3, and 15 (4%) were unscorable. There were 36 complications (10%), and median postoperative days on ventilator were 2 (IQR, 1 to 3) days. There were 34 postdischarge reinterventions (10%). Median follow-up was 2.6 years (IQR, 0.09 to 7.9) years. On multivariable modeling, class 3 TPS was associated with complications (odds ratio 5.45, 95% confidence interval [CI]: 1.06 to 28.1, p= 0.04), prolonged postoperative ventilator days (hazard ratio [HR] 0.54, 95% CI: 0.37 to 0.80, p= 0.002), and postdischarge reintervention (HR 5.61, 95% CI: 1.28 to 24.5, p= 0.02) after adjusting for covariates such as age, weight, genetic abnormality, concomitant procedure, prematurity, and second bypass run. At our center, CAVSD repair was associated with low morbidity. TPS may identify patients with complications, prolonged days on ventilator, and who require postdischarge reinterventions; thus, it provides feedback on areas of improvement and allows identification of patients who warrant closer follow-up.

Impact of Variability in Echocardiographic Interpretation on Assessment of Adequacy of Repair Following Congenital Heart Surgery: A Pilot Study.

Technical Performance Score (TPS) is based largely on the presence and magnitude of residual lesions on postoperative echocardiograms; this score correlates with outcomes following repair of congenital heart defects. We evaluated reader variability for echocardiographic components of TPS for complete repair of tetralogy of Fallot (TOF) and arterial switch operation (ASO) in two centers and measured its effect on TPS. Postoperative echocardiograms were evaluated in 67 children (39 TOF and 28 ASO). Two readers (one per center) interpreted each echocardiogram. Reader variability in image quality assessments and measurements was compared using weighted kappa (κ), percent agreement, and intra-class correlation. TPS class (1 optimal-no residua, 2 adequate-minor residua, 3 inadequate-major residua) was assigned for each echocardiographic review by an independent investigator. The effect of reader interpretation variability on TPS classification was measured. There was strong agreement for TPS between the two readers (κ = 0.88). The readers were concordant for TPS classes for 57 children (85%) and discordant for classes 2 (minor residua) versus 3 (major residua) in six (9%). Coronary arteries and branch pulmonary arteries were frequently suboptimally visualized. Although inter-reader agreement for TPS was strong, inter-reader variation in echocardiographic interpretations had a small, but important effect on TPS for TOF and ASO, particularly for the distinction between minor and major residua. Further studies of generalizability and reproducibility of TPS and refinement of scoring modules may be needed before it can be used as a tool to assess pediatric cardiac surgical performance and outcomes.

Abstract 16887: Impact of Variability in Echocardiographic Interpretation on Assessment of Repair Following Congenital Heart Surgery

Background: Technical Performance Score (TPS), a tool based largely on the presence and magnitude of residua on postoperative echocardiograms (echo), has been used for assessing surgical repair and correlates with outcomes. The reproducibility of the echo measures that drive TPS classification has not been tested. We evaluated reader variability for echo components of TPS for tetralogy of Fallot (TOF) repair and arterial switch operation (ASO) in 2 centers and measured its effect on TPS. Hypothesis: Inter-reader echo measurement variability will not substantially impact TPS classification. Methods: Postoperative echos were evaluated in 67 subjects (39 TOF and 28 ASO). Two readers (1 per center) read each echo, blinded to center of origin. To assess intra-reader variability, 25% of echoes were re-reviewed by each reader. Measurements between readers were compared with Intra-class correlation (ICC). TPS Class (1 Optimal no residua , 2 Adequate minor residua , 3 Inadequate major residua ) was assigned for each echo review by an independent investigator. The impact of measurement variability on overall TPS variability was compared using weighted Kappa (K) and % raw agreement. Results: ICC was highest for Doppler velocity data and lower for measurements of small linear structures such as septal defects and vena contracta Figure. Overall TPS demonstrated good agreement (between reader TOF K = 0.82 and ASO K = 0.81). The 2 readers were concordant for TPS Class for 53 subjects (79%) and discordant for Classes 2 vs. 3 in 6 (9%); no readings were discordant between Classes 1 and 3 Table . Conclusions: Although overall TPS demonstrated good agreement, inter-reader variation for echo measurements had a small, but important effect on TPS for ASO and TOF, particularly for the distinction between minor and major residua. Future studies of generalizability and reproducibility of TPS across centers and lesions are needed before TPS could be adopted as a national quality measure.