Heart Surgery Mortality Research Articles

The Impact of Medicaid Expansion on Congenital Heart Surgery Outcomes: Data From the Society of Thoracic Surgeons Database

BACKGROUND: The Affordable Care Act expanded Medicaid eligibility and increased public insurance coverage for children across the United States. As only a subset of states adopted expansion of coverage, disparities in insurance coverage between expansion and nonexpansion states emerged. We examined the association between Medicaid expansion and cardiac surgery outcomes to understand the impact of Medicaid expansion in a medically complex pediatric population. We hypothesized that expansion of Medicaid eligibility would be associated with greater improvement in surgical outcomes. METHODS: The Society of Thoracic Surgeons Congenital Heart Surgery Database was used to evaluate perioperative outcomes for children 0 to 18 years undergoing cardiac surgery between January 2010 and December 2019. We used a difference-in-differences (DiD) design to estimate the impact of Medicaid expansion on surgical outcomes by comparing changes in outcomes between individuals in expansion states and those in nonexpansion states, both before and after the expansion. Outcomes included operative mortality, major complications and postoperative length of stay (PLOS). RESULTS: The interaction between Medicaid expansion and time period post- vs preexpansion was not significant for any of the outcome variables. The odds ratio (OR) for mortality related to the Medicaid expansion was 1.12 (confidence interval [CI], 0.95–1.32, P = .161). For major complications, the OR was 0.99 (CI, 0.90–1.09, P = .770). For PLOS, the incidence rate ratio was 1.02 (CI, 0.99–1.05, P = .141). CONCLUSIONS: There was an overall decline in congenital heart surgery mortality over time; however, states that expanded Medicaid eligibility did not experience a greater improvement in mortality relative to states that did not expand eligibility. Similarly, there was no significant difference in major complications or PLOS related to Medicaid expansion. Further studies are needed to examine long-term outcomes and the larger spectrum of accessibility to congenital cardiac care which may benefit from insurance coverage.

Using Machine Learning and Feature Importance to Identify Risk Factors for Mortality in Pediatric Heart Surgery.

Background: The objective of this IRB-approved retrospective monocentric study was to identify risk factors for mortality after surgery for congenital heart defects (CHDs) in pediatric patients using machine learning (ML). CHD belongs to the most common congenital malformations, and remains the leading mortality cause from birth defects. Methods: The most recent available hospital encounter for each patient with an age <18 years hospitalized for CHD-related cardiac surgery between the years 2011 and 2020 was included in this study. The cohort consisted of 1302 eligible patients (mean age [SD]: 402.92 [±562.31] days), who were categorized into four disease groups. A random survival forest (RSF) and the 'eXtreme Gradient Boosting' algorithm (XGB) were applied to model mortality (incidence: 5.6% [n = 73 events]). All models were then applied to predict the outcome in an independent holdout test dataset (40% of the cohort). Results: RSF and XGB achieved average C-indices of 0.85 (±0.01) and 0.79 (±0.03), respectively. Feature importance was assessed with 'SHapley Additive exPlanations' (SHAP) and 'Time-dependent explanations of machine learning survival models' (SurvSHAP(t)), both of which revealed high importance of the maximum values of serum creatinine observed within 72 h post-surgery for both ML methods. Conclusions: ML methods, along with model explainability tools, can reveal interesting insights into mortality risk after surgery for CHD. The proposed analytical workflow can serve as a blueprint for translating the analysis into a federated setting that builds upon the infrastructure of the German Medical Informatics Initiative.

The Effect of the Presence of Barrier during Resternotomy in Congenital Heart Surgery.

Reoperation is an important cause of morbidity and mortality in congenital heart surgery. The aim of this study was to assess whether the presence of barrier during resternotomy affected the outcomes of infants and children who underwent congenital heart surgery. A total of 110 (7.6%) patients who underwent reoperations among 1445 consecutive patients between February 2018 and June 2023 were evaluated. The patients were divided into two groups: those with barrier (n = 72) and those without barrier (n = 38). Demographic, intraoperative and postoperative data were retrospectively analyzed. Among the 110 patients, the age at reoperation was 10.1 ± 1.4 years in the group with barrier and 10.9 ± 2.8 years in the group without barrier. There were no statistically significant differences in the age at surgery, preoperative saturation, interval since preceding surgery (years), and aortic cross clamp time (minutes) between the groups. However, there were significantly higher rates of injuries during dissection (p = 0.001) and adverse events (p = 0.002) during dissection in the non-barrier group. One patient in the group without barrier underwent reoperation but subsequently died. The usage of any barrier in front of the right ventricle can decrease the incidence of adverse events, morbidity and mortality.

Association Between Past and Present Operative Mortality in Congenital Heart Surgery: An Analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database

BackgroundMortality after congenital heart surgery is an important metric across benchmarking, quality, and reporting initiatives. All rely on estimates from prior years, and how well these reflect current outcomes is unclear. MethodsIndex operations from The Society of Thoracic Surgeons Congenital Database (2014-2019) were included. Adjusted operative mortality in “past” 4-year and 1-year intervals vs the most recent year (“present”) was evaluated using Bayesian hierarchical logistic regression with results presented as odds ratios and 95% credible intervals (CrI). ResultsAmong 115,699 operations (106 hospitals), overall present observed mortality was 2.5%. Regression to the mean was evident, and individual hospital’s present vs past adjusted mortality were only weakly correlated (−0.11 vs past 1-year data, 0.22 vs past 4-year data). A significant relationship was found between past and present mortality only for the group of hospitals in the highest mortality quartile, most prominent for past 4-year data (adjusted odds ratio vs lowest mortality quartile, 2.04; 95% CrI, 1.44-2.80). The proportion of present hospital mortality variation explained by past mortality quartile was 52% (95% CrI, 20%-90%) using past 4-year data and only 27% (95% CrI, 92%-83%) using past 1-year data. Overall 66% of hospitals changed mortality quartiles from past to present (30% by ≥2 quartiles). ConclusionsPast mortality relates to present primarily for groups of hospitals at the extremes, with past 4-year data more informative than past 1-year data. For individual hospitals, past may differ from present, regression to the mean is common, and many change quartiles. Past mortality should be used thoughtfully and not as the sole factor informing present decision making.

Clinical Variables Specific to Timing of Tracheal Extubation Following Pediatric Cardiac Surgery.

The primary objective of this study was to identify specific factors in pediatric cardiac surgical patients when tracheal extubation was performed on the operating table after completion of open-heart surgery (Group-1), postoperatively in the intensive care unit within 6 h (Group-II) or after 6 h (Group-III). The causes of failed extubation, the presence of chromosomal disorders in addition to arterial blood gas analysis parameters at the time of tracheal extubation, and the duration of intensive care unit stay were also evaluated in each group. In addition to the three groups, Groups I and II were combined as a "fast-track" extubation group. The demographic data, Risk Adjustment for Congenital Heart Surgery (RACHS-1) score, the Society of Thoracic Surgeons - European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Category (STAT Mortality Category), cardiopulmonary bypass (CPB) time, aortic cross-clamp (ACC) time, and vasoactive-inotropic score (VIS) at the time of tracheal extubation along with data related to secondary objectives were recorded for each patient. A significant association was found by bivariate analysis between clinical variables and for both operating table and fast-track extubation in terms of age, weight, RACHS-1 score, STAT category, CPB and ACC time, and VIS. A multivariate-adjusted analysis showed weight, lower STAT category, CPB time, and VIS were independent predictors for operating table and fast-track extubation. Younger age, lower weight, higher RACHS-1, STAT category, and VIS, along with longer CPB and ACC, are associated with delay in the timing of tracheal extubation in pediatric cardiac surgical patients.

Morbidity and Mortality in Adult Congenital Heart Surgery: Physiologic Component Augments Risk Prediction

BackgroundWe sought to evaluate whether the anatomic and physiologic stratification system (ACAP score), released as part of the American College of Cardiology/American Heart Association updated guidelines for management of adult congenital heart disease (ACHD) in 2018, better estimated mortality and morbidity after cardiac operations for ACHD. MethodsThe ACAP score was determined for 318 patients (age ≥18 years) with ACHD undergoing heart surgery at our institution between December 2001 and August 2019. The primary end point was perioperative mortality. The secondary aim was to evaluate the performance of the ACAP, The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) Congenital Heart Surgery Mortality Categories, and ACHS mortality scores/categories at predicting a composite adverse outcome of perioperative mortality, prolonged ventilation, and renal failure requiring replacement therapy. Logistic regression models were built to estimate mortality and the composite outcome using anatomic and physiologic components independently and together. Receiver operating characteristic curves were created, and area under the curves were compared using the Delong test. ResultsThe median age was 37 years (interquartile range, 26.3-50.0 years). There were 9 perioperative mortalities (2.8%). With respect to perioperative mortality, the area under the curve using the anatomic component only was 0.74, which improved to 0.81 after including physiologic severity (P = .05). When physiologic severity was added to the model for the composite outcome, the discriminatory abilities of the ACHS mortality score and the STAT categories increased significantly to 0.83 (95% CI, 0.75-0.91; P = .02) and 0.82 (95% CI, 0.73-0.90; P = .04), comparable to the predictive power of ACAP. ConclusionsPhysiologic severity augments ability to predict mortality and morbidity after cardiac surgery for ACHD. There is need for more robust ACHD-specific risk models.

Encouraging results of blood conservation in neonatal open-heart surgery

ObjectiveTo report early outcomes of blood conservation in neonatal open-heart surgery. MethodsNinety-nine patients undergoing neonatal open-heart surgery during the implementation of a blood conservation program between May 2021 and February 2023 were reviewed. Patients either received traditional blood management (blood prime, n = 43) or received blood conservation strategies (clear prime, n = 56). Baseline characteristics and outcomes were compared between groups. ResultsThere was no difference in body weight (median, 3.2 kg vs 3.3 kg; P = .83), age at surgery (median, 5 days vs 5 days; P = .37), distribution of The Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Categories categories or duration of cardiopulmonary bypass. Patients in the clear prime group had higher preoperative hematocrit (median, 41% vs 38%; P < .01), shorter postoperative mechanical ventilation time (median, 48 hours vs 92 hours; P = .02) and postoperative intensive care unit length of stay (median, 6 days vs 9 days; P < .01) than patients in the blood prime group. Fourteen patients (25%) in the clear prime group, including 1 Norwood patient, were discharged without any transfusion. Among patients within the clear prime group, hospitalizations without blood exposure were associated with higher preoperative hematocrit (median, 43% vs 40%; P = .02), shorter postoperative mechanical ventilation times (median, 22 hours vs 66 hours; P = .01) and shorter postoperative hospital stays (median, 10 days vs 15 days; P = .02). ConclusionsBloodless surgery is possible in a significant proportion of neonates undergoing open-heart surgery, including the Norwood operation, even in the early stages of experience. Early clinical results are favorable but long-term follow-up and continued efforts are warranted to prove safety and reproducibility.

Trend of fetal echocardiography use and comparison of medical costs for congenital heart disease treatment based on fetal echocardiography use in a Korean single center.

The rate of the prenatal diagnosis of congenital heart disease is increasing along with advances in fetal echocardiography techniques. Here, we aimed to investigate the trend of the use of fetal echocardiography over time and to compare the medical costs of congenital heart disease treatment according to whether fetal echocardiography was performed. We reviewed our hospital's database, and patients who underwent the first surgery for congenital heart disease within 30 days of birth during 2005-2007, 2011-2013, and 2017-2019 were included. The severity of congenital heart disease diagnosed in each case was evaluated according to The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Scores (STS-EACTS Mortality Scores) and Mortality Categories (STAT Mortality Categories). In total, 375 patients were analyzed, and fetal echocardiography use increased significantly after the 2010s compared with in 2005-2007 (19.1% vs. 39%, p = 0.032 in Mortality Category 1-3; 15.5% vs. 69.5%, p = 0.000 in Mortality Category 4-5). Additionally, the mean STS-EACTS Mortality Score was higher in prenatally diagnosed patients than in postnatally diagnosed patients (2.287 vs. 1.787, p = 0.001). In the recent period, there was no significant difference in hospitalization durations and medical costs according to whether or not fetal echocardiography was performed. This single center study showed the use of fetal echocardiography is increasing. Further, prenatal diagnosis with fetal echocardiography causing no differences in medical costs in recent years. Therefore, we suggest that fetal echocardiography can be applied more widely without increasing the economic burden.

Capillary Refill Time and Serum Lactate as Predictors of Mortality and Postoperative Extracorporeal Membrane Oxygenation Requirement in Congenital Heart Surgery.

Multiple tissue perfusion markers are described to guide therapy in critically ill pediatric patients undergoing congenital heart surgery. Given the advantages of capillary refill time, our goal is to determine its predictive capacity for mortality and postoperative extracorporeal oxygenation requirements in congenital heart surgery and compare it to serum lactate. We conducted a prospective cohort observational study in a single high-complexity university hospital. Serum lactate and capillary refill time were measured at five predetermined time points: preoperative, immediate postoperative, 6, 12, and 24 h after the surgery. Prolonged immediate postoperative, 6 h, and 12 h capillary refill time measurements turned out to be independent risk factors for both outcomes. The capillary refill time area under the curve ranged between 0.70 and 0.80, while the serum lactate resulted between 0.79 and 0.92 for both outcomes. Both tissue perfusion markers resulted in mortality and extracorporeal oxygenation requirement predictors. Given the advantages of capillary refill time over serum lactate, a monitoring strategy including these two perfusion markers should be considered for congenital heart surgeries.

Association of body mass index with 30-day mortality and red blood cell transfusions in open heart surgery.

Obesity is associated with increased burden of cardiovascular risk factors, morbidity and mortality. However, several studies have counterintuitively shown better outcome after cardiac surgery in obese than in normal weight patients, a phenomenon known as obesity paradox. Furthermore, obesity has been linked with decreased need of red blood cell (RBC) transfusions. The purpose of this study was to evaluate the impact of body mass index (BMI) on 30-day mortality and RBC transfusions in patients undergoing cardiac surgery, a clinically important topic with conflicting previous data. We retrospectively investigated 1691 patients who underwent coronary and/or valve or aortic root surgery using cardiopulmonary bypass between 2013 and 2016. The patients were categorized by BMI based on the World Health Organization classification. For analysis, logistic regression was used with adjustment for potential confounding factors. Of the patients, 28.7% were normal weight, 43.3% overweight, 20.5% mildly obese and 7.5% severely obese. Thirty-day mortality was 1.9% without significant differences between the BMI groups. 41.0% of patients received RBC transfusion. Overweight [odds ratio (OR) 0.75, 95% confidence interval (CI) 0.56-0.99, P = 0.045], mildly (OR 0.65, 95% CI 0.46-0.92, P = 0.016) and severely obese (OR 0.41, 95% CI 0.24-0.70, P = 0.001) patients needed less frequently RBC transfusions than patients with normal weight. Obesity was not associated with 30-day mortality but was associated with lower use of RBC transfusions in cardiac surgery.

Abstract 12623: Association Between Past and Present Operative Mortality in Congenital Heart Surgery

Introduction: Operative mortality following congenital heart surgery is a foundational metric used across a variety of benchmarking, quality improvement, and public reporting initiatives. All of these efforts rely on mortality estimates reported from prior years, and it is unclear how well these reflect current outcomes. Methods: Adjusted operative mortality among Society of Thoracic Surgeons Congenital Heart Surgery Database index operations (2014-2019) was analyzed using standard risk-models. The association of mortality in “past” 4- and 1-year time intervals vs. the most recent year in the dataset (“present”) was evaluated using Bayesian hierarchical logistic regression. Estimates and 95% credible intervals (CrI) are presented. Results: Among 115,699 operations (106 hospitals) present observed mortality ranged from 2.3%-3.1% across quartiles, with regression to the mean evident more so vs. past 1-year than past 4-year data. Odds of present mortality were 2.04 (95%CrI 1.44-2.80) times higher for those in the past worst vs. best 4-year mortality quartile; no significant association was observed for the middle quartiles. The proportion of present hospital mortality variation explained by past mortality quartile was 52% (95%CrI 20%-90%) using past 4-year and 27% (95%CrI 2%-83%) using past 1-year data. Overall 66% of hospitals changed mortality quartiles from past to present (30% by 2 or more quartiles), with lower volume hospitals most impacted. Conclusions: Past mortality relates to present mortality primarily for groups of hospitals at the extremes, with past 4-year more informative than past 1-year data. However when considering individual hospitals, past may differ from present, regression to the mean is common, and many hospitals change quartiles. Past mortality estimates should be used thoughtfully and not as the sole factor informing present decision making.

Congenital Heart Surgery Program Variable Case Mix: Risk Associated With Adjusted Mortality Rate

BackgroundCongenital heart operations are categorized into risk categories based on The Society of Thoracic Surgeons–European Association of Cardio-Thoracic Surgery Congenital Heart Surgery (STAT) Mortality Categories. The adjusted mortality rate should adjust for case mix. MethodsThe Society of Thoracic Surgeons Congenital Heart Surgery Public Reporting data were extracted for the top 50 U.S. News & World Report Cardiology and Heart Surgery Programs in 2021 (operations from January 2015 to December 2018). Variability in STAT 1 as a percentage of total operations and as a ratio to STAT 4+5 operations was evaluated. ResultsSTAT 1 cases varied between centers from 18% to 37% of total. The ratio of STAT 1 to STAT 4+5 varied from 0.52 to 1.97. There was an inverse relationship between the STAT 1:STAT 4+5 ratio and adjusted mortality rate that did not reach statistical significance (P = .12). When programs (n = 12) in the quartiles with the highest vs lowest STAT 1:STAT 4+5 ratio were compared, a significant difference was found in the median adjusted mortality rate (2.2% vs 2.95%, P = .03). ConclusionsThere is a 4-fold difference in the ratio of STAT 1 to STAT 4+5 cases among congenital heart surgery programs, even when smaller programs are excluded, suggesting significant differences in the decision-making philosophy. Programs with the highest proportion of STAT 1 cases had lower adjusted mortality rate, suggesting that The Society of Thoracic Surgery Congenital Heart Surgery Database mortality risk model adjusts well but not completely for case-mix variability between programs.

Effect of procedural volume on the outcomes of congenital heart surgery in Japan

ObjectivesThe present study developed a new risk model for congenital heart surgery in Japan and determined the relationship between hospital procedural volume and mortality using the developed model. MethodsWe analyzed 47,164 operations performed between 2013 and 2018 registered in the Japan Cardiovascular Surgery Database-Congenital and created a new risk model to predict the 90-day/in-hospital mortality using the Japanese congenital heart surgery mortality categories and patient characteristics. The observed/expected ratios of mortality were compared among 4 groups based on annual hospital procedural volume (group A [5539 procedures performed in 90 hospitals]: ≤50, group B [9322 procedures in 24 hospitals]: 51-100, group C [13,331 procedures in 21 hospitals]: 101-150, group D [18,972 procedures in 15 hospitals]: ≥151). ResultsThe overall mortality rate was 2.64%. The new risk model using the surgical mortality category, age-weight categories, urgency, and preoperative mechanical ventilation and inotropic use achieved a c-index of 0.81. The observed/expected ratios based on the new risk model were 1.37 (95% confidence interval, 1.18-1.58), 1.21 (1.08-1.33), 1.04 (0.94-1.14), and 0.78 (0.71-0.86) in groups A, B, C, and D, respectively. In the per-procedure analysis, the observed/expected ratios of the Rastelli, coarctation complex repair, and arterial switch procedures in group A were all more than 3.0. ConclusionsThe risk-adjusted mortality rate for low-volume hospitals was high for not only high-risk but also medium-risk procedures. Although the overall mortality rate for congenital heart surgeries is low in Japan, the observed volume-mortality relationship suggests potential for improvement in surgical outcomes.

Fast-tracking with continuous thoracic epidural analgesia in paediatric congenital heart surgeries: an institutional experience.

To assess the success of fast-tracking in infants and small children undergoing paediatric cardiac surgery under general anaesthesia with continuous thoracic epidural analgesia (TEA). It is a retrospective study at a tertiary care hospital. A total of 461 children, aged 12years or younger, were operated for congenital heart disease over a 2-year period from January 2018 to December 2019. After the exclusion of 71 patients, data from the remaining 390 patients were analysed. The median time for extubation after intensive care unit admission was 2h and 25min (0-20h). Extubation within 6h was achieved in 215 patients (~ 55%). Patients in the early extubation group had significantly shorter hospital stay (4.1 ± 2.3 vs 6.9 ± 3.9days, p = 0.004) than patients in the ventilated group. Reintubation was required in 27 (6.9%) patients. Thirteen patients died postoperatively on ventilator. Patients with low nadir temperature intraoperatively and cardiopulmonary bypass time > 90min significantly predicted failure in fast-trackingwith an odds ratio (OR) = 1.27; CI: 1.18-1.38 and OR = 2.3; CI: 1.8-2.96 respectively. The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery mortality score, younger age, Down syndrome and high vasopressor inotropic score did not adversely affect early extubation, contrary to contemporary concerns. A multimodal approach for perioperative pain relief and sedation consisting of propofol and dexmedetomidine infusion along with TEA ensures early extubation in 59% of the cases undergoing paediatric cardiac surgery. Our data suggests that fast-tracking is feasible with safe and superior outcomes in a subset of appropriate patients undergoing paediatric cardiac surgery. The online version contains supplementary material available at 10.1007/s12055-022-01373-8.

Risk evaluation in adult congenital heart surgery: analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database risk models on data from the European Congenital Heart Surgeons Association Congenital Database.

We sought to evaluate the predictive power of the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) mortality score and the adult congenital heart surgery (ACHS) mortality score for the adults undergoing congenital heart operations entered into the European Congenital Heart Surgeons Association (ECHSA) database. The data set comprised 17 662 major operations performed between 1997 and 2019, on patients 18 years of age or older, in European centres participating in the ECHSA database. Each operation was assigned a STAT mortality score and category and an ACHS mortality score. Operative mortality was based on the 30-day status and on the status at hospital discharge. The discriminatory power of the STAT and ACHS scores was assessed using the area under the receiver operating characteristic curve (c-index). A total of 17 214 (97.46%) operations were assigned ACHS scores. The 3 most frequent primary procedures were closure of the atrial septal defect (19.0%), aortic valve replacement (8.8%) and non-valve-sparing aortic root replacement (6.1%). Operative mortality for ACHS-coded operations was 2.07%. The procedures with the highest mortality were atrial septal defect creation/enlargement (19.0%), lung transplantation (18.8%) and heart transplantation (18.2%). A total of 17 638 (99.86%) operations were assigned a STAT score and category. The operative mortality for STAT-coded operations was 2.27%. The c-index for mortality was 0.720 for the STAT mortality score and 0.701 for the ACHS score. The ACHS mortality score and the STAT mortality score reached similar, moderate predictive power in adult patients undergoing congenital heart surgery in ECHSA database.

The Association of Workload and Outcomes in the Pediatric Cardiac ICU.

Healthcare workload has emerged as an important metric associated with poor outcomes. To measure workload, studies have used bed occupancy as a surrogate. However, few studies have examined frontline provider (fellows, nurse practitioners, physician assistants) workload and outcomes. We hypothesize frontline provider workload, measured by bed occupancy and staffing, is associated with poor outcomes and unnecessary testing. A retrospective single-center, time-stamped orders, ordering provider identifiers, and patient data were collected. Regression was performed to study the influence of occupancy on orders, length of stay, and mortality, controlling for age, weight, admission type, Society of Thoracic Surgery-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality score, diagnosis, number of surgeries, orders, provider staffing, attending experience, and time fixed effects. Twenty-seven bed tertiary cardiac ICU in a free-standing children's hospital. Patients (0-18 yr) admitted to the pediatric cardiac ICU, January 2018 to December 2019. None. There were 16,500 imaging and 73,113 laboratory orders among 1,468 patient admissions. Median age 6 months (12 d to 5 yr), weight 6.2 kg (3.7-16.2 kg); 840 (57.2%) surgical and 628 (42.8%) medical patients. ICU teams consisted of 16 attendings and 31 frontline providers. Mortality 4.4%, median stay 5 days (2-11 d), and median bed occupancy 89% (78-93%). Every 10% increase in bed occupancy had 7.2% increase in imaging orders per patient (p < 0.01), 3% longer laboratory turn-around time (p = 0.015), and 3 additional days (p < 0.01). Higher staffing (> 3 providers) was associated with 6% less imaging (p = 0.03) and 3% less laboratory orders (p = 0.04). The number of "busy days" (bed occupancy > 89%) was associated with longer stays (p < 0.01), and increased mortality (p < 0.01). Increased bed occupancy and lower staffing were associated with increased mortality, length of stay, imaging orders, and laboratory turn-around time. The data demonstrate performance of the cardiac ICU system is exacerbated during high occupancy and low staffing.

COVID-19 pandemic implications in paediatric and congenital heart surgery in Brazil.

The Coronavirus Disease 2019 (COVID-19) pandemic negatively impacted global healthcare. Consequences in Pediatric and Congenital Heart Surgery programmes and mortality of congenital heart patients infected with severe acute respiratory syndrome coronavirus-2 (SARS-Cov-2) is still to be determined. To study the COVID-19 pandemic implications in Brazilian Pediatric and Congenital Heart Surgery programmes. We conducted a national online survey covering all states that perform Pediatric and Congenital Heart Surgery from 10 November to 22 November, 2020, using a Google forms questionnaire. We formulated questions related to impact on surgical volume, case-mix, and mortality. Then we asked about short-term post-operative COVID-19 infection and outcomes. We received responses from 46 centres representing all states where there were a Pediatric and Congenital Heart Surgery programme and all high-volume centres across the country. All but one centre experienced a significant decrease in surgical volume, and 23.9% of the responders revealed less than one-quarter of volume decrement. On the other hand, in over 70% of the centres, there was a significant surgical volume reduction. In addition to this, there was a shift in case-mix in 41 centres (89.1%) towards more complex cases. More than one-third of the responders revealed increased mortality in 2020 compared to previous years, and 43.5% of the programmes (20 centres) had at least one patient contaminated by SARS-Cov-2, accounting for 48 patients. Mortality in post-operative infected patients was 45.8% (22 patients). In general, Brazilian Pediatric and Congenital Heart Surgery programmes were severely affected by decreased surgical volume, unbalanced case-mix towards more complex cases, and increased mortality. Almost half of the programmes related post-operative COVID-19 contamination with high mortality.

Invited Commentary: Updating an Empirically Based Tool for Analyzing Congenital Heart Surgery Mortality: STAT 2020.

Invited Commentary: Updating an Empirically Based Tool for Analyzing Congenital Heart Surgery Mortality: STAT 2020.

Updating an Empirically Based Tool for Analyzing Congenital Heart Surgery Mortality.

STAT Mortality Categories (developed 2009) stratify congenital heart surgery procedures into groups of increasing mortality risk to characterize case mix of congenital heart surgery providers. This update of the STAT Mortality Score and Categories is empirically based for all procedures and reflects contemporary outcomes. Cardiovascular surgical operations in the Society of Thoracic Surgeons Congenital Heart Surgery Database (January 1, 2010 - June 30, 2017) were analyzed. In this STAT 2020 Update of the STAT Mortality Score and Categories, the risk associated with a specific combination of procedures was estimated under the assumption that risk is determined by the highest risk individual component procedure. Operations composed of multiple component procedures were eligible for unique STAT Scores when the statistically estimated mortality risk differed from that of the highest risk component procedure. Bayesian modeling accounted for small denominators. Risk estimates were rescaled to STAT 2020 Scores between 0.1 and 5.0. STAT 2020 Category assignment was designed to minimize within-category variation and maximize between-category variation. Among 161,351 operations at 110 centers (19,090 distinct procedure combinations), 235 types of single or multiple component operations received unique STAT 2020 Scores. Assignment to Categories resulted in the following distribution: STAT 2020 Category 1 includes 59 procedure codes with model-based estimated mortality 0.2% to 1.3%; Category 2 includes 73 procedure codes with mortality estimates 1.4% to 2.9%; Category 3 includes 46 procedure codes with mortality estimates 3.0% to 6.8%; Category 4 includes 37 procedure codes with mortality estimates 6.9% to 13.0%; and Category 5 includes 17 procedure codes with mortality estimates 13.5% to 38.7%. The number of procedure codes with empirically derived Scores has grown by 58% (235 in STAT 2020 vs 148 in STAT 2009). Of the 148 procedure codes with empirically derived Scores in 2009, approximately one-half have changed STAT Category relative to 2009 metrics. The New STAT 2020 Scores and Categories demonstrated good discrimination for predicting mortality in an independent validation sample (July 1, 2017-June 30, 2019; sample size 46,933 operations at 108 centers) with C-statistic = 0.791 for STAT 2020 Score and 0.779 for STAT 2020 Category. The updated STAT metrics reflect contemporary practice and outcomes. New empirically based STAT 2020 Scores and Category designations are assigned to a larger set of procedure codes, while accounting for risk associated with multiple component operations. Updating STAT metrics based on contemporary outcomes facilitates accurate assessment of case mix.

Status of cardiovascular surgery in Japan: A report based on the Japan Cardiovascular Surgery Database 2017-2018. 1. Congenital heart surgery.

We aimed to analyze the mortality and morbidity associated with congenital heart surgery in Japan. Data on congenital heart surgeries performed between January 2017 and December 2018 were obtained from Japan Cardiovascular Surgery Database. The 20 most frequent procedures were selected, and mortalities and major morbidities associated with the procedures were analyzed. All procedures were classified into Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery mortality categories, and mortalities in each category were also analyzed. The mortality rates in atrial septal defect repair and ventricular septal repair were 0% and 0.2%, respectively. The mortality rates in more complex cases (tetralogy of Fallot repair, complete atrioventricular repair, bidirectional Glenn, and total cavopulmonary connection) were 2%-3%. The mortality rates in systemic-to-pulmonary shunt, total anomalous pulmonary venous connection repair, and the Norwood procedure were 4.9%, 11.1%, and 15.7%, respectively, which were not different from those reported in 2015-2016. The mortalities according to the Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery categories 1-5 were 0.3%, 2.7%, 2.9%, 5.9%, and 15.5%, respectively, and comparable to those of the Society of Thoracic Surgeons database (2013-2016). The mortality rates and frequency of complications in major surgical procedures for congenital heart disease in Japan in 2017-2018 will play an important role as a basis for trends in Japan and for comparison with results from other countries.