Congenital Heart Surgery Outcomes Research Articles

Impact of Preoperative Location on Outcomes in Congenital Heart Surgery

Little is known about the impact of preoperative location on outcomes in infants undergoing cardiac surgery for congenital heart disease. This study was designed to evaluate the morbidity and mortality among infants who were cared for in a neonatal ICU (NICU) versus dedicated cardiovascular intensive care unit (CVICU) prior to cardiac surgery in a multi-institutional population. Data were obtained from a multicenter, administrative, national dataset, Pediatric Health Information System (PHIS). Patients 0 to 45 days undergoing surgery for congenital heart disease (with or without cardiopulmonary bypass) at a PHIS-participating hospital (2004 to 2013) were included. Propensity score matching was performed to match the NICU and the CVICU patients with similar demographic and preoperative clinical characteristics. A total of 5,376 patients from 20 hospitals met inclusion criteria. By propensity score matching, 2,456 patients matched 1 to 1 between the NICU and the CVICU groups. Outcomes including mortality (NICU vs CVICU, 11.9% vs 8.8%, p < 0.001), preoperative and total hospital length of stay (LOS), and total length of mechanical ventilation were significantly greater among the NICU patients compared with the CVICU patients. There was no significant difference in mortality among the patients undergoing "low" complexity operations (NICU vs CVICU, 8.4% vs 6.7%, p = 0.22), and patients undergoing treatment at high volume hospitals (NICU vs CVICU, 9.6% vs 9.5%, p = 0.95). This study demonstrates that preoperative location might impact outcomes in children undergoing operation for congenital heart disease. It is possible that preoperative location may be surrogate for other factors that may bias the results. Further study is warranted.

Does ICU Structure Impact Patient Outcomes After Congenital Heart Surgery? A Critical Appraisal of “Care Models and Associated Outcomes in Congenital Heart Surgery” by Burstein et al (Pediatrics 2011; 127

To review the findings and discuss the implications of different ICU care models on morbidity and mortality in pediatric patients after congenital heart surgery. The electronic PubMed database was used to perform the clinical query, as well as to search for additional pertinent literature. The article by Burstein DS et al "Care Models and Associated Outcomes in Congenital Heart Surgery. Pediatrics 2011; 15:77-81" was selected for critical appraisal and literature review. The authors evaluated in-hospital mortality, postoperative length of stay, and postoperative complications in pediatric patients after congenital heart surgery and compared the odds of these outcomes by model of care received (cardiac ICU or mixed ICU). The data for the study was extracted from the Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery (STS-EACTS) database. Overall, the cardiac ICU group represented hospitals with higher surgical volumes and included more patients with high-risk defects. After multivariate analysis, the adjusted in-hospital mortality was not associated with the care model (cardiac ICU vs. ICU). The only significant finding was a lower morality in the STS-EACTS risk category 3 (odds ratio, 0.47 [95% CI, 0.25-0.86]). There were no significant differences between groups for adjusted postoperative length of stay or postoperative complications. This paper suggests that the composition of the ICU is not a critical factor in determining outcomes after congenital heart surgery. Other factors, such as expertise of the nurses, physicians, and surgeons, as well as technical performance, should be considered.

Congenital heart surgery outcome analysis: Indian experience

The study aimed to analyze the outcome of congenital heart surgery in a subset of Indian patients, using the Aristotle Basic Complexity score, the Risk Adjustment for Congenital Heart Surgery categories, and the Society of Thoracic Surgeons and European Association for Cardiothoracic Surgery mortality categories. 1312 patients <18 years of age undergoing congenital heart surgery were assigned the 3 scores and studied for outcome indices of difficulty (cardiopulmonary bypass time or duration of surgery >120 min), morbidity (intensive care unit stay >7 days), and mortality. The overall mortality was 6.85%, with mean a Aristotle Basic Complexity score, Risk Adjustment for Congenital Heart Surgery category, and Society of Thoracic Surgeons and European Association for Cardiothoracic Surgery mortality category of 7.17 ± 2.04, 2.28 ± 0.78, and 2.24 ± 1.06, respectively. The mortality predictive capacity of the Risk Adjustment for Congenital Heart Surgery category (c = 0.76) was similar to that of the Society of Thoracic Surgeons and European Association for Cardiothoracic Surgery mortality category (c = 0.75); both were better compared to the Aristotle Basic Complexity score (c = 0.66). The Risk Adjustment for Congenital Heart Surgery category and Aristotle Basic Complexity score correlated with morbidity and difficulty outcomes. The study shows that the Aristotle Basic Complexity score, the Risk Adjustment for Congenital Heart Surgery category, and the Society of Thoracic Surgeons and European Association for Cardiothoracic Surgery mortality category are tools of case mix stratification to analyze congenital heart surgery outcomes in a subset of the Indian population.

Clinical Outcome of Patients in a Start‐Up Congenital Heart Surgery Program in Turkey

This study summarizes the clinical outcome data of a start-up congenital heart surgery program in Turkey. Between December 2009 and February 2012, 616 operations have been performed in 132 newborns (22%), 260 infants (42%), and 224 children/adolescents (36%). Risk adjustment analysis was performed using the risk adjustment in congenital heart surgery (RACHS-1) risk assessment model. There were 66 mortalities (10.7%). According to the RACHS-1 categories, there were 51 cases in level I (8.2%) with no mortality (0%), 250 in level II (40.6%) with 11 (4.4%) mortalities, 199 in level III (32.3%) with 33 (16.5%) mortalities, 53 in level IV (8.6%) with 10 (18.8%) mortalities, 14 in level V and VI (2.2%) with 11 (78.5%) mortalities, and 49 cases (7.9%) out of the RACHS-1 categories with one (2.0%) mortality. Mortality was higher in neonates compared to infants, and in infants compared to children/adolescents. Mortality was higher in palliative procedures compared to corrective procedures. The data demonstrate that a start-up program with a relatively loaded surgical volume may achieve acceptable clinical results with a good teamwork. Collaboration of anesthesiologists, perfusionists, pediatric cardiologists, intensivists, and cardiovascular surgeons is necessary to provide a better outcome in congenital heart surgery.

CONGENITAL HEART DISEASE IN CHILDREN AND ADULTS Application of four complexity stratification tools (Aristotle Basic Score, RACHS-1, STAT Mortality Score, and STAT Mortality Categories) to evaluate early congenital heart surgery outcomes over 16 years at a single institution

CONGENITAL HEART DISEASE IN CHILDREN AND ADULTS Application of four complexity stratification tools (Aristotle Basic Score, RACHS-1, STAT Mortality Score, and STAT Mortality Categories) to evaluate early congenital heart surgery outcomes over 16 years at a single institution

An empirically based tool for analyzing morbidity associated with operations for congenital heart disease

Congenital heart surgery outcomes analysis requires reliable methods of estimating the risk of adverse outcomes. Contemporary methods focus primarily on mortality or rely on expert opinion to estimate morbidity associated with different procedures. We created an objective, empirically based index that reflects statistically estimated risk of morbidity by procedure. Morbidity risk was estimated using data from 62,851 operations in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2002-2008). Model-based estimates with 95% Bayesian credible intervals were calculated for each procedure's average risk of major complications and average postoperative length of stay. These 2 measures were combined into a composite morbidity score. A total of 140 procedures were assigned scores ranging from 0.1 to 5.0 and sorted into 5 relatively homogeneous categories. Model-estimated risk of major complications ranged from 1.0% for simple procedures to 38.2% for truncus arteriosus with interrupted aortic arch repair. Procedure-specific estimates of average postoperative length of stay ranged from 2.9 days for simple procedures to 42.6 days for a combined atrial switch and Rastelli operation. Spearman rank correlation between raw rates of major complication and average postoperative length of stay was 0.82 in procedures with n greater than 200. Rate of major complications ranged from 3.2% in category 1 to 30.0% in category 5. Aggregate average postoperative length of stay ranged from 6.3 days in category 1 to 34.0 days in category 5. Complication rates and postoperative length of stay provide related but not redundant information about morbidity. The Morbidity Scores and Categories provide an objective assessment of risk associated with operations for congenital heart disease, which should facilitate comparison of outcomes across cohorts with differing case mixes.

Use of an Administrative Database to Determine Clinical Management and Outcomes in Congenital Heart Disease

We review our 16-year experience using the large, multi-institutional database of the University HealthSystem Consortium to study management and outcomes in congenital heart surgery for hypoplastic left heart syndrome, transposition of the great arteries, and neonatal coarctation. The advantages, limitations, and use of administrative databases by others to study congenital heart surgery are reviewed.

Outcomes in adult congenital heart surgery: Analysis of the Society of Thoracic Surgeons Database

Outcomes data for adults undergoing congenital heart surgery are limited. Previous analyses used administrative data or focused on single-center outcomes. We describe the most common operations, patient characteristics, and postoperative outcomes using a multicenter clinical database. The study included adults (aged ≥ 18 years) listed in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2000-2009). We describe patient characteristics and morbidity and mortality, and examine congenital procedures in the Society of Thoracic Surgeons Adult Cardiac Surgery Database to permit consideration of the primary dataset within a broader context. A total of 5265 patients (68 centers) from the Society of Thoracic Surgeons Congenital Heart Surgery Database were included. Patients' median age was 25 years (interquartile range, 20-35). Common preoperative risk factors included noncardiac abnormalities (17%) and arrhythmia (14%). Overall, in-hospital mortality was 2.1%, 27% had 1 or more complication, and median length of stay was 5 days. Common operations included right ventricular outflow tract procedures (21%) and pacemaker/arrhythmia procedures (20%). We further evaluated cardiopulmonary bypass procedures in more than 100 patients. Mortality ranged from 0% (atrial septal defect repair) to 11% (Fontan revision/conversion). Separate evaluation of the Society of Thoracic Surgeons Adult Cardiac Surgery Database revealed 39,872 adults undergoing congenital heart operations. Most adult congenital heart operations listed in the Society of Thoracic Surgeons Congenital Heart Surgery Database are performed in the third to fourth decades of life; approximately half are for right heart pathology or arrhythmia. Many patients have complications, but mortality is low with the exception of those undergoing Fontan revision/conversion. Many more adults undergoing congenital heart surgery are entered into the Society of Thoracic Surgeons Adult Cardiac Surgery Database.

Care Models and Associated Outcomes in Congenital Heart Surgery

Recently, there has been a shift toward care of children undergoing heart surgery in dedicated pediatric cardiac intensive care units (CICU). The impact of this trend on patient outcomes is unclear. We evaluated postoperative outcomes associated with a CICU versus other ICU models. Society of Thoracic Surgeons Congenital Heart Surgery Database participants (2007-2009) who completed an ICU survey were included. In multivariable analysis, we evaluated outcomes associated with a CICU versus other ICUs, adjusting for center volume, patient factors, and Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery surgical risk category. A total of 20 922 patients (47 centers; 25 with a CICU) were included. Overall unadjusted mortality was 3.8%, median length of stay was 6 days (interquartile range: 4-13), and 21% had 1 or more complications. In multivariable analysis, there was no difference in mortality comparing CICUs versus other ICUs (odds ratio: 0.88 [95% confidence interval: 0.65-1.19]). In stratified analysis, CICUs were associated with lower mortality only among those in Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery category 3 (odds ratio: 0.47 [95% confidence interval: 0.25-0.86]), primarily related to atrioventricular canal repair and arterial switch operation. There was no difference in length of stay or complications overall or in stratified analysis. We were not able to detect a difference in postoperative morbidity or mortality associated with the presence of a dedicated CICU for children undergoing heart surgery. There may be a survival benefit in certain subgroups .

Care Models and Associated Outcomes in Congenital Heart Surgery

Care Models and Associated Outcomes in Congenital Heart Surgery

Outcome of Complex Adult Congenital Heart Surgery in the Developing World

There is scanty information on the outcome of adult congenital heart disease surgery from the developing world. This was a retrospective chart review of the surgical outcome of 153 adults with congenital heart disease over a 5-year period. Surgical atrial septal defect closure was considered "simple" while all other surgeries were considered "complex." There were 102 patients in the "simple" group and 51 in the "complex" group. Only three (2%) patients had prior operations. The "complex" group had longer bypass time and cross clamp time. Intensive care unit stay, ventilation time, and inotrope administration were longer. Major complications were more common and there were two deaths in the "complex" group. Age more than 30 years, cyanosis, and New York Heart Association class more than II were predictors of longer stay in the intensive care unit. Surgical repair of Tetralogy of Fallot in adults tended to have a longer ventilation time and intensive care unit stay with a mortality of 4%. At follow up, all patients were in New York Heart Association class I or II. Improvement of the functional class with negligible adverse events was noted in both groups. A retrospective evaluation of 153 adults with congenital heart disease who underwent open heart surgery at a single center in India showed strikingly fewer reoperations compared with large European studies. There was a similar prevalence of complex lesions. Surgical mortality was low, and long-term functional outcome was gratifying.

Coagulation considerations for infants and children undergoing cardiopulmonary bypass

Cardiac surgery involving cardiopulmonary bypass imposes a significant pathophysiologic burden on patients. Pediatric patients are especially predisposed to the adverse effects of surgery and bypass on the coagulation system, with resultant bleeding, transfusion, and poor outcomes. These risks accrue to pediatric patients in inverse proportion to their weight and are attributable to hematologic immaturity, coagulation defects associated with congenital heart disease, bypass equipment, and the nature of congenital heart surgery. Standard anticoagulation does not completely inhibit thrombin generation, and continuous consumption of coagulation factor continues throughout bypass. Conventional measurements of anticoagulation during bypass poorly reflect this incomplete anticoagulation, and alternate methods may improve anticoagulant therapy. Emerging therapies for blocking the effects of bypass on the coagulation system hold promise for decreasing bleeding and related complications, and improving outcomes in congenital heart surgery.

Congenital Heart Surgery Outcomes in Down Syndrome: Analysis of a National Clinical Database

We describe patient characteristics and postoperative morbidity and mortality rates for patients with Down syndrome undergoing congenital heart disease surgery. This retrospective cohort study used the Society of Thoracic Surgeons Congenital Heart Surgery Database to compare patient characteristics and postoperative outcomes for patients (0-18 years) with or without Down syndrome who underwent surgery in 2000-2008. A total of 45,579 patients (4350 patients with Down syndrome and 41,229 without Down syndrome) were included (median age: 7 months [interquartile range [IQR]: 47 days to 4 years]; 56% male). Patients with Down syndrome were younger at surgery, with the exception of those undergoing tetralogy of Fallot repair or atrioventricular septal defect repair. Mortality rates for patients with or without Down syndrome did not differ significantly. Lengths of stay were prolonged for patients with Down syndrome undergoing atrial septal defect closure (median: 4 days [IQR: 3-5 days] vs 3 days [IQR: 2-4 days]; P < .0001), ventricular septal defect closure (median: 5 days [IQR: 4-8 days] vs 4 days [IQR: 3-6 days]; P < .0001), or tetralogy of Fallot repair (7 days [IQR: 5-10 days] vs 6 days [IQR: 5-9 days]; P < .001) and were associated with postoperative respiratory and infectious complications. Patients with Down syndrome undergoing ventricular septal defect closure had a higher rate of heart block requiring pacemaker placement (2.9% vs 0.8%; P < .0001). In this large, contemporary cohort, Down syndrome did not confer a significant mortality risk for the most common operations; however, postoperative morbidity remained common.

Analysis of 14,843 Neonatal Congenital Heart Surgical Procedures in the European Association for Cardiothoracic Surgery Congenital Database

Early outcomes of congenital heart surgery in neonates have significantly improved during the last decade. Further improvements require identification of specific risk factors correlating with early mortality and morbidity. Between January 1999 and May 2008 data on 14,843 congenital heart procedures performed in 118 congenital heart surgery centers in 34 countries were submitted to the European Association for Cardiothoracic Surgery Congenital Database. Mean age at surgery was 11.8 days and mean body weight was 2.9 kg. Multivariate stepwise regression analysis was used to assess the risk factors for postoperative complications and death. Thirty-day mortality of 9.1% was significantly different from hospital mortality (10.7%). Postoperative complications occurred in 29.2% of neonates. In multivariate analysis, early death rate was statistically significantly modified by body weight, Aristotle basic score (ABS), cardiopulmonary bypass time (CPB time), aortic cross-clamp time, circulatory arrest time, and univentricular physiology. The rate of complications was associated with ABS, CPB time, and circulatory arrest time. In neonatal congenital heart surgery significant risk of early death extends beyond 30 postoperative days. Multivariate analysis confirmed that lower body weight, higher ABS, longer CPB time, longer aortic cross-clamp time, longer circulatory arrest time, and univentricular physiology are risk factors for hospital mortality. Higher ABS as well as longer CPB time and circulatory arrest time are associated with the rate of complications.

The Congenital Heart Surgeons Society Datacenter: Unique Attributes as a Research Organization

Over the last 25 years, the Congenital Heart Surgeons Society (CHSS) has evolved from an informal club to a mature organization. A central feature of the CHSS has been dedication to evaluating outcomes of congenital heart surgery across a wide array of clinical diagnoses. These research activities have been orchestrated through the CHSS Datacenter, which has developed a unique organizational structure that has strengths and weaknesses in comparison to other research organizational structures (e.g., prospective randomized trials, registries, etc). This review will highlight the unique attributes of the CHSS Datacenter with emphasis on the Datacenter's strengths and weaknesses in comparison to other organizational structures.

Invited Commentary

Invited Commentary

Monitoring Risk-Adjusted Outcomes in Congenital Heart Surgery: Does the Appropriateness of a Risk Model Change With Time?

Risk adjustment of outcomes in pediatric congenital heart surgery is challenging due to the great diversity in diagnoses and procedures. We have previously shown that variable life-adjusted display (VLAD) charts provide an effective graphic display of risk-adjusted outcomes in this specialty. A question arises as to whether the risk model used remains appropriate over time. We used a recently developed graphic technique to evaluate the performance of an existing risk model among those patients at a single center during 2000 to 2003 originally used in model development. We then compared the distribution of predicted risk among these patients with that among patients in 2004 to 2006. Finally, we constructed a VLAD chart of risk-adjusted outcomes for the latter period. Among 1083 patients between April 2000 and March 2003, the risk model performed well at predicted risks above 3%, underestimated mortality at 2% to 3% predicted risk, and overestimated mortality below 2% predicted risk. There was little difference in the distribution of predicted risk among these patients and among 903 patients between June 2004 and October 2006. Outcomes for the more recent period were appreciably better than those expected according to the risk model. This finding cannot be explained by any apparent bias in the risk model combined with changes in case-mix. Risk models can, and hopefully do, become out of date. There is scope for complacency in the risk-adjusted audit if the risk model used is not regularly recalibrated to reflect changing standards and expectations.

Heart Failure in Children

Why is heart failure in children important? If we just consider the number of individuals affected, adult heart failure is clearly a more compelling public health problem. However, the relatively small numbers belie the overall economic and social impact of pediatric heart failure. When a child is admitted to the hospital for heart failure, the costs are considerably higher for children than adults because of the frequent need for surgical or catheter-based intervention. The demands of medical care can fray the family structure and adversely affect parental economic productivity. When a child dies of heart failure, the economic impact is magnified enormously because of the number of potentially productive years lost per death. For these and other reasons, heart failure in children is a serious public health concern. In addition, growing numbers of children with heart failure are reaching adulthood because of the successful application of medical and surgical heart failure therapies and the improved outcomes of congenital heart surgery. A greater understanding of the pathophysiology of heart failure in childhood may help inform therapeutic strategies once these children become adults. Furthermore, given the recent explosion of research in the impact of cardiac development and cardiogenetics on pediatric cardiovascular disease, it is not outside the realm of possibility for a pediatric discovery to be made that will also benefit adults with heart failure. We may not yet be able to agree on a definition of heart failure, but the cardinal symptoms, dyspnea, anasarca (“dropsy”), and cachexia, were well recognized in antiquity.1 These symptoms were not specific for cardiac pathology, and it was not until the 17th century, when William Harvey definitively identified the heart as an organ that pumped blood rather than generating heat, that the heart could begin to be understood as a source of dyspnea, edema, and …

Databases for assessing the outcomes of the treatment of patients with congenital and paediatric cardiac disease – the perspective of cardiac surgery

This review includes a brief discussion, from the perspective of cardiac surgeons, of the rationale for creation and maintenance of multi-institutional databases of outcomes of congenital heart surgery, together with a history of the evolution of such databases, a description of the current state of the art, and a discussion of areas for improvement and future expansion of the concept. Five fundamental areas are reviewed: nomenclature, mechanism of data collection and storage, mechanisms for the evaluation and comparison of the complexity of operations and stratification of risk, mechanisms to ensure the completeness and accuracy of the data, and mechanisms for expansion of the current capabilities of databases to include comparison and sharing of data between medical subspecialties. This review briefly describes several European and North American initiatives related to databases for pediatric and congenital cardiac surgery the Congenital Database of The European Association for Cardio-Thoracic Surgery, the Congenital Database of The Society of Thoracic Surgeons, the Pediatric Cardiac Care Consortium, and the Central Cardiac Audit Database in the United Kingdom. Potential means of approaching the ultimate goal of acquisition of long-term follow-up data, and input of this data over the life of the patient, are also considered.

Achieving Excellence

Achieving Excellence