Pediatric Heart Surgery Research Articles

Development of the ICF-CY Set for Cardiac Rehabilitation After Pediatric Congenital Heart Surgery.

BackgroundMost children with congenital heart disease (CHD) require surgical repair, and postoperative rehabilitation is an essential step to restore the quality of life. The present study constructs and confirms the International Classification of Functioning, Disability, and Health for Children and Youth core set for children with congenital heart disease 1 year after surgery (ICF-CY-CHDS).MethodsFrom February 2021 to August 2021, 340 children aged 3–6 years after CHD surgery were evaluated using the ICF-CY-CHDS and analyzed using the Rasch model.ResultsThe final ICF-CY-CHDS contained 22 categories; it exhibited a nonsignificant χ2 test result for the item-trait interaction (χ2 = 6736.37, p = 0.8660, Bonferroni-adjusted p = 0.0023). The average severity of children was less than the average difficulty of categories (−2.26 logit <0 logit). The weighted k of all the categories was 0.964 (p < 0.001), and the item separation index was 0.96. The area under the ROC curve of children with a diagnosis result of heart failure was 0.866 (95% CI: 0.801 ~0.931) with good sensitivity (0.875) and specificity (0.759).ConclusionThe ICF-CY-CHDS presents a preliminary practical direction during early cardiac rehabilitation after pediatric CHD surgery, and thus provides a basis and scope for clinical evaluation and intervention program formulation.

Narrative review in pediatric and congenital heart surgery in sub-Saharan Africa: challenges and opportunities in a new era

Narrative review in pediatric and congenital heart surgery in sub-Saharan Africa: challenges and opportunities in a new era

Pediatric heart surgery minimally invasive: experience of a Colombian center

ResumenObjetivo:Durante las últimas décadas, la cirugía cardiaca ha evolucionado, existe un interés creciente en minimizar la agresión corporal de procedimientos quirúrgicos, buscando una rápida recuperación, los abordajes mínimamente invasivos han sido tendencia en los últimos años, con seguridad y eficacia equivalente a las técnicas tradicionales de esternotomía. El objetivo de este estudio es comparar resultados clínicos entre pacientes pediátricos con cardiopatías congénitas sometidos a cirugía mínimamente invasiva frente a esternotomía estándar.Métodos:Estudio de casos y controles, anidado en una cohorte retrospectiva. Se incluyeron todos los pacientes pediátricos mayores de 10 kg de peso, sometidos entre 2014 a 2019 a corrección quirúrgica de cardiopatías congénitas simples, en un centro cardiovascular en Medellín. Se definió caso aquel que fuera sometido a abordaje mínimamente invasivo (MICS) y control los pacientes que se abordaron de manera convencional (CONV). Un total de 122 pacientes fueron admitidos, con una media de edad (MICS: 6 [4-12] vs. CONV: 5 [2-8 años]). No se encontraron diferencias en las características basales de ambos grupos. No se documentó diferencia estadísticamente significativa en los tiempos de perfusión (MICS: 67 min [50-90] vs. CONV 53 min: [42–90]; p= 0,54), ni diferencias en las complicaciones (MICS; 7.4% vs. CONV: 8.8%; p = 0.77). Los pacientes MICS tuvieron un lactato al ingreso y una estadía en la UCI menor que los controles.Conclusión:El abordaje MICS resulta ser una técnica novedosa, menos invasiva, segura y eficiente, frente al abordaje quirúrgico CONV, para la reparación de cardiopatías congénitas simples en paciente pediátricos.

Application of Near-Infrared Spectroscopy to Monitor Perfusion During Extracorporeal Membrane Oxygenation After Pediatric Heart Surgery.

Objective: Venoarterial extracorporeal membrane oxygenation is an effective mechanical circulatory support that is used to rescue critically ill patients after congenital heart surgery. As there was still no recommended guideline for monitoring parameters during extracorporeal membrane oxygenation (ECMO), this study aimed to investigate the role of near-infrared spectroscopy (NIRS) in the early period of venoarterial (VA)-ECMO.Method: This study enrolled patients with NIRS monitoring during ECMO after pediatric cardiac surgery at Shanghai Children's Medical Center (2018–2020). The information obtained from the retrospective, the observational dataset included the demographic information, diagnoses, baseline characteristics, procedural details, ECMO data, monitoring data, in-hospital mortality, and complications of the patients.Results: The overall mortality rate was 43.6%. Lactate was significantly higher in non-survivors compared to survivors at 12 h (11.25 ± 7.26 vs. 6.96 ± 5.95 mmol/l, p = 0.022) and 48 h [2.2 (0.7, 20) vs. 1.4 (0.7, 5.8) mmol/l, p = 0.008] after initiation of ECMO. The cranial regional oxygen saturation (CrSO2) was significantly higher in survivors compared to non-survivors at 24 h (62.5 ± 14.61 vs. 52.05 ± 13.98%, p = 0.028), 36 h (64.04 ± 14.12 vs. 51.27 ± 15.65%, p = 0.005), and 48 h (65.32 ± 11.51 vs. 55.00 ± 14.18%, p = 0.008). Multivariate logistics regression analysis of the hemodynamic and laboratory parameters revealed that the CrSO2 at 36 h (OR = 0.945, p = 0.049) and 48 h (OR = 0.919, p = 0.032) was related to mortality. The use of continuous renal replacement therapy (OR = 14.940, p = 0.039) was also related to mortality. The optimal cutoff values for CrSO2 for predicting mortality after weaning off ECMO at 36 and 48 h were 57% (sensitivity: 61.5%, specificity: 80%) and 56% (sensitivity: 76.9%, specificity: 70%), respectively. The risk of mortality was higher among patients with a CrSO2(36h) < 57% (p = 0.028) by Kaplan-Meier analysis.Conclusion: Near-infrared spectroscopy may be a useful tool for monitoring the hemodynamic stability during the early period of ECMO, while CrSO2 can predict the in-hospital mortality after ECMO.

Abstract 10834: Novel Biomarkers and Machine Learning Models for the Prediction of 30-Day Readmission Following Pediatric Congenital Heart Surgery

Introduction: Hospital readmissions after congenital heart surgery (CHS) are common in pediatric patients and are linked to higher risks of complications, mortality, and increased treatment costs. Accurate prediction of 30-day readmission after CHS could help clinicians identify high risk patients and enable tailored care. Hypothesis: Novel biomarkers alone enhance prediction of readmission risk using XGBoost model and augmenting clinical features to the Society of Thoracic Surgeons (STS)-risk model improves predictions of 30-day readmissions. Methods: The prospective cohort included children of 18 years or younger who underwent congenital heart surgery at Johns Hopkins Hospital. Of the 162 patients, 159 survived discharge and were therefore included in the study. We used pre- and post-operative biomarkers ST2, Galectin-3, NT-proBNP and GFAP as features for the biomarker model, covariates from the STS CHS Database Mortality Risk Model for the STS-risk model and augmenting clinical features to STS-risk variables for clinical model. We implemented the XGBoost model and compared the biomarker model and clinical model performance to the STS-risk model. Results: Readmissions within 30 days of surgery occurred among 9% of pediatric patients. Using XGBoost, the STS-risk model derived an AUROC of 0.978 (95% CI: 0.955-1.0). The biomarker model performed better than the STS-risk model with AUROC of 0.982 (95% CI: 0.959-1.0, p=0.8). The augmented clinical model outperformed the STS-risk model with an AUROC of 0.997 (95% CI: 0.99-1, p=0.1). Conclusions: Novel biomarkers alone perform better compared to the STS- risk model in predicting 30-day readmission risk. XGBoost model improves risk prediction when adding additional clinical features to the existing STS-risk model which outperformed the STS-risk model. Depending on healthcare systems clinical resources and data availability, an optimized XGBoost model can improve the readmission risk prediction outcome.

Mechanical ventilation management in patients diagnosed with Covid-19 who underwent pediatric openheart surgery

Mechanical ventilation management in patients diagnosed with Covid-19 who underwent pediatric openheart surgery

Perspective on Cerebral Autoregulation Monitoring in Neonatal Cardiac Surgery Requiring Cardiopulmonary Bypass.

The autoregulation of cerebral blood flow protects against brain injury from transient fluctuations in arterial blood pressure. Impaired autoregulation may contribute to hypoperfusion injury in neonates and infants. Monitoring cerebral autoregulation in neonatal cardiac surgery as a guide for arterial blood pressure management may reduce neurodevelopmental morbidity. Cerebral autoregulation monitoring has been validated in animal models and in an adult trial autoregulation monitoring during bypass improved postoperative delirium scores. The nuances of pediatric cardiac disease and congenital heart surgery make simply applying adult trial findings to this unique population inappropriate. Therefore, dedicated pediatric clinical trials of cerebral autoregulation monitoring are indicated.

Neurological complications after pediatric cardiac surgery

BackgroundThe number of pediatric patients who survive open-heart surgery has increased in recent years and the complications seen in this patient group continue to decrease with each technological advance, including new surgical and neuroprotective techniques and the improvement in surgeons’ experience with this patient population. However, neurological complications, which are the most feared and difficult to manage, require long-term follow-up, and increase hospital costs remain a leading cause of mortality and morbidity in this cohort.ResultsWe evaluated the neurological physical examination, cranial computed tomography (CT), and magnetic resonance (MRI) records of 162 pediatric patients with neurological symptoms lasting more than 24 h after undergoing heart surgery in our clinic between June 2012 and May 2020. The patients’ ages ranged from 0 to 205 months, with a mean of 60.59 ± 46.44 months.Of the 3849 pediatric cardiac surgery patients we screened, 162 had neurological complications in the early period (the first 10 days after surgery). The incidence was calculated as 4.2%; 69 patients (42.6%) experienced seizures, 17 (10.5%) experienced confusion, 39 (24.1%) had stupor, and 37 (22.8%) had hemiparesis. Of the patients who developed neurological complications, 54 (33.3%) died. Patients with neurological complications were divided into 3 groups: strokes (n = 90), intracranial bleeding (n = 37), and no radiological results (n = 35). Thirty-four patients (37.8%) in the stroke group died, as did 15 (40%) in the bleeding group, and 5 (14.3%) in the no radiological results group.ConclusionsStudies on neurological complications after pediatric heart surgery in the literature are currently insufficient. We think that this study will contribute to a more detailed discussion of the issue. Responses to neurological events and treatment in the pediatric group may differ compared to the adult age group. Primary prevention methods should be the main approach in combating neurological complications; their formation mechanisms should be carefully monitored and preventive treatment strategies should be developed.

Factors Associated With Increased Laboratory Use in the Pediatric Cardiac Intensive Care Unit.

Laboratory testing is frequently used to guide postoperative management and contributes to hospital resource utilization; however, there is little evidence identifying patient or clinical factors to inform the appropriate frequency of laboratory testing in the pediatric cardiac intensive care unit. To examine the factors associated with increased laboratory utilization following pediatric congenital heart surgery. For each patient, the total number of tests and types of laboratory tests were recorded. Patients whose number of tests was greater than the 90th percentile were categorized as increased laboratory use. A sample of 250 unique patients and 909 nursing shifts were obtained for patient- and shift-level analyses. The top 10% of patients identified as the high laboratory utilization group (>128 laboratory tests). High-use group reported significantly younger patients and longer bypass time (P < .001). Patients in the highest Risk Adjustment for Congenital Heart Surgery 1 risk category were 34.7 times more likely to be in high laboratory utilization group (P = .006), independent of age at time of surgery and time on bypass (receiver operating characteristic curve = 0.855). At the shift level, time on bypass (P = .002), age younger than 30 days at surgery (P < .001), 3 to 5 years' registered nurse experience (P < .001), staff precepting (P = .03), and weekday shift status (P = .03) were all independently associated with high laboratory utilization. There are multiple factors associated with increased laboratory utilization. Recognition of specific patient and nursing factors can be used to impact patient management.

Malnutrition on admission to the paediatric cardiac intensive care unit increases the risk of mortality and adverse outcomes following paediatric congenital heart surgery: A prospective cohort study

BackgroundMalnutrition is a common problem in children with congenital heart disease, and it increases the risk of adverse outcomes in the postoperative period. ObjectivesWe aimed to assess the association between malnutrition and cardiac surgery outcomes in paediatric patients aged 0–36 months. MethodsThis prospective cohort study was performed in a hospital specialising in paediatric cardiothoracic surgery. Children aged 0–36 months admitted to the paediatric cardiac intensive care unit after elective cardiac surgery between January 2018 and July 2018 were included in the study. We evaluated the patients' demographics and clinical variables, nutritional status, adverse outcomes, and 30-day mortality rates. ResultsA total of 124 cases met the inclusion criteria. Results showed that the Risk Adjustment for Congenital Heart Surgery score ≥5, underweight status (weight-for-age Z score ≤−2), and stunting (length-for-age Z score ≤−2) were all indicators for increased mortality following congenital heart surgery. Underweight children also spent a prolonged stay in the intensive care unit. Stunting (length-for-age Z score ≤−2) was the most strongly associated variable with mortality. ConclusionThe results confirm the impact of malnutrition on mortality, postoperative infection, and length of hospitalisation in children undergoing surgery for congenital heart disease.

Explainable machine-learning predictions for complications after pediatric congenital heart surgery

The quality of treatment and prognosis after pediatric congenital heart surgery remains unsatisfactory. A reliable prediction model for postoperative complications of congenital heart surgery patients is essential to enable prompt initiation of therapy and improve the quality of prognosis. Here, we develop an interpretable machine-learning-based model that integrates patient demographics, surgery-specific features and intraoperative blood pressure data for accurately predicting complications after pediatric congenital heart surgery. We used blood pressure variability and the k-means algorithm combined with a smoothed formulation of dynamic time wrapping to extract features from time-series data. In addition, SHAP framework was used to provide explanations of the prediction. Our model achieved the best performance both in binary and multi-label classification compared with other consensus-based risk models. In addition, this explainable model explains why a prediction was made to help improve the clinical understanding of complication risk and generate actionable knowledge in practice. The combination of model performance and interpretability is easy for clinicians to trust and provide insight into how they should respond before the condition worsens after pediatric congenital heart surgery.

Biomarkers in low cardiac output syndrome after open cardiac surgery in children

Background Corrective cardiac surgery is the standard management for complex congenital heart disease. Cardiopulmonary bypass surgery and post-surgical intensive care may lead to low cardiac output syndrome (LCOS), as a major complication after open heart surgery. To diagnose early LCOS, lactate level, pCO2 gap, and mixed venous oxygen saturation (SvO2) are parameters reported to have correlations with decreased cardiac output, morbidity, and post-cardiac surgery mortality. Objective To determine the usefulness of lactate level, pCO2 gap (arterial-vein), and SvO2 for early detection of LCOS in children post-open heart surgery. Methods This prospective cohort study was done from August to October 2017 in the ICU of the Integrated Cardiac Center, Dr. Cipto Mangunkusumo Hospital, Jakarta. Subjects were pediatric patients who underwent cardiac surgery. After surgery, patients underwent monitoring in the ICU for clinical signs of LCOS and examinations for lactate levels, pCO2 gap, and SvO2 at 15 minutes, 4 hours and 8 hours. Results Thirty-three open heart surgery patients were the subjects. Lactate level at 4 hours and 8 hours post-operative were significantly higher in the LCOS group compared to non-LCOS group. For the pCO2 gap, only the 4-hour post-operative results were significantly higher in LCOS group compared to non-LCOS groups. In addition, only SvO2 at 4 hours after surgery was significantly lower in LCOS group compared to non-LCOS group. Conclusion Elevated lactate, high pCO2 gap, as well as decreased SvO2 at 4 hours post-operatively are the most reliable markers of LCOS after pediatric open heart surgery.

Effect of High-Flow Nasal Oxygen on Respiratory Parameters and Pulmonary Complications After Early Extubation Following Pediatric Heart Surgery

Objectives: The aim of this study was to evaluate the effect of high-flow nasal cannula (HFNC) after early extubation on children undergoing cardiac surgery. Methods: This randomized controlled clinical trial was performed among 92 children aged 1 to 24 months undergoing cardiac surgery from March 5 to August 30, 2020, in a pediatric post-cardiac surgery intensive care unit (ICU). The patients were randomized to receive either HFNC or conventional oxygen therapy after extubation. Arterial blood samples were collected after anesthesia induction, after the end of the surgery, at the time of entering the ICU while they were intubated, 6 hours after entering the ICU, before removing the endotracheal tube, immediately after extubation, as well as 1, 6, 12, 24, and 36 hours after extubation. The patients were compared regarding PaCO2, PaO2/FiO2 ratios, respiratory failure, need for reintubation, development of atelectasis, pneumothorax, pleural effusion, and length of ICU stay. Results: The patients were similar regarding demographic characteristics, the duration of surgery, and mechanical ventilation (P &gt; 0.05). On the first and second days after the surgery, the mean modified radiologic atelectasis score (m-RAS) was lower in the HFNC group compared to the conventional oxygen therapy group (P &lt; 0.05). The frequency of respiratory failure did not differ in the groups before and after the surgery (P &gt; 0.05). PaCO2 was lower in the HFNC group than in the control group after extubation (P &lt; 0.001). PaO2/FIO2 ratio was significantly higher in the HFNC group one hour after extubation and afterward in comparison to the control group (P &lt; 0.001). The need for re-intubation (P &lt; 0.013) and the length of ICU stay (P &lt; 0.001) were significantly lower in the HFNC group compared to the control group. Conclusions: It was found that HFNC could improve the respiratory parameters and reduce postoperative pulmonary complications in infants following a congenital heart surgery.

Effects of Pulsatile and Non-Pulsatile Perfusion On Oxygenator Fibers During Pediatric Cardiopulmonary Bypass

In cardiopulmoner operations patients can be perfused with a pulsatile or nonpulsatile pump mode. The extra energy maintained by the pulsatile perfusion may have different effects on the patient and the oxygenator fiber rather than nonpulsatile perfusion. Especially the effect of pulsatile perfusion on the fibers isn’t clearly known. The purpose of this study is to investigate the effects of pulsatile and non-pulsatile blood flows on oxygenator fibers. 18 out of 32 patients that had an pediatric open heart surgery was chosen according to their aortic clamp times. 9 of 18 patients were perfused in a pulsatile mode, other 9 patients were perfused in a nonpulsatile mode. The patient blood was collected before the open heart surgery (T1), before aortic clamp (T2), after aortic clamp (T3), after 1st intensive care hour (T4) and after the 1st intensive care day (T5) in order to compare the results of whole blood and plasma proteins. At the end of the open heart operation 10 cm of oxygenator fiber was removed from the fiber bundle and taken into the phosfate buffer saline (PBS) solution after the patient had a stabile outcome. Whole blood and micro protein measurements were applied in both first fiber solution and sonicated solution. No harmful effect of pulsatile perfusion on blood cells and proteins was observed according to patient results. More blood cell aggregation and total protein adsorption was observed in nonpulsatile mode fibers results. In this study pulsatile perfusion maintained better blood compability over nonpulsatile perfusion and the extra energy in pulsatile perfusion caused better microcirculation.

Disease Oriented ECMO Results; Specific Considerations for Different Pathologies

Introduction: Extracorporeal membrane oxygenation (ECMO), whose use has increased with technological developments in pediatric heart surgery, is a life-saving treatment modality that is used in patients with cardiac or pulmonary insufficiency who are unresponsive to medical treatment. We investigated the effect of operation technique and cardiac morphology of patients undergoing pediatric cardiac surgery in our clinic on ECMO prognosis in this retrospective cohort study. Patients and Methods: Seventy patients in need of ECMO after pediatric heart surgery were enrolled be- tween May 2010 and April 2020 in our clinic. 44.3% (n= 31) of patients were female and 55.7% (n= 39) were male. Their ages ranged from 0 to 575 months, with a mean of 32.59 ± 147.26. RACHS-1 was 25%, RACHS-2 was 23.07%, RACHS-3 was 33.33%, RACHS-4 was 35.71%, RACHS-5 was 100%, and RACHS-6 was 50% according to the ECMO result. No statistically significant difference was found between mortality and RACHS scoring. Results: As a consequence, scoring systems used in the evaluation and measurement of ECMO use in the pediatric age group can be deceptive. Conclusion: We attribute this to the fact that ECMO is a complex and complicated treatment that affects all systems in general and has a lot of mechanical and physiological complications. We think that the combination of scoring systems used in these patients with other scoring methods will give more accurate results than using them alone.

Treatment of systemic inflammatory response syndrome following on-pump pediatric congenital heart surgery

Highlights. The article discusses the pathophysiological aspects of cardiopulmonary bypass and the mechanisms underlying the development of the systemic inflammatory response in children following congenital heart surgery. We summarize and report the most relevant preventive strategies aimed at reducing the systemic inflammatory response, including both, CPB-related methods and pharmacological ones.The growing number of children with congenital heart defects requires the development of more advanced technologies for their surgical treatment. However, cardiopulmonary bypass is required in almost all surgical techniques. Despite the tremendous progress and recent advances in cardiopulmonary bypass techniques, the systemic inflammatory response syndrome associated with these surgeries remains unresolved. The review summarizes the causes and mechanisms underlying its development. The most commonly used preventive strategies are reported, including standard and modified ultrafiltration, leukocyte filters, and pharmacological agents (systemic glucocorticoids, aprotinin, and antioxidants).The role of cardioplegia and hypothermia in the reduction of systemic inflammation is defined. Cardiac surgery centers around the world use a variety of techniques and pharmacological approaches, drawing on the results of randomized clinical studies. However, there are no clear and definite clinical guidelines aimed at reducing the systemic inflammatory response during cardiopulmonary bypass in children. It remains a significant problem for pediatric intensive care by aggravating their postoperative status, prolonging the length of the in-hospital stay, and reducing the survival rates.

Evolving Cost-Quality Relationship in Pediatric Heart Surgery

BackgroundFor the more than 40,000 children in the United States undergoing congenital heart surgery annually, the relationship between hospital quality and costs remains unclear. Prior studies report conflicting results and clinical outcomes have continued to improve over time. We examined a large contemporary cohort, aiming to better inform ongoing initiatives seeking to optimize health care value in this population. MethodsClinical information (The Society of Thoracic Surgeons Congenital Database) was merged with standardized cost data (Pediatric Health Information Systems) for children undergoing heart surgery from 2010 to 2015. In-hospital cost variability was analyzed using Bayesian hierarchical models adjusted for case-mix. Quality metrics examined included in-hospital mortality, postoperative complications, postoperative length of stay (PLOS), and a composite. ResultsOverall, 32 hospitals (n = 45,315 patients) were included. Median adjusted cost per case varied across hospitals from $67,700 to $51,200 in the high vs low cost tertile (ratio 1.32; 95% credible interval, 1.29 to 1.35), and all quality metrics also varied across hospitals. Across cost tertiles, there were no significant differences in the quality metrics examined, with the exception of PLOS. The PLOS findings were driven by high-risk The Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery categories 4 and 5 cases (adjusted median length of stay 16.8 vs 14.9 days in high vs low cost tertile [ratio 1.13, 1.05 to 1.24]), and intensive care unit PLOS. ConclusionsContemporary congenital heart surgery costs vary across hospitals but were not associated with most quality metrics examined, highlighting that performance in one area does not necessarily convey to others. Cost variability was associated with PLOS, particularly related to intensive care unit PLOS and high-risk cases. Care processes influencing PLOS may provide targets for value-based initiatives in this population.

The Effect of Perioperative and Postoperative Theophylline Administration on Inflammation in Patients Undergoing Pediatric Open-Heart Surgery

Introduction: The aim of this study was to evaluate the effects of intraoperative and postoperative theophyl- line infusion on inflammation in children who underwent open heart surgery with cardiopulmonary bypass (CPB) for congenital heart diseases. Patients and Methods: This randomized controlled study was carried out with 140 children who underwent open heart surgery with CPB in a tertiary hospital. The patients were randomly enrolled into two groups (the- ophylline group= 70, control group= 70). Following the induction of anesthesia, theophylline infusion was applied to theophylline recipients from the beginning of the operation to the end of the 24th hour after surgery via a central venous catheter (CVC). The patients in the control group were infused with 0.9% NaCl solution at the same volume and duration via CVC. Results: Postoperative red blood cell distribution width was significantly higher than preoperative values in the theophylline group (p= 0.003), but no significant difference was found in the control group (p= 0.188). In both groups, postoperative vasoactive-inotropic scores, and lymphocyte and platelet counts were lower than preoperative measurements (p&lt; 0.001 for each in both groups). While preoperative white blood cell counts were similar, postoperative values were found to be lower in the theophylline group (p= 0.022). Conclusion: In pediatric patients undergoing open heart surgery with CPB, the use of intraoperative and post- operative theophylline may be effective in reducing postoperative inflammation, as demonstrated by lower white blood cell counts; but it does not significantly affect other clinical features.

Abstract P013: Validating The Utility Of Plasma Biomarkers In The Prediction Of Readmission Or Mortality Following Congenital Heart Surgery

Introduction: Unplanned readmission is associated with higher risks of complications, death, and increased costs. Accurate statistical models to stratify the risk of 30-day readmission or death after congenital heart surgery could help clinical teams focus care on those patients at highest risk. We hypothesized biomarkers could improve prediction for readmission or mortality. Methods: Levels of pre- and postoperative ST2, Galectin-3, NT-proBNP and GFAP were measured in plasma samples from 162 pediatric congenital heart surgery patients from Johns Hopkins Hospital with external validation in 360 pediatric patients from an international multi-center TRIBE-AKI cohort. A model based on clinical variables from the Society of Thoracic Surgery Congenital database (STS-CHSD) was developed in the Hopkins cohort. We tested and externally validated the clinical models and biomarker panels in the TRIBE-AKI cohort using AUROC statistics and Kaplan-Meier cox hazard regression models. Results: There were 55 patients (10.5%) that experienced unplanned readmission or died within 30 days after congenital heart surgery. The STS-CHSD clinical model resulted in an AUROC of 0.617 (95% CI: 0.47 - 0.76). The derivation cohort with the biomarker augmented STS-CHSD clinical model resulted in a significantly improved AUROC of 0.802 (95%CI: 0.72 - 0.89; p=0.003). External validation of the biomarker augmented STS-CHSD clinical model showed limited improvement (AUROC: 0.60; 95% CI: 0.49-0.72; p value= 0.47). Conclusions: Our findings indicate that these biomarkers can be used for early identification of children at increased risk of readmission or death after pediatric congenital heart surgery. While the addition of biomarkers improve prediction in our derivation cohort, external validation was poor. Our findings suggest there are other potential biomarkers and factors to be explored to improve prediction of readmission or mortality for children following congenital heart surgery.

Abstract P180: Hospital Readmission After Pediatric Congenital Heart Surgery: A Systematic Review And Meta-analysis Of Potential Risk Factors

Objective: Over 40,000 infants are born annually with a heart defect; 25% require surgery and of those 20% result in hospital readmissions. We sought to identify risk factors for short- and long-term readmission following pediatric congenital heart surgery (CHS) to reduce avoidable future admissions. Methods: A systematic approach was used to search four electronic databases and retrieve articles published through 05/2020. We included observational and experimental studies that observed factors associated with 30-day or 1-year readmission after CHS. Studies with a composite outcome of readmission and death were excluded. For each independent risk factor, we assessed the pooled effect size and heterogeneity using a random-effects model. Risk of bias was assessed via the Newcastle-Ottawa scale. Results: After removing 970 duplicates, we screened 5,084 studies; 17 were included in the systematic review and 15 (N= 82,794; 9,856 readmitted) in the meta-analysis. Hospital readmission was significantly and positively associated with gestational age, non-white race, Hispanic ethnicity, government insurance, genetic abnormality, renal dysfunction, failure to thrive, mechanical ventilation, intraoperative ventricular dysfunction, RACHS score, STAT mortality score, cross clamp time, gastroesophageal reflux disease, postoperative arrhythmia, valve regurgitation, feeding difficulties, and ICU and hospital length of stay (LOS). Readmission definition (i.e., 1-yr vs 30-day) and LOS dichotomization (i.e., ≥ 10 or ≥ 14) resulted in significant subgroup differences for age at surgery and LOS. Five studies had higher potential for risk of bias. Conclusions: This is the first meta-analysis to identify patient and clinical factors associated with short and long-term readmission after pediatric CHS. Findings may support clinical decisions before undergoing surgery and identify patients that may benefit from receiving more aggressive care transitions prior to discharge to reduce avoidable hospital readmissions.