RACHS-1 Score Research Articles

Excessive Postoperative Bleeding and Outcomes in Neonates Undergoing Cardiopulmonary Bypass

Neonates undergoing cardiac surgery are especially prone to the hemostatic alterations of cardiopulmonary bypass (CPB) and are at high risk for post-CPB bleeding. An immature coagulation system, significant hemodilution from the CPB prime, long CPB times at low temperatures, and extensive suture lines increase neonates' susceptibility to bleeding after CPB. In this study, we examined the relationship between excessive bleeding in neonates after CPB and major postoperative adverse events. We retrospectively reviewed the medical records of 169 neonates who underwent complex congenital heart surgery with CPB between January 1, 2010, and December 31, 2011. Perioperative data were collected and analyzed with specific focus on post-CPB bleeding as measured by 24-hour postoperative chest tube output (CTO), post-CPB transfusion requirements, and major postoperative adverse events, including renal dysfunction, dialysis, thrombosis, extracorporeal membrane oxygenation (ECMO), and in-hospital mortality. We used Spearman correlation to determine correlations between multiple perioperative variables and 24-hour CTO and postoperative blood product requirements. Also, we used logistic regression analysis to determine the association between excessive bleeding (defined as 24-hour CTO >75th percentile) and major postoperative adverse events. Significant correlations were found between 24-hour CTO and postoperative blood product transfusion with weight, Risk Adjustment for Congenital Heart Surgery (RACHS-1) score, CPB time, and lowest temperature. Logistic regression found that excessive bleeding after CPB was an independent predictor of postoperative dialysis (relative risk [RR] 12.0; confidence interval, 1.50-54.69; P = 0.02) and ECMO (RR 9.95; confidence interval, 3.07-28.47; P = 0.0008). RACHS-1 score was a significant predictor of in-hospital mortality (P = 0.03). Excessive postoperative bleeding in neonates after CPB is independently associated with increased adverse events, specifically the need for postoperative dialysis and ECMO support. Our findings in neonates are congruent with other recent research that also has found increasing transfusion requirements after pediatric CPB to be independently associated with an increase in major postoperative adverse events. Our results may aid clinicians in anticipating potential adverse events after neonatal bypass and in allocating the resources necessary to manage these events.

Abstract 18701: Frequency and Contributing Factors to Diaphragm Paresis Following Pediatric Cardiac Surgery

Introduction: Diaphragm paresis can occur as a complication of pediatric cardiac surgery that can prolong ventilation and length of ICU stay. Diaphragm plication (DP) may be necessary to improve respiratory mechanics and decrease duration of ventilation support. Early identification of patients who are likely to benefit from DP has not been studied. Methods: Patients at our institution diagnosed with diaphragm paresis between 2002 - 2012 were identified. Mode of diagnosis, demographics, operative procedures during index admission, and intervals of care were evaluated. Associations between predictors and DP were assessed by univariable and multivariable logistic regressions. Results: Diaphragm paresis was diagnosed in 161 patients following 6448 index surgeries, of whom 31 (19%) underwent DP (DP+). Paresis was diagnosed by ultrasound in 160 (99%) subjects at a median (IQR) time from surgery of 7 (3, 11) days in DP+ vs 10 (6, 19) days in DP- (p=0.02). DP was completed after a median (IQR) of 4 (1, 17) days after diagnosis. DP+ were younger in age [median (IQR) days DP+ 42 (14, 84) vs DP- 168 (28, 784); p<0.001], underwent surgery of higher RACHS-1 score [DP+ 3 (3, 4) vs DP- 3 (2, 4); p=0.02], and had a higher rate of hypothermic circulatory arrest [DP+ 14 (45%) vs DP- 23 (18%); p=0.001]. DP+ subjects had a rate of single ventricle physiology (32%), median sternotomy (94%), and bypass (87%) similar to DP- subjects. Only younger age (OR 1.003 per day, p=0.02) and use of hypothermic circulatory arrest (OR 3.06, p=0.01) remained significant on multivariable modeling. DP+ subjects had longer duration of ventilator support [DP+ 15 (9, 30) vs DP- 6.5 (3, 12.5) days; p<0.001] and ICU admission [DP+ 23 (18, 42) vs DP- 8 (5, 17) days; p<0.001]. However, ventilation was discontinued after a median of 1 (1,2) day after plication. The time interval from index surgery to diagnosis (EST 0.91, p<0.0001) and interval from diagnosis to DP (EST 0.94, p<0.0001; r2=0.91) were associated with a longer ICU stay even after adjusting for age and bypass time. Conclusion: Diaphragm paresis is common after congenital heart surgery. Earlier diagnosis and plication may shorten length of ventilation support and ICU stay, particularly in younger patients. Long-term outcome studies following DP are required.

PS-137 Low Biochemical Nutritional Indices Predict Clinical Outcomes In Children Undergoing Cardiac Surgery

Aim To determine whether biochemical nutritional indices predict clinical outcomes in children undergoing cardiac surgery. Methods Retrospective single centre study between July 2012 and June 2013. Biochemical nutritional indices included serum albumin and total lymphocyte count (TLC) which was used to calculate Onodera’s prognostic nutritional index (PNI) [10 x serum albumin (g/dL) + 0.005 x TLC (/mL)]. Severity of illness assessed using Paediatric Risk of Mortality (PRISM) III score. Surgery categorised using the risk adjusted classification for congenital heart surgery (RACHS-1) score. Outcomes included hospital mortality, paediatric intensive care unit (PICU) length of stay (LOS) and duration of mechanical ventilation (MV). Results Total of 31 patients identified. Median age was 2.0 (0.7–41.0) months. Median PRISM III score was 8.0 (5.0–13.0). 14 (45%) underwent RACHS-1 category 2 surgery and 6 (20%) had ventricular septal defects. Median albumin and TLC were 3.2 (2.6–4.2) g/dL and 4280 (2810–5100)/uL respectively. Median PNI score was 52.7 (41.2–69.7). There was no hospital mortality. Median PICU LOS was 5.0 (3.0–8.0) days. Hypoalbuminaemia ≤3.0 g/dL associated with longer median PICU LOS (7.0 vs. 4.0 days, p = 0.016) and duration of MV (156 vs. 33 h, p = 0.007). PNI ≤ 58 associated with longer median PICU LOS (6.0 vs. 3.0 days, p = 0.041). Adjusting for age and RACHS-1 score, for every 1 g/dL drop in albumin, PICU LOS increased by 0.5 days (p = 0.006). Conclusions Hypoalbuminaemia and PNI ≤ 58 were associated with adverse postoperative outcomes. Future studies to study effect of perioperative aggressive nutrition care on biochemical indices and clinical outcomes.

Mexican registry of pediatric cardiac surgery. First report

BackgroundCurrently, there is a spreading worldwide tendency to characterize health issues and to propose alternative solutions via the creation of computerized databases. The aim of this study was to present the results in a computerized database of pediatric cardiac surgeries developed under the auspices of the Mexican Association of Specialists in Congenital Heart Diseases (Asociación Mexicana de Especialistas en Cardiopatías Congénitas A.C) and coordinated by the collegiate group of Pediatric Cardiology and Surgery as petitioned by the National Institutes of Health and High Specialty Hospitals Coordinating Commission. MethodsWe analyzed all cases registered in the database during a 1-year observation period (August 1, 2011 to July 31, 2012) by all major Health Ministry-dependent institutes and hospitals offering surgical services related to pediatric cardiopathies to the non-insured population. ResultsSeven institutions participated voluntarily in completing the database. During the analyzed period, 943 surgeries in 880 patients with 7% reoperations (n=63) were registered. Thirty-eight percent of the surgeries were performed in children <1 year of age. The five most common cardiopathies were patent ductus arteriosus (n=96), ventricular septal defect (n=86), tetralogy of Fallot (n=72), atrial septal defect (n=68), and aortic coarctation (n=54). Ninety percent of surgeries were elective and extracorporeal circulation was used in 62% of surgeries. Global mortality rate was 7.5% with the following distribution in the RACHS-1 score categories: 1 (n=4, 2%), 2 (n=19, 6%), 3 (n=22, 8%), 4 (n=12, 19%), 5 (n=1, 25%), 6 (n=6, 44%), and non-classifiable (n=2, 9%). ConclusionsThis analysis provides a representative view of the surgical practices in cardiovascular diseases in the pediatric population at the national non-insured population level. However, incorporating other health institutions to the national registry database will render a more accurate panorama of the national reality in surgical practices in the population <18 years of age.

Predictors of 90-day mortality after congenital heart surgery: The first report of risk models from a Japanese database

The purpose of this study was to develop risk models for congenital heart surgery short-term and midterm outcomes from a nationwide integrated database drawn from hospitals in Japan. The Japan Congenital Cardiovascular Surgery Database collects clinical information from institutions throughout Japan specializing in congenital heart surgery. Variables and definitions used in the Japan Congenital Cardiovascular Surgery Database are almost identical to those of the Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery database for congenital heart surgery. We used logistic regression to develop risk models, which were then validated through spilt-sample validation. In addition to procedural complexity categories by Risk Adjustment in Congenital Heart Surgery (RACHS-1) score, we incorporated patient characteristics to predict surgical outcome. Among 8923 congenital heart operations performed at 69 sites with cardiac surgical programs, 30-day mortalities by RACHS-1 category were as follows: I, 0.1% (n=1319); II, 0.5% (n=3211); III, 2.2% (n=3285); IV, 4.3% (n=818); and V and VI, 8.6% (n=290). From the test data set (n=7223), we developed 3 risk models (30-day mortality, 90-day mortality, and 90-day and in-hospital mortality) with 11 variables, including age category, RACHS-1 category, preoperative risk factors, number of surgical procedures, unplanned reoperations, status of surgery, surgery type, asplenia, and prematurity (<35 weeks). For the performance metrics of the risk models, C statistic values of 30-day, 90-day, and 90-day and in-hospital mortalities for the test data set were 0.85, 0.85, and 0.84, respectively. When only the RACHS-1 score was used for discrimination, the C statistic values of 30-day, 90-day, and 90-day and in-hospital mortalities for the validation data set were 0.73, 0.73, and 0.77, respectively. The proposed risk scores and categories have high discrimination power for predicting mortality, demonstrating improvement relative to existing consensus-based methods. Risk models incorporating these measures may be useful for comparing mortality outcomes cross institutions or countries with mixed cases.

Patients with Single Ventricle Anatomy May Respond Better to Octreotide Therapy for Chylothorax After Congenital Heart Surgery

Chylothorax (CTX) occurs in 3% to 6% of children after surgery for congenital heart disease with significant morbidity and mortality. Octreotide has been proposed as therapy, but there are no predictors of response. The objective of this study was to identify possible predictors of response to octreotide. Single-center retrospective review of patients who developed CTX after cardiac surgery. Data collected included demographics, cardiac lesion, surgical data, hospital course, CTX volume and duration, and interventions for CTX. Patients who received octreotide as part of their therapy were compared to those who did not. A total of 1150 patients underwent 1455 cardiac surgeries with 67 (4.6%) episodes of CTX. Patients with CTX were younger, lower weight, more likely to undergo cardiopulmonary bypass, and had higher RACHS-1 scores and mortality. Nineteen patients with CTX received octreotide as part of their treatment and six (32%) had at least 50% reduction in CTX volume. Patients who responded to octreotide had lower CTX volume (18 mL/kg/day vs. 55 mL/kg/day, p=0.023) and a higher proportion of patients with single ventricle anatomy (67% vs. 18%, p=0.046). There is a subset of patients who seem to respond to octreotide, but they have lower CTX volume and may have already been improving before octreotide therapy. Patients with single ventricle anatomy seemed to respond to octreotide and may benefit from its use.

Assessing surgical risk for adults with congenital heart disease: Are pediatric scoring systems appropriate?

Patients with congenital heart disease are frequently surviving into adulthood, and many of them will require surgery. Currently, there is no validated risk scoring system for adult congenital heart surgery, and predicting outcomes in these patients is challenging. Our objective was to determine if commonly used pediatric congenital heart disease surgery risk scores are also applicable to adults. Four hundred fifty-eight adult (age ≥ 18 years) operations involving cardiac surgery for congenital heart disease between 2000 and 2010 at a single institution were studied retrospectively. The pediatric scores evaluated were the Risk Adjustment for Congenital Heart Surgery (RACHS-1) score, the Aristotle Basic Score, and the Society of Thoracic Surgery-European Association for Cardio-Thoracic Surgery (STAT) Congenital Heart Surgery Mortality score. Receiver operating characteristic (ROC) curves were generated to assess the ability of the scoring systems to predict mortality, major adverse events (stroke, renal failure, prolonged ventilation, prolonged coma, deep sternal infection, reoperation, and operative mortality), and prolonged length of stay (>7 days). Of 458 operations, there were 16 (3%) deaths, 94 (21%) major adverse events, and 90 (20%) prolonged lengths of stay. Four hundred thirty (94%) of the operations were included in all 3 scoring systems and the ROC analysis. For mortality, areas under the ROC curve were 0.91, 0.91, and 0.65 for the Aristotle, STAT, and RACHS-1 scores, respectively. For major adverse event, areas under the ROC curves were 0.81, 0.76, and 0.61 for the Aristotle, STAT, and RACHS-1 scores, respectively. For prolonged length of stay, areas under the ROC curve were 0.82, 0.76, and 0.61 for the Aristotle, STAT, and RACHS-1 scores, respectively. Pediatric risk scoring systems such as Aristotle, STAT, and RACHS-1 offer prognostic value in adults undergoing congenital heart surgery. The scores are predictive of mortality, major adverse events, and prolonged lengths of stay. The STAT and Aristotle systems fared best.

Psychological well-being and sexual function in adults with congenital heart disease: Not tonight, dear, I have an ICD

The bar has been raised. In the days of Lillehei, an operative and early postoperative mortality rate of 38% was considered “remarkable” for surgical repair of ventricular septal defects, atrioventricular septal defects, and tetralogy of Fallot. 1 Moller J.H. Shumway S.J. Gott V.L. The first open-heart repairs using extracorporeal circulation by cross-circulation: a 53-year follow-up. Ann Thorac Surg. 2009; 88: 1044-1046 Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Today, these same lesions would be considered no more than moderate in complexity, earning only a 2 or 3 (on a scale of 6) in the RACHS-1 scoring system, with an associated mortality between 3.5% and 8.5%. 2 Jenkins K.J. Gauvreau K. Newburger J.W. Spray T.L. Moller J.H. Iezzoni L.I. Consensus-based method for risk adjustment for surgery for congenital heart disease. J Thorac Cardiovasc Surg. 2002; 123: 110-118 Abstract Full Text Full Text PDF PubMed Scopus (1009) Google Scholar As a consequence, the expectation has become for children born with congenital heart disease not only to survive but also to thrive. A new and increasing emphasis has been placed on the neurodevelopmental outcomes of children undergoing complex cardiac repairs and palliations, prompting the rise of specialized clinics in many of the major centers to focus specifically on the neuropsychiatric and developmental needs of this at-risk population. 3 Marino B.S. Lipkin P.H. Newburger J.W. et al. Neurodevelopmental outcomes in children with congenital heart disease: evaluation and management. A scientific statement from the American Heart Association. Circulation. 2012; 126: 1143-1172 Crossref PubMed Scopus (873) Google Scholar Shock-related anxiety and sexual function in adults with congenital heart disease and implantable cardioverter-defibrillatorsHeart RhythmVol. 10Issue 6PreviewAn increasing number of adults with congenital heart disease (CHD) require implantable cardioverter-defibrillators (ICDs), yet little is known about their impact on psychological well-being and sexual function. Full-Text PDF

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Introduction: Hyperglycemia is associated with poor outcomes in critically-ill adults with central line associated bloodstream infections (CLABSI). The impact of hyperglycemia on outcomes in critically-ill children with CLABSI is unknown. Hypothesis: Hyperglycemia is associated with intensive care unit (ICU) mortality in children with CLABSI. Methods: This is an IRB-approved retrospective review of pediatric (non-cardiac) ICU and pediatric cardiac ICU patients with CLABSI and? 1 measured blood glucose (BG) during the 4 days pre-CLABSI to 7 days post-CLABSI; we excluded patients with diabetes mellitus, metabolic disorders and those with a “do not attempt resuscitation” (DNAR) order. Demographic information, measures of illness severity including Pediatric Risk of Mortality (PRISM) III scores for pediatric ICU patients and Risk Adjustment for Congenital Heart Surgery (RACHS)-1 scores for cardiac ICU patients, data on ventilator/vasopressor use, steroid use, and nutrition were collected. Primary outcome was ICU mortality. Analysis was by t-test and multivariable logistic regression. Results: 109 patients (57% cardiac ICU) were enrolled with a mortality of 24% and median ICU length of stay of 38 days (IQR: 20-91.5). The mean PRISM III score for PICU patients was 9 ± 9.35 at 12 hours and 12 ± 10.21 at 24 hours. Mean RACHS-1 score for cardiac ICU patients was 4 ± 1.68. Ninety-three percent of all patients required mechanical ventilation, 81% received total parenteral nutrition, 78% received steroids, and 78% required? 1 vasopressor during their ICU stay. Mean BG was significantly higher after CLABSI than before (149.3 ± 85 mg/dL vs. 138.5 ± 70 mg/dL, p<0.001). Non-survivors compared to survivors had higher mean BG (125 ± 56 mg/dL vs. 106 ± 32 mg/dL, p=0.03) and higher peak BG (250 ± 136 mg/dL vs. 189 ± 104 mg/dL, p=0.04). After controlling for confounders, peak BG was independently associated with ICU mortality (adjusted OR 1.01, 95% CI 1.01-1.03, p=0.02). Conclusions: Hyperglycemia is associated with ICU mortality in children with CLABSI. Control of blood glucose may improve outcomes in this population.Funded by Russell Raphaely Endowed Chair, CCM

Early Extubation in Adults Undergoing Surgery for Congenital Heart Disease

Early extubation in adults undergoing surgery for congenital heart disease has not been described. The authors report their experience with extubation in the operating room (OR), including factors associated with the decision to defer extubation to a later time. A retrospective chart review. A tertiary-care teaching hospital. This study included adults undergoing surgery for congenital heart disease using cardiopulmonary bypass. Exclusion criteria were as follows: preoperative mechanical ventilation, age >70 years, inotrope score >20 after surgery, and surgical risk (Risk Adjustment for Congenital Heart Surgery [RACHS] score ≥4). A stepwise logistic regression model was used to test for the independent influence of the various factors on extubation in the OR. Sixty-seven patients (age 18-59 years, median = 32 years) were included. Overall, 79% of patients were extubated in the OR. The RACHS score was the strongest predictor of deferring extubation (RACHS 3 v 1 or 2: odds ratio = 16.7; 95% confidence interval, 3.3-84.2; p = 0.0006). Further exploration of the high-risk group (RACHS 3) showed that 75% of the RACHS 3 patients with a body mass index <25 were extubated compared with only 20% of patients who had a body mass index ≥25 (p = 0.01). Other factors included in the analysis did not contribute any additional independent information. Extubation of adult patients in the OR after surgery for congenital heart disease is feasible in most cases. Surgical risk (RACHS score) and body mass index predict the decision for OR extubation in this patient population.

Five-year Analysis of Operative Mortality and Neonatal Outcomes in Congenital Heart Disease

We sought to compare overall mortality with neonatal outcomes over a five year period to define risk factors for mortality and service development priorities. A retrospective cohort study of surgical outcomes following repair or palliation of structural congenital heart defects January 2005-2010. We defined mortality according to contemporary international guidelines and classified surgical procedures using the Risk Adjustment in Congenital Heart Surgery (RACHS-1) score. The effect of age and weight at operation on mortality and annual variation in case-complexity and surgeon case-mix were assessed. Subgroup analysis was performed in patients who were ≤30 days at operation (neonates). Overall mortality within 30 days of operation or prior to hospital discharge was 1.3 and 1.9%, respectively. Mortality was higher in neonates (6.8%) and low birth weight infants (≤2.5kg) (12.1%). Mortality was similar in bypass versus non-bypass procedures (odds ratio 0.74, p=0.425). Annual mortality rates were consistent despite a marked increase in case-complexity. Neonates overall required longer periods of intensive care support and were more likely to suffer serious complications compared to older children. Age, weight and RACHS-1 score were independent risk factors for mortality on multivariate analysis. In neonates undergoing bypass procedures, only RACHS-1 score was a significant risk factor. This study provides an accurate and contemporary audit of mortality risk associated with congenital heart surgery. Outcomes compare favourably to international benchmarks but highlight the risks of morbidity and mortality associated with neonatal cardiac surgery.

Factors Affecting the Decision to Defer Endotracheal Extubation After Surgery for Congenital Heart Disease

Fast-tracking and early endotracheal extubation have been described in patients undergoing surgery for congenital heart disease (CHD); however, criteria for patient selection have not been validated in a prospective manner. Our goal in this study was to prospectively identify factors associated with the decision to defer endotracheal extubation in the operating room (OR). We performed a prospective observational study of 275 patients (median age 18 months) at the Mount Sinai Medical Center (MSMC), New York, New York, and 49 patients (median age 25 months) at the University of Tokyo Hospital (UTH), Tokyo, Japan, undergoing surgery for CHD requiring cardiopulmonary bypass. These patients were all eligible for fast-tracking, including extubation in the OR immediately after surgery, according to the respective inclusion/exclusion criteria applied at the 2 sites. Eighty-nine percent of patients at the MSMC, and 65% of patients at the UTH were extubated in the OR. At the MSMC, all patients without aortic cross-clamp, and patients with simple procedures (Risk Adjustment for Congenital Heart Surgery [RACHS] score 1) were extubated in the OR. Among the remaining MSMC patients, regression analysis showed that procedure complexity was still an independent predictor for not proceeding with planned extubation in the OR. Extubation was more likely to be deferred in the RACHS score 3 surgical risk patients compared with the RACHS score 2 group (P = 0.005, odds ratio 3.8 [CI: 1.5, 9.7]). Additionally, trisomy 21 (P = 0.0003, odds ratio 9.9 [CI: 2.9, 34.5]) and age (P = 0.0015) were significant independent predictors for deferring OR extubation. We tested our findings on the patients from the UTH by developing risk categories from the MSMC data that ranked eligible patients according to the chance of OR extubation. The risk categories proved to predict endotracheal extubation in the 49 patients who had undergone surgery at the UTH relative to their overall extubation rate, despite differences in anesthetic regimen and inclusion/exclusion criteria. Preoperatively known factors alone can predict the relative chances of deferring extubation after surgery for CHD. The early extubation strategies applied in the 2 centers were successful in the majority of cases.

628 The Impact of Aprotinin in Acute Kidney Injury After Cardiopulmonary Bypass in Pediatric Patients

Background and aims: The use of aprotinin as antifibrinolytic agent in cardiopulmonary bypass (CPB) has been associated with increased postoperative morbidity and kidney damage in adults. Our goal was to evaluate the relationship between the antifibrinolytic used and development of postoperative renal damage in children.Methods: Retrospective study including children undergoing CPB surgery during 3 years. Demographic variables, clinical and surgical-related aggressions and antifibrinolytic treatment used were collected. Kidney damage was assesed with pediatric RIFLE criteria (RIFLE-p). Data analysed with chi-square test and multivariate logistic regression.Results: 403 patients were included. Median age: 7 months (18.1% neonates). Clamping was used in 302 children and circulatory arrest (CA) in 131. The RACHS-1 score was ≥ 4 in 101 patients. Aprotinin was used in 243, and tranexamic acid in 122 children.128 children showed kidney damage. 57 required renal replacement therapy. The group receiving aprotinin showed less kidney damage (27.3% vs 39.5%, p = 0.012). This group had shorter CPB (130 vs 151 min.; p=0.006), less use of CA (23% vs 47%), lower RACHS-1 (23% vs 33% RACHS-1> 4) and included fewer infants (10% vs 31%), p < 0.001. Controlling the effect of age and surgical aggression, no association between use of aprotinin and kidney damage was observed [OR 1.32, IC95% (0.78-2.24), p=0.291].Conclusions: The antifibrinolytic treatment with aprotinin in extracorporeal circulation has not been associated with increased renal damage in our pediatric group. Further investigations are needed to evaluate the safety profile of aprotinin in children and its influence in renal failure.

Perioperative Hyperglycemia: Effect on Outcome After Infant Congenital Heart Surgery

Studies demonstrate that cardiopulmonary bypass (CPB) causes intraoperative and postoperative hyperglycemia. Hyperglycemia has been associated with morbidity and mortality after infant cardiac surgery. We studied the effects on early postoperative outcomes of glucose (GLU) changes during and after pediatric cardiac surgery. The records of 144 infants less than 10 kg who underwent CPB for a variety of congenital cardiac procedures were reviewed. The GLU values (at multiple intervals during and after surgery), age, weight, CPB time, ultrafiltration volume, and risk adjustment for congenital heart surgery (RACHS-1) score were recorded. Univariate and multivariate linear and binary logistic regression were used to examine the dependence of the composite outcome mortality or postoperative infection, the mechanical ventilation time (VENT time), and the length of stay (LOS), on these variables. The RACHS-1 score was the only significant predictor of the composite variable "mortality or infection" (p = 0.008). Glucose at any time was not a significant factor predicting this outcome. Lower pre-CPB GLU, younger age, and higher RACHS-1 score were significant predictors of greater LOS and VENT time. In this study, post-CPB and postoperative hyperglycemia were not risk factors for postoperative morbidity and mortality after infant cardiac surgery.

An empirically based tool for analyzing mortality associated with congenital heart surgery

Analysis of congenital heart surgery results requires a reliable method of estimating the risk of adverse outcomes. Two major systems in current use are based on projections of risk or complexity that were predominantly subjectively derived. Our goal was to create an objective, empirically based index that can be used to identify the statistically estimated risk of in-hospital mortality by procedure and to group procedures into risk categories. Mortality risk was estimated for 148 types of operative procedures using data from 77,294 operations entered into the European Association for Cardiothoracic Surgery (EACTS) Congenital Heart Surgery Database (33,360 operations) and the Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database (43,934 patients) between 2002 and 2007. Procedure-specific mortality rate estimates were calculated using a Bayesian model that adjusted for small denominators. Each procedure was assigned a numeric score (the STS-EACTS Congenital Heart Surgery Mortality Score [2009]) ranging from 0.1 to 5.0 based on the estimated mortality rate. Procedures were also sorted by increasing risk and grouped into 5 categories (the STS-EACTS Congenital Heart Surgery Mortality Categories [2009]) that were chosen to be optimal with respect to minimizing within-category variation and maximizing between-category variation. Model performance was subsequently assessed in an independent validation sample (n = 27,700) and compared with 2 existing methods: Risk Adjustment for Congenital Heart Surgery (RACHS-1) categories and Aristotle Basis Complexity scores. Estimated mortality rates ranged across procedure types from 0.3% (atrial septal defect repair with patch) to 29.8% (truncus plus interrupted aortic arch repair). The proposed STS-EACTS score and STS-EACTS categories demonstrated good discrimination for predicting mortality in the validation sample (C-index = 0.784 and 0.773, respectively). For procedures with more than 40 occurrences, the Pearson correlation coefficient between a procedure's STS-EACTS score and its actual mortality rate in the validation sample was 0.80. In the subset of procedures for which RACHS-1 and Aristotle Basic Complexity scores are defined, discrimination was highest for the STS-EACTS score (C-index = 0.787), followed by STS-EACTS categories (C-index = 0.778), RACHS-1 categories (C-index = 0.745), and Aristotle Basic Complexity scores (C-index = 0.687). When patient covariates were added to each model, the C-index improved: STS-EACTS score (C-index = 0.816), STS-EACTS categories (C-index = 0.812), RACHS-1 categories (C-index = 0.802), and Aristotle Basic Complexity scores (C-index = 0.795). The proposed risk scores and categories have a high degree of discrimination for predicting mortality and represent an improvement over existing consensus-based methods. Risk models incorporating these measures may be used to compare mortality outcomes across institutions with differing case mixes.

Profile of congenital heart disease and correlation to risk adjustment for surgery; an echocardiographic study.

To determine the pattern and profile of Congenital Heart Diseases (CHD) in paediatric patients (age 1 day to 18 years) presenting to a paediatric tertiary referral centre and its correlation to risk adjustment for surgery for congenital heart disease. Descriptive case series. Paediatric Cardiology Department, Armed Forces Institute of Cardiology/National Institute of Heart Diseases, Rawalpindi (AFIC/NIHD). Over a period of 6 months, 1149 cases underwent 2-D echocardiography. It was a non-probability purposive sampling. This study showed 25% of all referrals had normal hearts. A male preponderance (38%) was observed from 1 year to 5 years age group. Nineteen percent of the cases were categorized as cyanotic CHD with the remaining as acyanotic variety. Tetralogy of Fallot (TOF) represented 10%, Ventricular Septal Defects (VSD) 24%, followed by Patent Ductus Arteriosus (PDA) and Atrial Septal Defect (ASD), which comprised 6.6% and 6.5% respectively. VSD was the most common association in patients with more complex CHD (10%) followed by PDA in 3% and ASD in 1.2% of the cases. Most of the cases were category 2 in the RACHS-1 scoring system. VSD and TOF formed the major groups of cases profiled. Most of the cases recommended for surgery for congenital heart disease belonged to the risk category 2 (28.1%) followed by the risk category 1 (12.7%) of the RACHS-1 scoring system.

Clinical outcome in children with acute renal failure treated with peritoneal dialysis after surgery for congenital heart disease

The present single-center cohort study was based on a clinical intensive care unit database containing data on 1128 consecutive children undergoing their first operation for congenital heart disease between 1993 and 2002 at Aarhus University Hospital, Skejby, Denmark. A total of 130 (11.5%) children developed postoperative acute renal failure (ARF) managed with peritoneal dialysis (PD). Logistic regression analysis was used to examine risk factors for complications related to PD and to compare mortality between ARF and non-ARF patients controlling for potential confounding factors. A total of 43 complications related to PD were registered in 27 (20.8%) patients. Major complications were seen in eight (6.2%) patients, and only two (1.5%) patients were switched to hemodialysis after peritonitis and hemicolectomy due to bowel perforation. The main risk factors for complications to PD were duration of PD, high RACHS-1 score (Risk Adjusted Classification for Congenital Heart Surgery), and hyperkalemia at initiation of PD. Overall, in-hospital mortality was 6.8% (76/1128). Mortality of ARF patients was 20.0% compared to 5.0% among non-ARF patients (adjusted odds ratio=1.91, 95% confidence interval=1.10-3.36). After stratification, ARF was strongly associated with increased mortality in the subgroups of patients with the lowest overall risk of dying (age> or =1 year, body weight> or =5 kg, RACHS-1 score <3, and no preoperative cyanosis). For patients at high risk of dying (age <1 year, body weight <5 kg, RACHS-1 score> or =3, cardiopulmonary bypass time> or =60 min, and preoperative cyanosis), the association between ARF and mortality was substantially weaker. In conclusion, postoperative ARF was associated with increased mortality in children operated for congenital heart disease. Major complications to PD were few, and our data strongly support that PD is a simple, safe, feasible, and robust dialysis modality for the management of ARF in children.

Risk factors for acute renal failure requiring dialysis after surgery for congenital heart disease in children

Limited data exist on the risk factors for acute renal failure (ARF) following cardiac surgery in children with congenital heart disease. This cohort study was conducted to examine this subject, as well as changes in the incidence of ARF from 1993 to 2002, the in-hospital mortality and the time spent in the intensive care unit (ICU). One thousand, one hundred and twenty-eight children, operated on for congenital heart disease between 1993 and 2002, were identified from our prospectively collected ICU database to obtain data on potential risk factors. A total of 130 children (11.5%) developed ARF after surgery. A young age [> or =1.0 vs. <0.1 year; odds ratio (OR), 0.23; 95% confidence interval (CI), 0.12-0.46], high Risk Adjusted Classification of Congenital Heart Surgery (RACHS-1) score (OR, 2.72; 95% CI, 1.66-4.45) and cardiopulmonary bypass (CPB) (<90 min vs. none; OR, 2.68; 95% CI, 1.03-6.96; > or =90 min vs. none; OR, 12.94; 95% CI, 5.46-30.67) were independent risk factors for ARF. The risk of ARF decreased during the study period. Children with ARF spent a significantly longer time in the ICU (2-7 days vs. <2 days, P = 0.002; > or =7 days vs. <2 days, P < 0.001) compared with non-ARF patients, and showed increased in-hospital mortality (20% vs. 5%, P < 0.001). A young age, high RACHS-1 score and CPB were independent risk factors for ARF after surgical procedures for congenital heart disease in children. The risk of ARF decreased during the study period. Children with severe ARF spent a longer time in the ICU, and the mortality in ARF patients was higher than that in non-ARF patients.

Point of care testing: improving pediatric outcomes

Objective: Goal-directed therapy (GDT) has been proven to reduce morbidly and mortality in critical illness. Point of care testing (POCT) allows rapid turn around time (TAT) of critical data, yet data suggesting improved outcomes are very limited. The impact of these two strategies on improving outcomes for patients after congenital heart surgery has never been evaluated. Design: Beginning July 2001, POCT in the form of the i-STAT handheld analyzer was incorporated in the management of patients after congenital heart surgery at our institution. Blood lactate measurements were performed serially for 24 h after surgery. Based on a lactate value, medical therapy was escalated, diminished or left unchanged after surgery. Outcome data were collected prospectively for later review. Mortality at 30 days after surgery was compared for patients undergoing a GDT protocol to a group of historical cohorts. The operative risk for all operations was determined using the RACHS-1 scoring system. Setting: A 16-bed Cardiac Intensive Care Unit (CICU) in a 268-bed free-standing pediatric hospital. Patients: Outcomes of infants and neonates operated on from July 2001 through July 2003 (Group B) were compared to historical controls in our institution from June 1995 through June 2001 (Group A). There were 851 patients in Group A and 378 patients in Group B. Patients in Group B were smaller and younger than those in group A (median weight 3.8 vs. 4.3 kg, P < 0.001; median age 42 vs. 76 days, P = 0.02). Measurements and results: Overall mortality was lower for Group B as compared to Group A (2.4% vs. 6.2%, P < 0.007). Significant reduction in mortality between Group B and Group A was noted in neonates (4.3% vs. 12%, P = 0.008) but did not reach significance in infants (0.9% vs. 2.6%, P = NS). Patients undergoing the highest-risk operations (RACHS-1 groups 5 + 6) had a 70% reduction in mortality when comparing Group B to Group A, (9% vs. 30%, P = 0.03), but no statistical difference in mortality was noted in those patients undergoing lower-risk operations (RACHS-1 groups 1 and 2, Group B 0.5% vs. Group A 1.5%, P = NS). Conclusions: The combination of goal-directed therapy and point of care testing significantly reduced mortality in patients undergoing congenital heart surgery. This improvement is greatest in the youngest patients and those undergoing higher-risk surgeries.