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Dawes TJW, Woodham V, Sharkey E, McEwan A, Derrick G, Muthurangu V, Moledina S, Hepburn L. Predicting Peri-Operative Cardiorespiratory Adverse Events in Children with Idiopathic Pulmonary Arterial Hypertension Undergoing Cardiac Catheterization Using Echocardiography: A Cohort Study. Pediatr Cardiol 2024:10.1007/s00246-024-03447-3. [PMID: 38512488 DOI: 10.1007/s00246-024-03447-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 02/07/2024] [Indexed: 03/23/2024]
Abstract
General anesthesia in children with idiopathic pulmonary arterial hypertension (PAH) carries an increased risk of peri-operative cardiorespiratory complications though risk stratifying individual children pre-operatively remains difficult. We report the incidence and echocardiographic risk factors for adverse events in children with PAH undergoing general anesthesia for cardiac catheterization. Echocardiographic, hemodynamic, and adverse event data from consecutive PAH patients are reported. A multivariable predictive model was developed from echocardiographic variables identified by Bayesian univariable logistic regression. Model performance was reported by area under the curve for receiver operating characteristics (AUCroc) and precision/recall (AUCpr) and a pre-operative scoring system derived (0-100). Ninety-three children underwent 158 cardiac catheterizations with mean age 8.8 ± 4.6 years. Adverse events (n = 42) occurred in 15 patients (16%) during 16 catheterizations (10%) including cardiopulmonary resuscitation (n = 5, 3%), electrocardiographic changes (n = 3, 2%), significant hypotension (n = 2, 1%), stridor (n = 1, 1%), and death (n = 2, 1%). A multivariable model (age, right ventricular dysfunction, and dilatation, pulmonary and tricuspid regurgitation severity, and maximal velocity) was highly predictive of adverse events (AUCroc 0.86, 95% CI 0.75 to 1.00; AUCpr 0.68, 95% CI 0.50 to 0.91; baseline AUCpr 0.10). Pre-operative risk scores were higher in those who had a subsequent adverse event (median 47, IQR 43 to 53) than in those who did not (median 23, IQR 15 to 33). Pre-operative echocardiography informs the risk of peri-operative adverse events and may therefore be useful both for consent and multi-disciplinary care planning.
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Affiliation(s)
- Timothy J W Dawes
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 1LE, UK.
- UCL Institute of Cardiovascular Science, University College London, London, UK.
| | - Valentine Woodham
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 1LE, UK
| | - Emma Sharkey
- Department of Anaesthesia, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Angus McEwan
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 1LE, UK
| | - Graham Derrick
- UCL Institute of Cardiovascular Science, University College London, London, UK
- Department of Paediatric Cardiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Vivek Muthurangu
- UCL Institute of Cardiovascular Science, University College London, London, UK
| | - Shahin Moledina
- UCL Institute of Cardiovascular Science, University College London, London, UK
- National Paediatric Pulmonary Hypertension Service UK, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Lucy Hepburn
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 1LE, UK
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Kobayashi D, Amin EK, Morgan GJ, Reddy SRV, Fleming GA, Forbes TJ, Nykanen DG. Usefulness of PREDIC 3T Case Type Risk Category in the CRISP Registry. Am J Cardiol 2024; 212:73-79. [PMID: 38040279 DOI: 10.1016/j.amjcard.2023.11.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/07/2023] [Accepted: 11/14/2023] [Indexed: 12/03/2023]
Abstract
Procedural risk in Congenital Cardiac Catheterization (PREDIC3T) was recently reported as the contemporary procedure-type risk metric by the Congenital Cardiac Catheterization Project on Outcomes (C3PO) registry. The usefulness of this metric has not been evaluated elsewhere. The CRISP registry of Congenital Cardiovascular Interventional Study Consortium (CCISC) data set was analyzed. The study period was 14 years (2009 to 2022). The primary outcome was significant adverse event (SAE). Cases were assigned to the 6 PREDIC3T risk categories. Univariate and multivariable logistic regression models were used to evaluate the association between PREDIC3T and the primary outcome. The model discriminative performance was evaluated by the c-statistic. In a total of 64,419 enrolled cases, PREDIC3T case types were assigned in 59,822 cases (93%). The frequency for PREDIC3T category was 0 = 7,494 (12.5%), 1 = 16,932 (28.3%), 2 = 17,023 (28.5%), 3 = 9,885 (16.5%), 4 = 4,403 (7.4%), and 5 = 4,085 (6.8%). SAE was observed in 2,474 cases (4.1%). The SAE rates for category were 0 = 1.0%, 1 = 2.3%, 2 = 4.0%, 3 = 6.2%, 4 = 8.2%, and 5 = 9.0%. In a multivariable model, PREDIC3T case type risk category (odds ratios for category: 0 = 0.49, 1 = 1.00, 2 = 1.40, 3 = 2.06, 4 = 2.79, and 5 = 3.15; p <0.001) were significantly associated with SAE (c-statistic of 0.707) after adjusting for age, preprocedural inotropic support and systemic illness, low systemic saturation, high pulmonary vascular resistance, and the use of general anesthesia. The PREDIC3T case type risk category was associated with the risk of SAE in the CRISP registry data set and appeared to be a useful procedural risk classification tool.
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Affiliation(s)
- Daisuke Kobayashi
- Division of Cardiology, Department of Pediatrics, St. Louis Children's Hospital / Washington University School of Medicine, St. Louis, Missouri.
| | - Elena K Amin
- Division of Pediatric Cardiology, UCSF Benioff Children's Hospitals, University of California, San Francisco, San Francisco, California
| | - Gareth J Morgan
- School of Medicine, University of Colorado Anschutz Medical Campus, Denver, Colorado
| | | | - Gregory A Fleming
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Thomas J Forbes
- Division of Cardiology, Joe DiMaggio Children's Hospital, Hollywood, Florida
| | - David G Nykanen
- Division of Cardiology, Arnold Palmer Hospital, Orlando, Florida
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Holzer RJ, Bergersen L, Thomson J, Aboulhosn J, Aggarwal V, Akagi T, Alwi M, Armstrong AK, Bacha E, Benson L, Bökenkamp R, Carminati M, Dalvi B, DiNardo J, Fagan T, Fetterly K, Ing FF, Kenny D, Kim D, Kish E, O'Byrne M, O'Donnell C, Pan X, Paolillo J, Pedra C, Peirone A, Singh HS, Søndergaard L, Hijazi ZM. PICS/AEPC/APPCS/CSANZ/SCAI/SOLACI: Expert Consensus Statement on Cardiac Catheterization for Pediatric Patients and Adults With Congenital Heart Disease. JACC Cardiovasc Interv 2024; 17:115-216. [PMID: 38099915 DOI: 10.1016/j.jcin.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Affiliation(s)
- Ralf J Holzer
- UC Davis Children's Hospital, Sacramento, California.
| | | | - John Thomson
- Johns Hopkins Children's Center, Baltimore, Maryland
| | - Jamil Aboulhosn
- UCLA Adult Congenital Heart Disease Center, Los Angeles, California
| | - Varun Aggarwal
- University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
| | | | - Mazeni Alwi
- Institut Jantung Negara, Kuala Lumpur, Malaysia
| | | | - Emile Bacha
- NewYork-Presbyterian Hospital, New York, New York
| | - Lee Benson
- Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | | | | | - Thomas Fagan
- Children's Hospital of Michigan, Detroit, Michigan
| | | | - Frank F Ing
- UC Davis Children's Hospital, Sacramento, California
| | | | - Dennis Kim
- Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Emily Kish
- Rainbow Babies Children's Hospital, Cleveland, Ohio
| | - Michael O'Byrne
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Xiangbin Pan
- Cardiovascular Institute, Fu Wai, Beijing, China
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Backer CL, Overman DM, Dearani JA, Romano JC, Tweddell JS, Kumar SR, Marino BS, Bacha EA, Jaquiss RDB, Zaidi AN, Gurvitz M, Costello JM, Pierick TA, Ravekes WJ, Reagor JA, St Louis JD, Spaeth J, Mahle WT, Shin AY, Lopez KN, Karamlou T, Welke KF, Bryant R, Husain SA, Chen JM, Kaza A, Wells WJ, Glatz AC, Cohen MI, McElhinney DB, Parra DA, Pasquali SK. Recommendations for centers performing pediatric heart surgery in the United States. J Thorac Cardiovasc Surg 2023; 166:1782-1820. [PMID: 37777958 DOI: 10.1016/j.jtcvs.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
Care and outcomes for the more than 40,000 patients undergoing pediatric and congenital heart surgery in the United States annually are known to vary widely. While consensus recommendations have been published across numerous fields as one mechanism to promote a high level of care delivery across centers, it has been more than two decades since the last pediatric heart surgery recommendations were published in the United States. More recent guidance is lacking, and collaborative efforts involving the many disciplines engaged in caring for these children have not been undertaken to date. The present initiative brings together professional societies spanning numerous care domains and congenital cardiac surgeons, pediatric cardiologists, nursing, and other healthcare professionals from diverse programs around the country to develop consensus recommendations for United States centers. The focus of this initial work is on pediatric heart surgery, and it is recommended that future efforts focus in detail on the adult congenital population. We describe the background, rationale, and methodology related to this collaborative effort, and recommendations put forth for Essential Care Centers (essential services necessary for any program), and Comprehensive Care Centers (services to optimize comprehensive and high-complexity care), encompassing structure, process, and outcome metrics across 14 domains.
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Affiliation(s)
- Carl L Backer
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - David M Overman
- Division of Cardiovascular Surgery, Children's Minnesota, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, Minn
| | | | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Mich
| | - James S Tweddell
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - S Ram Kumar
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, Calif
| | - Bradley S Marino
- Department of Pediatric Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Emile A Bacha
- Department of Surgery, Columbia University/New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | | | - Ali N Zaidi
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michelle Gurvitz
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - John M Costello
- Department of Pediatrics, Medical University of South Carolina, Shawn Jenkins Children's Hospital, Charleston, SC
| | - Trudy A Pierick
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa
| | - William J Ravekes
- Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, Md
| | - James A Reagor
- Department of Cardiovascular Perfusion, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - James Spaeth
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - William T Mahle
- Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Andrew Y Shin
- Department of Pediatrics, Stanford Medicine Children's Health, Palo Alto, Calif
| | - Keila N Lopez
- Department of Pediatrics, Texas Children's Hospital, Houston, Tex
| | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Karl F Welke
- Department of Surgery, Atrium Health Levine Children's Hospital, Charlotte, NC
| | - Roosevelt Bryant
- Department of Surgery, Phoenix Children's Hospital, Phoenix, Ariz
| | - S Adil Husain
- Department of Surgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Jonathan M Chen
- Department of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Aditya Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Winfield J Wells
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, Calif
| | - Andrew C Glatz
- Department of Pediatrics, St. Louis Children's Hospital, St. Louis, Mo
| | - Mitchell I Cohen
- Department of Pediatrics, Inova Children's Hospital, Fairfax, Va
| | - Doff B McElhinney
- Department of Pediatrics, Stanford Medicine Children's Health, Palo Alto, Calif
| | - David A Parra
- Department of Pediatrics, Vanderbilt Children's Hospital, Nashville, Tenn
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Mich
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5
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Backer CL, Overman DM, Dearani JA, Romano JC, Tweddell JS, Kumar SR, Marino BS, Bacha EA, Jaquiss RDB, Zaidi AN, Gurvitz M, Costello JM, Pierick TA, Ravekes WJ, Reagor JA, St Louis JD, Spaeth J, Mahle WT, Shin AY, Lopez KN, Karamlou T, Welke KF, Bryant R, Husain SA, Chen JM, Kaza A, Wells WJ, Glatz AC, Cohen MI, McElhinney DB, Parra DA, Pasquali SK. Recommendations for Centers Performing Pediatric Heart Surgery in the United States. Ann Thorac Surg 2023; 116:871-907. [PMID: 37777933 DOI: 10.1016/j.athoracsur.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
Care and outcomes for the more than 40,000 patients undergoing pediatric and congenital heart surgery in the United States annually are known to vary widely. While consensus recommendations have been published across numerous fields as one mechanism to promote a high level of care delivery across centers, it has been more than two decades since the last pediatric heart surgery recommendations were published in the United States. More recent guidance is lacking, and collaborative efforts involving the many disciplines engaged in caring for these children have not been undertaken to date. The present initiative brings together professional societies spanning numerous care domains and congenital cardiac surgeons, pediatric cardiologists, nursing, and other healthcare professionals from diverse programs around the country to develop consensus recommendations for United States centers. The focus of this initial work is on pediatric heart surgery, and it is recommended that future efforts focus in detail on the adult congenital population. We describe the background, rationale, and methodology related to this collaborative effort, and recommendations put forth for Essential Care Centers (essential services necessary for any program), and Comprehensive Care Centers (services to optimize comprehensive and high-complexity care), encompassing structure, process, and outcome metrics across 14 domains.
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Affiliation(s)
- Carl L Backer
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - David M Overman
- Division of Cardiovascular Surgery, Children's Minnesota, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, Minnesota
| | | | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - James S Tweddell
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - S Ram Kumar
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, California
| | - Bradley S Marino
- Department of Pediatric Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Emile A Bacha
- Department of Surgery, Columbia University/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Robert D B Jaquiss
- Department of Surgery, UT-Southwestern, Children's Health, Dallas, Texas
| | - Ali N Zaidi
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michelle Gurvitz
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - John M Costello
- Department of Pediatrics, Medical University of South Carolina, Shawn Jenkins Children's Hospital, Charleston, South Carolina
| | - Trudy A Pierick
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa
| | - William J Ravekes
- Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, Maryland
| | - James A Reagor
- Department of Cardiovascular Perfusion, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - James D St Louis
- Department of Surgery, Inova Children's Hospital, Fairfax, Virginia
| | - James Spaeth
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - William T Mahle
- Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Geogria
| | - Andrew Y Shin
- Department of Pediatrics, Stanford Medicine Children's Health, Palo Alto, California
| | - Keila N Lopez
- Department of Pediatrics, Texas Children's Hospital, Houston, Texas
| | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Karl F Welke
- Department of Surgery, Atrium Health Levine Children's Hospital, Charlotte, North Carolina
| | - Roosevelt Bryant
- Department of Surgery, Phoenix Children's Hospital, Phoenix, Arizona
| | - S Adil Husain
- Department of Surgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Jonathan M Chen
- Department of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Aditya Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Winfield J Wells
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, California
| | - Andrew C Glatz
- Department of Pediatrics, St. Louis Children's Hospital, St. Louis, Missouri
| | - Mitchell I Cohen
- Department of Pediatrics, Inova Children's Hospital, Fairfax, Virginia
| | - Doff B McElhinney
- Department of Pediatrics, Stanford Medicine Children's Health, Palo Alto, California
| | - David A Parra
- Department of Pediatrics, Vanderbilt Children's Hospital, Nashville, Tennessee
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
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6
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Backer CL, Overman DM, Dearani JA, Romano JC, Tweddell JS, Ram Kumar S, Marino BS, Bacha EA, Jaquiss RDB, Zaidi AN, Gurvitz M, Costello JM, Pierick TA, Ravekes WJ, Reagor JA, St Louis JD, Spaeth J, Mahle WT, Shin AY, Lopez KN, Karamlou T, Welke KF, Bryant R, Adil Husain S, Chen JM, Kaza A, Wells WJ, Glatz AC, Cohen MI, McElhinney DB, Parra DA, Pasquali SK. Recommendations for Centers Performing Pediatric Heart Surgery in the United States. World J Pediatr Congenit Heart Surg 2023; 14:642-679. [PMID: 37737602 DOI: 10.1177/21501351231190353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
Care and outcomes for the more than 40,000 patients undergoing pediatric and congenital heart surgery in the United States annually are known to vary widely. While consensus recommendations have been published across numerous fields as one mechanism to promote a high level of care delivery across centers, it has been more than two decades since the last pediatric heart surgery recommendations were published in the United States. More recent guidance is lacking, and collaborative efforts involving the many disciplines engaged in caring for these children have not been undertaken to date. The present initiative brings together professional societies spanning numerous care domains and congenital cardiac surgeons, pediatric cardiologists, nursing, and other healthcare professionals from diverse programs around the country to develop consensus recommendations for United States centers. The focus of this initial work is on pediatric heart surgery, and it is recommended that future efforts focus in detail on the adult congenital population. We describe the background, rationale, and methodology related to this collaborative effort, and recommendations put forth for Essential Care Centers (essential services necessary for any program), and Comprehensive Care Centers (services to optimize comprehensive and high-complexity care), encompassing structure, process, and outcome metrics across 14 domains.
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Affiliation(s)
- Carl L Backer
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David M Overman
- Division of Cardiovascular Surgery, Children's Minnesota, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, MN, USA
| | | | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - James S Tweddell
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - S Ram Kumar
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Bradley S Marino
- Department of Pediatric Cardiology, Cleveland Clinic, Cleveland, OH, USA
| | - Emile A Bacha
- Department of Surgery, Columbia University/New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Robert D B Jaquiss
- Department of Surgery, UT-Southwestern, Children's Health, Dallas, TX, USA
| | - Ali N Zaidi
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michelle Gurvitz
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - John M Costello
- Department of Pediatrics, Medical University of South Carolina, Shawn Jenkins Children's Hospital, Charleston, SC, USA
| | - Trudy A Pierick
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - William J Ravekes
- Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - James A Reagor
- Department of Cardiovascular Perfusion, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - James D St Louis
- Department of Surgery, Inova Children's Hospital, Fairfax, VA, USA
| | - James Spaeth
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - William T Mahle
- Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Andrew Y Shin
- Department of Pediatrics, Stanford Medicine Children's Health, Palo Alto, CA, USA
| | - Keila N Lopez
- Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Karl F Welke
- Department of Surgery, Atrium Health Levine Children's Hospital, Charlotte, NC, USA
| | - Roosevelt Bryant
- Department of Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - S Adil Husain
- Department of Surgery, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Jonathan M Chen
- Department of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Aditya Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Winfield J Wells
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Andrew C Glatz
- Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Mitchell I Cohen
- Department of Pediatrics, Inova Children's Hospital, Fairfax, VA, USA
| | - Doff B McElhinney
- Department of Pediatrics, Stanford Medicine Children's Health, Palo Alto, CA, USA
| | - David A Parra
- Department of Pediatrics, Vanderbilt Children's Hospital, Vanderbilt, TN, USA
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
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Linnane N, Kenny DP, Hijazi ZM. Congenital heart disease: addressing the need for novel lower-risk percutaneous interventional strategies. Expert Rev Cardiovasc Ther 2023; 21:329-336. [PMID: 37114439 DOI: 10.1080/14779072.2023.2208862] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
INTRODUCTION With the advent of improved neonatal care, increasingly vulnerable higher-risk patients with complex congenital heart anomalies are presenting for intervention. This group of patients will always have a higher risk of an adverse event during a procedure but by recognising this risk and with the introduction risk scoring systems and thus the development of novel lower risk procedures, the rate of adverse events can be reduced. AREA COVERED This article reviews risk scoring systems for congenital catheterization and demonstrates how they can be used to reduce the rate of adverse events. Then novel low risk strategies are discussed for low weight infants e.g. patent ductus arteriosus (PDA) stent insertion; premature infants e.g. PDA device closure; and transcatheter pulmonary valve replacement. Finally, how risk is assessed and managed within the inherent bias of an institution is discussed. EXPERT OPINION There has been a remarkable improvement in the rate of adverse events in congenital cardiac interventions but now, as the benchmark of mortality rate is switched to morbidity and quality of life, continued innovation into lower risk strategies and understanding inherent bias when assessing risk will be key to continuing this improvement.
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Affiliation(s)
- N Linnane
- Department of Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - D P Kenny
- Department of Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
- Royal College of Surgeons, Dublin, Ireland
| | - Z M Hijazi
- Department of Cardiovascular Diseases, Sidra Medicine, Doha, Qatar
- Weill Cornell Medicine, New York, NY, USA
- Jordan University, Amman, Jordan
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Incidence, Predictors, and Outcomes of Cardiac Perforation During Pediatric Cardiac Catheterization: a Retrospective Observational Study from the Congenital Cardiac Interventional Study Consortium (CCISC). Pediatr Cardiol 2023; 44:867-872. [PMID: 36705683 DOI: 10.1007/s00246-023-03103-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 01/13/2023] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Cardiac perforation is a rare life-threatening complication of cardiac catheterization. There is very little published literature detailing risk factors for cardiac perforation and outcomes from this complication in children. MATERIALS AND METHODS This was a retrospective study analyzing the cardiac catheterization case registry of the Congenital Cardiovascular Interventional Study Consortium. Children aged < 18 years were included during the study period of 9 years (January 2009-December 2017). The primary outcome measures were incidence of cardiac perforation, risk factors for and outcomes of patients who experience cardiac perforation during cardiac catheterization. RESULTS Cardiac perforation occurred in 50 patients from a total of 36,986 (0.14%). Cardiac perforation was more likely to occur in younger, smaller patients undergoing urgent/emergent and interventional procedures (p < 0.01). Cardiac peroration risk was significantly different across diagnostic and procedure categories (p < 0.01). Higher CRISP score (Area Under Curve [AUC] = 0.87), lower age, and procedure category (radiofrequency perforation of pulmonary valve, AUC = 0.84) were independent predictors of cardiac perforation. Cardiac perforation was associated with a significantly higher rate of mortality (14%), further emergency procedure (42%), ECMO (14%), and cardiac arrest (6%), p < 0.01. CONCLUSIONS Cardiac perforation during cardiac catheterization is a life-threatening complication with a range of associated secondary complications. Higher CRISP score, lower age, and radiofrequency perforation of pulmonary valve are independent predictors.
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Yeh MJ, Lydon E, Gauvreau K, Jenkins KJ, Slater D, Bergersen L. Exploring procedure duration and risk for serious adverse events during congenital cardiac catheterization. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2023; 5:e000142. [PMID: 36643781 PMCID: PMC9835933 DOI: 10.1136/bmjsit-2022-000142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 11/15/2022] [Indexed: 01/12/2023] Open
Abstract
Objectives While procedure length is considered an important metric for cardiothoracic surgical procedures, the relationship between procedure length and adverse events (AEs) in congenital cardiac catheterizations has little published data available. Furthermore, most existing congenital cardiac catheterization risk prediction models are built on logistic regression models. This study aimed to characterize the relationship between case length and AE occurrence in congenital cardiac catheterization while adjusting for known risk factors and to investigate the potential role of non-linear analysis in risk modeling. Design Age, case type, and procedure duration were evaluated for relationships with the primary outcome using logistic regression. Non-linearity of the associations with continuous risk factors was assessed using restricted cubic spline transformations. Setting and participants All diagnostic and interventional congenital cardiac catheterization cases performed at Boston Children's Hospital between January 1, 2014 and October 31, 2019 were analyzed. Main outcome measure The primary outcome was defined as the occurrence of any clinically significant (level 3/4/5) AE. Results A total of 7011 catheterization cases met inclusion criteria, with interventional procedures accounting for 68% of cases. Median case duration was 97 min. A multivariable model including age, procedure type, and case duration showed a significant relationship between case duration and AE occurrence (OR 1.07 per 10 min increase, 95% CI 1.06 to 1.09, p<0.001). Conclusions This study demonstrated the importance of procedure duration as a potential frontier for procedure risk management. Better understanding of the role of procedure duration in cardiac catheterizations may provide opportunities for quality improvement in patient safety and resource planning.
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Affiliation(s)
- Mary J Yeh
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kathy J Jenkins
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Lisa Bergersen
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
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10
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Doi Y, Kim SH, Ishigaki M, Sato K, Yoshimoto J, Mitsushita N, Nii M, Ikai A, Sakamoto K, Tanaka Y. Catheter Intervention for Flow Regulatory Clips on Palliative Shunts and Conduits in Patients with Congenital Heart Disease. Pediatr Cardiol 2023; 44:210-217. [PMID: 35857080 DOI: 10.1007/s00246-022-02967-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 07/01/2022] [Indexed: 02/06/2023]
Abstract
Catheter intervention (CI) for a Blalock-Taussig shunt (BTS) or a ventricle-to-pulmonary artery conduit (VPC) is often required after a palliative surgery for congenital heart disease. Flow regulatory clips help improve interstage mortality; their use necessitates CIs to prevent cyanosis. To study the CI outcomes in patients who underwent palliative surgery with either BTSs or VPCs with flow regulatory clips. This single-center retrospective study evaluated demographic characteristics and interventional outcomes of 49 consecutive pediatric patients who required CI for BTS (BTS group) or VPC (VPC group) between January 2008 and September 2018. Overall, 34 and 18 procedures were performed in the BTS and VPC groups, respectively. Moreover, 19/32 (59.3%) and 12/17 (70.1%) patients from the BTS and VPC groups had flow regulatory clips, respectively. All clips were unclipped successfully; one patient in each group underwent staged unclipping. A higher proportion of "clipped patients" underwent CI due to desaturation [clipped vs. non-clipped: BTS, 10/20 (50.0%) vs. 3/14 (21.4%), p = 0.092; VPC, 9/13 (69.2%) vs. 1/5 (20.0%), p = 0.060]. Most clipped patients successfully progressed to the next stage [BTS, 19/20 (95.0%); VPC, 12/13 (92.3%)]. Severe adverse events (SAEs) were more frequent in the VPC group than in the BTS group [3/13 (23.1%) vs. 0/20 (0%), p = 0.024]. Two patients developed an atrioventricular block (requiring an atropine infusion), while one died due to pulmonary overcirculation. While the indication of CI was cyanosis for a higher proportion of clipped patients, all clips were unclipped successfully. The incidence of CI-related SAEs was higher in the VPC group than in the BTS group.
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Affiliation(s)
- Yuji Doi
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka, Japan.
- Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, Japan.
| | - Sung-Hae Kim
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Mizuhiko Ishigaki
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Keisuke Sato
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Jun Yoshimoto
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Norie Mitsushita
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Masaki Nii
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Akio Ikai
- Department of Cardiovascular Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Kisaburo Sakamoto
- Department of Cardiovascular Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Yasuhiko Tanaka
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka, Japan
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11
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ICU Admission Tool for Congenital Heart Catheterization (iCATCH): A Predictive Model for High Level Post-Catheterization Care and Patient Management. Pediatr Crit Care Med 2022; 23:822-830. [PMID: 35830709 DOI: 10.1097/pcc.0000000000003028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Currently, there are no prediction tools available to identify patients at risk of needing high-complexity care following cardiac catheterization for congenital heart disease. We sought to develop a method to predict the likelihood a patient will require intensive care level resources following elective cardiac catheterization. DESIGN Prospective single-center study capturing important patient and procedural characteristics for predicting discharge to the ICU. Characteristics significant at the 0.10 level in the derivation dataset (July 1, 2017 to December 31, 2019) were considered for inclusion in the final multivariable logistic regression model. The model was validated in the testing dataset (January 1, 2020 to December 31, 2020). The novel pre-procedure cardiac status (PCS) feature, collection started in January 2019, was assessed separately in the final model using the 2019 through 2020 dataset. SETTING Tertiary pediatric heart center. PATIENTS All elective cases coming from home or non-ICU who underwent a cardiac catheterization from July 2017 to December 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 2,192 cases were recorded in the derivation dataset, of which 11% of patients ( n = 245) were admitted to the ICU, while 64% ( n = 1,413) were admitted to a medical unit and 24% ( n = 534) were discharged home. In multivariable analysis, the following predictors were identified: 1) weight less than 5 kg and 5-9.9 kg, 2) presence of systemic illness, 3) recent cardiac intervention less than 90 days, and 4) ICU Admission Tool for Congenital Heart Catheterization case type risk categories (1-5), with C -statistics of 0.79 and 0.76 in the derivation and testing cohorts, respectively. The addition of the PCS feature fit into the final model resulted in a C -statistic of 0.79. CONCLUSIONS The creation of a validated pre-procedural risk prediction model for ICU admission following congenital cardiac catheterization using a large volume, single-center, academic institution will improve resource allocation and prediction of capacity needs for this complex patient population.
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12
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Severe Complications after General Anesthesia versus Sedation during Pediatric Diagnostic Cardiac Catheterization for Ventricular Septal Defect. J Clin Med 2022; 11:jcm11175165. [PMID: 36079095 PMCID: PMC9457307 DOI: 10.3390/jcm11175165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/28/2022] [Accepted: 08/30/2022] [Indexed: 11/24/2022] Open
Abstract
Pediatric cardiac catheterization requires unconsciousness and immobilization through general anesthesia or sedation. This study aimed to compare the occurrence of severe complications in pediatric diagnostic cardiac catheterization for ventricular septal defect between general anesthesia and sedation performed under similar institutional environments. Using the Japanese Diagnosis Procedure Combination database, we retrospectively identified pediatric patients (aged <2 years) who underwent diagnostic cardiac catheterization for ventricular septal defect between July 2010 and March 2019. The composite outcome was the occurrence of severe complications, including catecholamine use and intensive care unit admission, within seven days after catheterization. Overlap weighting based on propensity scores was used to adjust for patient- and hospital-level confounding factors. We identified 3159 patients from 87 hospitals, including 930 under general anesthesia and 2229 under sedation. The patient- and hospital-level baseline characteristics differed between the groups. After adjustment, the proportion of patients with severe complications was significantly higher in the general anesthesia group than in the sedation group (2.4% vs. 0.6%; risk difference, 1.8% [95% confidence interval, 0.93−2.6%]). Severe complications occurred more frequently in the general anesthesia group than in the sedation group. Further research on anesthetic methods is necessary to assess the safety and accuracy of pediatric diagnostic cardiac catheterization.
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13
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Nasef MA, Shahbah DA, Batlivala SP, Darwish R, Qureshi AM, Breatnach CR, Linnane N, Walsh KP, Oslizlok P, McCrossan B, Momenah T, Alshahri A, Abdulhamed J, Arafat A, Tamimi OA, Diraneyya OM, Goldestein BH, Kenny D. Short- and medium-term outcomes for patent ductus arteriosus stenting in neonates ≤2.5 kg with duct-dependent pulmonary circulation. Catheter Cardiovasc Interv 2022; 100:596-605. [PMID: 35904221 DOI: 10.1002/ccd.30351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 06/29/2022] [Accepted: 07/16/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Morbidity with surgical systemic-to-pulmonary artery shunting (SPS) in infants ≤2.5 kg has remained high. Patent ductus arteriosus (PDA) stenting may be a valid alternative. The objective of this study is to evaluate outcomes following PDA stenting in patients ≤2.5 kg from four large tertiary centers. METHODS Retrospective review of all neonates ≤2.5 kg with duct-dependent pulmonary circulation who underwent PDA stenting. Procedural details, pulmonary arterial growth, reinterventions, surgery type, and outcomes were assessed. RESULTS PDA stents were implanted in 37 of 38 patients attempted (18 female) at a median procedural weight of 2.2 kg (interquartile range [IQR], 2-2.4 kg). Seven patients (18%) had a genetic abnormality and 16 (42%) had associated comorbidities. The median intensive care unit stay was 4 days (IQR, 2-6.75 days), and the median hospital stay was 20 days (IQR, 16-57.25). One patient required a rescue shunt procedure, with three others requiring early SPS (<30 days postprocedure). Twenty patients (54%) required reintervention with either balloon angioplasty, restenting, or both. At 6-month follow-up, right pulmonary artery growth (median z-score -1.16 to 0.01, p = 0.05) was greater than the left pulmonary artery (median z-score -0.9 to -0.64, p = 0.35). Serious adverse effects (SAEs) were seen in 18% (N = 7) of our cohort. One patient developed an SAE during planned reintervention There were no intraprocedural deaths, with one early procedure-related mortality, and three interstage mortalities not directly related to PDA stenting. CONCLUSIONS PDA stenting in infants ≤2.5 kg is feasible and effective, promoting pulmonary artery growth. Reintervention rates are relatively high, though many are planned to allow for optimal growth before a definitive operation.
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Affiliation(s)
- Mohamed Al Nasef
- Children Health Ireland at Crumlin, Dublin, Ireland.,Prince Sultan Cardiac Center, Riyadh, Kingdom of Saudi Arabia
| | - Doaa A Shahbah
- The Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA.,Department of Pediatric Cardiology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Sarosh P Batlivala
- Department of Pediatric Cardiology Department, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Reem Darwish
- Prince Sultan Cardiac Center, Riyadh, Kingdom of Saudi Arabia
| | - Athar M Qureshi
- The Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | | | | | | | | | | | - Tarek Momenah
- Prince Sultan Cardiac Center, Riyadh, Kingdom of Saudi Arabia
| | - Atif Alshahri
- Prince Sultan Cardiac Center, Riyadh, Kingdom of Saudi Arabia
| | | | - Amr Arafat
- Prince Sultan Cardiac Center, Riyadh, Kingdom of Saudi Arabia
| | - Omar Al Tamimi
- Prince Sultan Cardiac Center, Riyadh, Kingdom of Saudi Arabia
| | | | | | - Damien Kenny
- Children Health Ireland at Crumlin, Dublin, Ireland
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14
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Yeh MJ, Shirley L, Balzer DT, Boe BA, El-Said H, Foerster S, Gauvreau K, Gudausky TM, Hainstock MR, Maschietto N, Nicholson GT, Quinn BP, Shahanavaz S, Trucco S, Whiteside W, Bergersen L. Interpreting Quality Improvement When Introducing New Technology: A Collaborative Experience in ASD Device Closures. Pediatr Cardiol 2022; 43:596-604. [PMID: 34743224 DOI: 10.1007/s00246-021-02762-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 10/22/2021] [Indexed: 11/28/2022]
Abstract
The objective of this study was to evaluate the impact of the regular introduction of new technologies into interventional cardiac catheterization procedures, in this case new atrial septal defect (ASD) closure devices, while conducting a multi-center collaborative initiative to reduce radiation usage during all procedures. Data were collected prospectively by 8 C3PO institutions between January 1, 2014 and December 31, 2017 for ASD device closure procedures in the cardiac catheterization lab during a quality improvement (QI) initiative aimed at reducing patient radiation exposure. Radiation exposure was measured in dose area product per body weight (µGy*m2/kg). Use of proposed practice change strategies at the beginning and end of the QI intervention period was assessed. Radiation exposure was summarized by institution and by initial type of device used for closure. This study included 602 ASD device closures. Without changes in patient characteristics, total fluoroscopy duration, or number of digital acquisitions, median radiation exposure decreased from 37 DAP/kg to 14 DAP/kg from 2014 to 2017. While all individual centers decreased overall median DAP/kg, the use of novel devices for ASD closure correlated with a temporary period of worsening institutional radiation exposure and increased fluoroscopy time. The introduction of new ASD closure devices resulted in increased radiation exposure during a QI project designed to reduce radiation exposure. Therefore, outcome assessment must be contextualized in QI projects, hospital evaluation, and public reporting, to acknowledge the expected variation during innovation and introduction of novel therapies.
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Affiliation(s)
- Mary J Yeh
- Department of Cardiology, Boston Children's Hospital, Bader 2, Attn: Lisa Bergersen, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Lauren Shirley
- Department of Cardiology, Boston Children's Hospital, Bader 2, Attn: Lisa Bergersen, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - David T Balzer
- Division of Cardiology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Brian A Boe
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Susan Foerster
- Division of Pediatric Cardiology, Medical College of Wisconsin and Herma Heart Institute, Children's Wisconsin, Milwaukee, WI, USA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Bader 2, Attn: Lisa Bergersen, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Todd M Gudausky
- Division of Pediatric Cardiology, Medical College of Wisconsin and Herma Heart Institute, Children's Wisconsin, Milwaukee, WI, USA
| | - Michael R Hainstock
- Division of Pediatric Cardiology, University of Virginia Children's Hospital, University of Virginia, Charlottesville, VA, USA
| | - Nicola Maschietto
- Department of Cardiology, Boston Children's Hospital, Bader 2, Attn: Lisa Bergersen, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - George T Nicholson
- Division of Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brian P Quinn
- Department of Cardiology, Boston Children's Hospital, Bader 2, Attn: Lisa Bergersen, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Shabana Shahanavaz
- The Heart Institute, Cincinnati Children's Hospital and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sara Trucco
- Heart Institute, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Wendy Whiteside
- Division of Pediatric Cardiology, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Lisa Bergersen
- Department of Cardiology, Boston Children's Hospital, Bader 2, Attn: Lisa Bergersen, 300 Longwood Avenue, Boston, MA, 02115, USA.
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15
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Haddad RN, Lange JM, Raisky O, Gaudin R, Barbanti C, Bonnet D, Malekzadeh-Milani S. Indications and outcomes of cardiac catheterization following congenital heart surgery in children. Eur J Cardiothorac Surg 2022; 61:1056-1065. [PMID: 35076064 DOI: 10.1093/ejcts/ezac026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 10/20/2021] [Accepted: 01/10/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Our goal was to evaluate the indications for postoperative cardiac catheterizations after paediatric cardiac surgeries and their impact on outcomes. METHODS Non-planned cardiac catheterizations performed after congenital heart surgeries and before discharge between January 2013 and July 2019 were reviewed. Hybrid procedures were excluded. Heart defects, illness course, surgeries and catheter procedures were classified. Indications and findings were comprehensively regrouped. Outcomes were analysed. RESULTS Cardiac catheterizations were performed on 192 patients (median age 2.3 months, weight 4.2 kg) on median postoperative day 7 (interquartile range, 2-17 days). Patients had defects of great complexity (79.9%), high disease severity index (46.4%), high Aristotle level of surgical complexity (75%) and a high Catheterization RISk Score for Pediatrics category of catheterizations (61%). Catheterizations confirmed 66% of suspected diagnoses. Confirmed diagnoses were more likely to be haemodynamic anomalies than anatomical lesions (81.3% > 53.7%, P < 0.001). Confirmed anatomical lesions were more likely to be residual than new lesions created by surgery (88.5% > 40.4%, P < 0.001). New diagnoses were identified in 36.5% of patients. Catheterization findings led to catheter-based or surgical interventions in 120 (62.5%) patients. Transcatheter interventions were successful (97.7%), immediate (89.5%) and performed across fresh suture lines (27.8%). Repeat catheterizations (76% interventional) were necessary in 25 (13%) patients. A high index of disease severity [odds ratio (OR): 16.26, 95% confidence interval (CI): 3.72-71.17], extracorporeal membrane oxygenation support (OR: 10.35, 95% CI: 2.78-38.56), delayed sternal closure (OR: 4.66, 95% CI: 1.25-17.32) and surgically acquired lesions (OR: 3.70, 95% CI: 1.22-11.16) were significant risk factors of 12-month mortality. CONCLUSIONS Postoperative cardiac catheterizations answer both anatomical and haemodynamic questions in high-risk patients with complicated courses and guide subsequent treatment with satisfactory outcomes.
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Affiliation(s)
- Raymond N Haddad
- Department of Congenital and Pediatric Cardiology, M3C-Necker, Necker-Enfants malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Juan Manuel Lange
- Department of Congenital and Pediatric Cardiology, M3C-Necker, Necker-Enfants malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Olivier Raisky
- Department of Pediatric Cardiac Surgery, Necker-Enfants malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,University of Paris, Paris, France
| | - Regis Gaudin
- Department of Pediatric Cardiac Surgery, Necker-Enfants malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Claudio Barbanti
- Division of Pediatric Cardiac Anesthesia, Department of Pediatric Cardiac Surgery, Necker-Enfants malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Damien Bonnet
- Department of Congenital and Pediatric Cardiology, M3C-Necker, Necker-Enfants malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,University of Paris, Paris, France
| | - Sophie Malekzadeh-Milani
- Department of Congenital and Pediatric Cardiology, M3C-Necker, Necker-Enfants malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
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16
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Stein ML, Staffa SJ, O'Brien Charles A, Callahan R, DiNardo JA, Nasr VG, Brown ML. Anesthesia in Children With Pulmonary Hypertension: Clinically Significant Serious Adverse Events Associated With Cardiac Catheterization and Noncardiac Procedures. J Cardiothorac Vasc Anesth 2022; 36:1606-1616. [PMID: 35181233 DOI: 10.1053/j.jvca.2022.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/03/2022] [Accepted: 01/09/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To determine the incidence of clinically significant serious adverse events in a contemporary population of pediatric patients with pulmonary hypertension who require anesthesia and identify factors associated with adverse outcomes. DESIGN A retrospective, cross-sectional study. SETTING A single-center quaternary-care freestanding children's hospital in the northeastern United States. PARTICIPANTS Pediatric patients with pulmonary hypertension based on hemodynamic criteria on cardiac catheterization during a 3-year period from 2015 to 2018. INTERVENTIONS Anesthesia care for cardiac catheterization, noncardiac surgery, and diagnostic imaging. MEASUREMENTS AND MAIN RESULTS Two hundred forty-nine children underwent 862 procedures, 592 for cardiac catheterization and 278 for noncardiac surgery and diagnostic imaging. The median age was 1.6 years, and the weight was 9.5 lbs. On index catheterization, median pulmonary artery pressure was 36 mmHg, and the pulmonary vascular resistance was 5.1 indexed Wood units. Ten percent of anesthetics were performed with a natural airway, and 80% used volatile anesthetics. Serious adverse events occurred in 26% of procedures (confidence interval [CI], 22%-30%). The rate of periprocedural cardiac arrest was 8 per 1,000 anesthetic administrations. In multivariate analysis, younger age (adjusted odds ratio [aOR], 1.4 per year; CI, 1.1-1.9; p = 0.01), location in the catheterization laboratory (aOR, 5.1; CI, 1.7-16; p = 0.004), and longer procedure duration (aOR, 1.3 per 30 minutes; CI, 1.1-1.4; p = 0.001) were associated with serious adverse events. Patients with a tracheostomy in place were less likely to experience an adverse event (aOR, 0.1; CI, 0.04-0.5; p = 0.001). The primary anesthetic technique was not associated with adverse events. Interventional cardiac catheterization was associated with an increased incidence of adverse events compared with diagnostic catheterization (42% v 21%; OR, 2.23; CI, 1.5-3.3; p < 0.001). CONCLUSIONS Serious adverse events were common in this cohort. Careful planning to minimize anesthesia time in young children with pulmonary hypertension should be undertaken, and these factors considered in designing risk mitigation strategies.
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Affiliation(s)
- Mary Lyn Stein
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Amy O'Brien Charles
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA; Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ryan Callahan
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - James A DiNardo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Morgan L Brown
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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17
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Quinn BP, Yeh M, Gauvreau K, Ali F, Balzer D, Barry O, Batlivala S, Berman D, Foerster S, Goldstein B, Hainstock M, Holzer R, Janssen D, O'Byrne ML, Shirley L, Trucco S, Whiteside W, Bergersen L. Procedural Risk in Congenital Cardiac Catheterization (PREDIC 3T). J Am Heart Assoc 2021; 11:e022832. [PMID: 34935425 PMCID: PMC9075192 DOI: 10.1161/jaha.121.022832] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Advancements in the field, including novel procedures and multiple interventions, require an updated approach to accurately assess patient risk. This study aims to modernize patient hemodynamic and procedural risk classification through the creation of risk assessment tools to be used in congenital cardiac catheterization. Methods and Results Data were collected for all cases performed at sites participating in the C3PO (Congenital Cardiac Catheterization Project on Outcomes) multicenter registry. Between January 2014 and December 2017, 23 119 cases were recorded in 13 participating institutions, of which 88% of patients were <18 years of age and 25% <1 year of age; a high‐severity adverse event occurred in 1193 (5.2%). Case types were defined by procedure(s) performed and grouped on the basis of association with the outcome, high‐severity adverse event. Thirty‐four unique case types were determined and stratified into 6 risk categories. Six hemodynamic indicator variables were empirically assessed, and a novel hemodynamic vulnerability score was determined by the frequency of high‐severity adverse events. In a multivariable model, case‐type risk category (odds ratios for category: 0=0.46, 1=1.00, 2=1.40, 3=2.68, 4=3.64, and 5=5.25; all P≤0.005) and hemodynamic vulnerability score (odds ratio for score: 0=1.00, 1=1.27, 2=1.89, and ≥3=2.03; all P≤0.006) remained independent predictors of patient risk. Conclusions These case‐type risk categories and the weighted hemodynamic vulnerability score both serve as independent predictors of patient risk for high‐severity adverse events. This contemporary procedure‐type risk metric and weighted hemodynamic vulnerability score will improve our understanding of patient and procedural outcomes.
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Affiliation(s)
- Brian P Quinn
- Department of Cardiology Boston Children's Hospital Boston MA
| | - Mary Yeh
- Department of Cardiology Boston Children's Hospital Boston MA
| | | | - Fatima Ali
- Section of Pediatric Cardiology Department of Pediatrics and Child Health The Aga Khan University Hospital Karachi Pakistan
| | - David Balzer
- Division of Pediatric Cardiology St. Louis Children's Hospital St. Louis MO
| | - Oliver Barry
- The Congenital Heart Center New York Presbyterian/Morgan Stanley Children's Hospital New York NY
| | - Sarosh Batlivala
- The Heart Institute Cincinnati Children's Hospital Cincinnati OH.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Darren Berman
- The Heart Center Nationwide Children's Hospital Columbus OH
| | - Susan Foerster
- Division of Pediatric Cardiology Children's Wisconsin Milwaukee WI
| | - Bryan Goldstein
- Heart Institute UPMC Children's Hospital of Pittsburgh Pittsburgh PA.,Department of Pediatrics University of Pittsburgh School of Medicine Pittsburgh PA
| | - Michael Hainstock
- Division of Pediatric Cardiology University of Virginia Children's HospitalUniversity of Virginia Charlottesville VA
| | - Ralf Holzer
- Division of Pediatric Cardiology Department of Pediatrics Weill Cornell Medicine New York NY
| | - Dana Janssen
- Division of Pediatric Cardiology Monroe Carell Jr. Children's Hospital at Vanderbilt University Medical Center Nashville TN
| | - Michael L O'Byrne
- Division of Cardiology Children's Hospital of Philadelphia Philadelphia PA.,Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Lauren Shirley
- Department of Cardiology Boston Children's Hospital Boston MA
| | - Sara Trucco
- Heart Institute UPMC Children's Hospital of Pittsburgh Pittsburgh PA.,Department of Pediatrics University of Pittsburgh School of Medicine Pittsburgh PA
| | - Wendy Whiteside
- Division of Pediatric Cardiology University of Michigan Medical School Ann Arbor MI
| | - Lisa Bergersen
- Department of Cardiology Boston Children's Hospital Boston MA
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18
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O'Callaghan B, Shepherd E, Taliotis D, Bentham J, Kenny D, Smith B, Franco SR, Morgan GJ. Validating a risk assessment tool in United Kingdom and Irish paediatric cardiac catheterisation practice. Cardiol Young 2021; 32:1-8. [PMID: 34645531 DOI: 10.1017/s1047951121004170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND No established risk prediction tool exists in United Kingdom and Irish Paediatric Cardiology practice for patients undergoing cardiac catheterisation. The Catheterisation RISk score for Paediatrics is used primarily in North American practice to assess risk prior to cardiac catheterisation. Validating the utility and transferability of such a tool in practice provides the opportunity to employ an already established risk assessment tool in everyday practice. AIMS To ascertain whether the Catheterisation RISk score for Paediatrics assessment tool can accurately predict complications within United Kingdom and Irish congenital catheterisation practice. METHODS Clinical and procedural data including National Institute for Cardiovascular Outcomes Research derived outcome data from 1500 patients across five large congenital cardiology centres in the United Kingdom and Ireland were retrospectively collected. Catheterisation RISk score for Paediatrics were then calculated for each case and compared with the observed procedural outcomes. Chi-square analysis was used to determine the relationship between observed and predicted events. RESULTS Ninety-eight (6.6%) patients in this study experienced a significant complication as qualified by National Institute for Cardiovascular Outcomes Research classification. 4% experienced a moderate complication, 2.3% experienced a major complication and 0.3% experienced a catastrophic complication resulting in death. Calculated Catheterisation RISk score for Paediatrics scores correlated well with all observed adverse events for paediatric patients across all CRISP categories. The association was also transferable to adult congenital heart disease patients in lower Catheterisation RISk score for Paediatrics categories (CRISP 1-3). CONCLUSION The Catheterisation RISk score for Paediatrics score accurately predicts significant complications in congenital catheterisation practice in the United Kingdom and Ireland. Our data validated the Catheterisation RISk score for Paediatrics assessment tool in five congenital centres using National Institute for Cardiovascular Outcomes Research-derived outcome data.
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Affiliation(s)
- Barry O'Callaghan
- The Heart Institute, Children's Hospital of Colorado, University of Colorado, Denver, CO, USA
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Trust, Bristol, UK
| | - Emma Shepherd
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Trust, Bristol, UK
| | - Demetris Taliotis
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Trust, Bristol, UK
| | - James Bentham
- Leeds Congenital Heart Unit, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Damien Kenny
- Department of Pediatric and Congenital Cardiology, Children's Health Ireland Crumlin, Dublin, Ireland
| | - Benjamin Smith
- Department of Pediatric and Congenital Cardiology, Royal Hospital for Children, Glasgow, NHS Greater Glasgow & Clyde, Glasgow, UK
| | | | - Gareth J Morgan
- The Heart Institute, Children's Hospital of Colorado, University of Colorado, Denver, CO, USA
- Department of Pediatric and Congenital Cardiology, The Evelina Children's Hospital, Guy's and St Thomas's NHS Trust, London, UK
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19
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Tomita H, Kim SH, Inuzuka R, Matsui H, Tachimori H, Kobayashi T, Kato A, Fujii T, Haishima Y, Okamoto Y, Sakoda H. Stent Implantation for Congenital Heart Diseases in Japan - Comprehensive Analysis From the Japanese Society of Congenital Interventional Cardiology Registry. Circ J 2021; 85:1517-1524. [PMID: 33692248 DOI: 10.1253/circj.cj-20-0915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Stent implantation for vascular stenosis associated with congenital heart diseases is commonly performed as an off-label procedure in Japan because there is no officially approved stent for any congenital heart disease.Methods and Results:We analyzed data from the Japanese Society of Congenital Interventional Cardiology Registry collected from January 2016 to December 2018. Patients who underwent stent implantation were enrolled in the present analysis. During the study period, there were 470 procedures, 443 sessions, and 391 cases. Of 443 sessions, 427 (96.4%) succeeded procedurally. There were no differences in the procedural success rates among age groups. In all, 416 sessions (367 patients; 94%) resulted in survival to 30 days after catheter intervention. Of 392 admissions, 357 patients (91%) survived to discharge. Only 4 deaths were directly related to stent implantation. Some in-hospital complications were observed during 55 of 443 sessions. Both hospital deaths and serious complications were significantly more frequent in the group with various preoperative risk factors. CONCLUSIONS Although not officially approved for congenital heart diseases in Japan, stent implantation in congenital heart diseases has been widely and routinely performed for many years with safety and efficacy. The aim of stenting was variable and broad because of many different applications and morphological variations. These data may facilitate approval of such an important device in Japan.
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Affiliation(s)
- Hideshi Tomita
- Pediatric Heart Disease and Adult Congenital Heart Disease Center, Showa University Hospital
| | - Sung-Hae Kim
- Department of Cardiology, Shizuoka Children's Hospital
| | - Ryo Inuzuka
- Department of Pediatrics, The University of Tokyo Hospital
| | - Hikoro Matsui
- Department of Pediatrics, The University of Tokyo Hospital
| | - Hisateru Tachimori
- Translational Medical Center, National Center of Neurology and Psychiatry
| | - Tohru Kobayashi
- Division of Clinical Research Planning, Department of Development Strategy, Center for Clinical Research and Development, National Center for Child Health and Development
| | - Atsuko Kato
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Takanari Fujii
- Pediatric Heart Disease and Adult Congenital Heart Disease Center, Showa University Hospital
| | - Yuji Haishima
- Division of Medical Devices, National Institute of Health Sciences
| | | | - Hideyuki Sakoda
- Division of Medical Devices, National Institute of Health Sciences
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20
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O'Byrne ML, Glatz AC. Managing confounding and effect modification in pediatric/congenital interventional cardiology research. Catheter Cardiovasc Interv 2021; 98:1159-1166. [PMID: 34420250 DOI: 10.1002/ccd.29925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/27/2021] [Accepted: 08/01/2021] [Indexed: 11/08/2022]
Abstract
Measuring the effect of a treatment on outcomes is an important goal for research in pediatric/congenital interventional cardiology. The breadth of anatomic and physiologic variations, patient ages, and genetic syndromes and noncardiac comorbid conditions all represent sources of potential confounding and effect modification that are major obstacles to this goal. If not accounted for, these factors can obscure the "true" treatment effect and lead to spurious conclusions about the relative efficacy and/or safety of therapies. In this review, we discuss the importance of confounding and effect modification in pediatric/congenital interventional cardiology research. We define these terms and discuss strategies (both in study design and data analysis) to mitigate error introduced by confounding and effect modification. The importance of confounding by indication in pediatric/congenital cardiology is discussed along with specific methods to address it.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology and Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew C Glatz
- Division of Cardiology and Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
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21
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O'Byrne ML, Kennedy KF, Steven JM, Hill KD, Chamberlain RC, Millenson ME, Smith CL, Dori Y, Gillespie MJ, Rome JJ, Glatz AC. Outcomes of Operator-Directed Sedation and Anesthesiologist Care in the Pediatric/Congenital Catheterization Laboratory: A Study Utilizing Data From the IMPACT Registry. JACC Cardiovasc Interv 2021; 14:401-413. [PMID: 33602437 DOI: 10.1016/j.jcin.2020.10.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/15/2020] [Accepted: 10/13/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective of this study was to assess contemporary use of operator directed sedation (ODS) and anesthesiologist care (AC) in the pediatric/congenital cardiac catheterization laboratory (PCCL), specifically evaluating whether the use of operator-directed sedation was associated with increased risk of major adverse events. BACKGROUND The safety of ODS relative to AC during PCCL procedures has been questioned. METHODS A multicenter, retrospective cohort study was performed studying procedures habitually performed with ODS or AC at IMPACT (Improving Adult and Congenital Treatment) registry hospitals using ODS for ≥5% of cases. The risks for major adverse events (MAE) for ODS and AC cases were compared, adjusted for case mix. Current recommendations were evaluated by comparing the ratio of observed to expected MAE for cases in which ODS was inappropriate (inconsistent with those guidelines) with those for similar risk AC cases, as well as those in which ODS or AC was appropriate. RESULTS Of the hospitals submitting data to IMPACT, 28 of 101 met inclusion criteria. Of the 7,042 cases performed using ODS at these centers, 88% would be inappropriate. Use of ODS was associated with lower likelihood of MAE both in observed results (p < 0.0001) and after adjusting for case-mix (odds ratio: 0.81; p = 0.006). Use of AC was also associated with longer adjusted fluoroscopy and procedure times (p < 0.0001 for both). The observed/expected ratio for ODS cases with high pre-procedural risk (inappropriate for ODS) was significantly lower than that for AC cases with comparable pre-procedural risk. Across a range of pre-procedural risks, there was no stratum in which risk for MAE was lower for AC than ODS. CONCLUSIONS Across a range of hospitals, ODS was used safely and with improved efficiency. Clinical judgment better identified cases in which ODS could be used than pre-procedural risk score. This should inform future guidelines for the use of ODS and AC in the catheterization laboratory.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Kevin F Kennedy
- Mid America Heart Institute St. Luke's Health System, Kansas City, Missouri, USA
| | - James M Steven
- Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia and Department of Anesthesia Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kevin D Hill
- Department of Pediatrics, Division of Pediatric Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Reid C Chamberlain
- Department of Pediatrics, Division of Pediatric Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Marisa E Millenson
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christopher L Smith
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yoav Dori
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew J Gillespie
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jonathan J Rome
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew C Glatz
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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22
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Operator-Directed Sedation in the Pediatric Cardiac Catheterization Laboratory: "The Wheel Has Come Full Circle". JACC Cardiovasc Interv 2021; 14:414-416. [PMID: 33602438 DOI: 10.1016/j.jcin.2020.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 11/16/2020] [Indexed: 11/24/2022]
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23
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O'Byrne ML, Huang J, Asztalos I, Smith CL, Dori Y, Gillespie MJ, Rome JJ, Glatz AC. Pediatric/Congenital Cardiac Catheterization Quality: An Analysis of Existing Metrics. JACC Cardiovasc Interv 2021; 13:2853-2864. [PMID: 33357522 DOI: 10.1016/j.jcin.2020.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/19/2020] [Accepted: 09/01/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of this study was to enumerate and categorize quality metrics relevant to the pediatric/congenital cardiac catheterization laboratory (PCCL). BACKGROUND Diagnostic and interventional catheterization procedures are an increasingly important part of the care of young patients with cardiac disease. Measurement of the performance of PCCL programs in a stringent and consistent fashion is a crucial step toward improving outcomes. To the best of our knowledge, a systematic evaluation of current quality metrics in PCCL has not been performed previously. METHODS Potential metrics were evaluated by: 1) a systematic review of peer-reviewed research; 2) a review of metrics from organizations interested in quality improvement, patient safety, and/or PCCL programs; and 3) a survey of U.S. PCCL cardiologists. Collected metrics were grouped on 2 dimensions: 1) Institute of Medicine domains; and 2) the Donabedian structure/process/outcome framework. Survey responses were dichotomized between favorable and unfavorable responses and then compared within and between categories. RESULTS In the systematic review, 6 metrics were identified (from 9 publications), all focused on safety either as an outcome (adverse events [AEs], mortality, and failure to rescue along with radiation exposure) or as a structure (procedure volume or operator experience). Four organizations measure quality metrics of PCCL programs, of which only 1 publicly reports data. For the survey, 229 cardiologists from 118 hospital programs responded (66% of individuals and 72% of hospital programs). The highest favorable ratings were for safety metrics (p < 0.001), of which major AEs, failure to rescue, and procedure-specific AEs had the highest ratings. Of respondents, 67% stated that current risk adjustment were not effective. Favorability ratings for hospital characteristics, PCCL characteristics, and quality improvement processes were significantly lower than for safety and less consistent within categories. CONCLUSIONS There is a limited number of PCCL quality metrics, primarily focused on safety. Confidence in current risk adjustment methodology is low. The knowledge gaps identified should guide future research in the development of new quality metrics.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Leonard Davis Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Jing Huang
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Biostatistics Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania, USA; Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ivor Asztalos
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christopher L Smith
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yoav Dori
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew J Gillespie
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jonathan J Rome
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew C Glatz
- Division of Cardiology, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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24
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Sobey J, Tsai MH, Evans RE. An update on pediatric sedation techniques in nonoperating room locations. Curr Opin Anaesthesiol 2021; 34:449-454. [PMID: 34039846 DOI: 10.1097/aco.0000000000001018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To review advancements in care for pediatric patients in nonoperating room settings. RECENT FINDINGS Advances in patient monitoring technology, utilization of Child Life specialists, and alternative staffing models are helping anesthesia providers meet the rising demand for coverage of pediatric nonoperating room anesthesia (NORA) cases. The Wake Up Safe and Pediatric Sedation Research Consortium registries are exploring outcome measures regarding the safety of pediatric anesthesia in off-site locations and have reported an increased risk for severe respiratory and cardiac adverse events when compared to OR anesthesia sites. Additionally, malpractice claims for NORA have a higher proportion of claims for death than claims in operating rooms. SUMMARY Pediatric NORA requires thorough preparation, flexibility, and vigilance to provide safe anesthesia care to children in remote locations. Emerging techniques to reduce anesthetic exposure, improve monitoring, and alternative staffing models are expanding the boundaries of pediatric NORA to provide a safer, more satisfying experience for diagnostic and interventional procedures.
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Affiliation(s)
- Jenna Sobey
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Mitchell H Tsai
- Department of Anesthesiology, Orthopaedics and Rehabilitation (by courtesy), and Surgery (by courtesy), Larner College of Medicine, University of Vermont
| | - Rebecca E Evans
- Division of Pediatric Anesthesiology, Larner College of Medicine, University of Vermont Medical Center, Burlington, Vermont, USA
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25
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Anaesthesia for minimally invasive cardiac procedures in the catheterization lab. Curr Opin Anaesthesiol 2021; 34:437-442. [PMID: 34184641 DOI: 10.1097/aco.0000000000001007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The share of cardiac procedures performed in settings involving nonoperating room anaesthesia (NORA) continues to grow rapidly, and the number of publications related to anaesthetic techniques in cardiac catheterization laboratories is substantial. We aim to summarize the most recent evidence about outcomes related to type of anaesthetic in minimally invasive cardiac procedures. RECENT FINDINGS The latest studies, primarily focused on transcatheter aortic valve replacement (TAVR) and transcatheter mitral valve repair (TMVr), demonstrate the need for reliable monitoring and appropriate training of the interdisciplinary teams involved in this high-risk NORA setting. SUMMARY Inappropriate sedation and concurrent inadequate oxygenation are main risk factors for claims involving NORA care. Current evidence deriving from TAVR shows that monitored anaesthesia care (MAC) is associated with shorter length of stay and lower mortality.
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Sehgal A, Steenhorst JJ, Mclennan DI, Merkus D, Ivy D, McNamara PJ. The Left Heart, Systemic Circulation, and Bronchopulmonary Dysplasia: Relevance to Pathophysiology and Therapeutics. J Pediatr 2020; 225:13-22.e2. [PMID: 32553872 DOI: 10.1016/j.jpeds.2020.06.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 06/06/2020] [Accepted: 06/09/2020] [Indexed: 12/25/2022]
Affiliation(s)
- Arvind Sehgal
- Monash Children's Hospital, Monash University, Melbourne, Australia; Department of Pediatrics, Monash University, Melbourne, Australia.
| | - Jarno J Steenhorst
- Department of Cardiology, Erasmus MC, Rotterdam, the Netherlands; Department of Pediatrics, Erasmus MC, Rotterdam, the Netherlands
| | - Daniel I Mclennan
- Department of Pediatrics, University of Iowa Children's Hospital, Dr, Iowa City, IA; Internal Medicine, University of Iowa Children's Hospital, Dr, Iowa City, IA
| | - Daphne Merkus
- Department of Cardiology, Erasmus MC, Rotterdam, the Netherlands; Department of Pediatrics, Erasmus MC, Rotterdam, the Netherlands; Institut für Chirurgische Forschung, Klinikum Universität München, Ludwig Maximillian Universität München, München, Germany
| | - Dunbar Ivy
- Pediatric Cardiology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Patrick J McNamara
- Department of Pediatrics, University of Iowa Children's Hospital, Dr, Iowa City, IA; Internal Medicine, University of Iowa Children's Hospital, Dr, Iowa City, IA
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The effect of the duration of the procedure on the risk of complications during pediatric cardiac catheterization. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 28:467-473. [PMID: 32953209 DOI: 10.5606/tgkdc.dergisi.2020.19057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 05/23/2020] [Indexed: 11/21/2022]
Abstract
Background This study aims to evaluate the frequency of and associated risk factors for adverse events caused by cardiac catheterization procedures in pediatric patients. Methods Between January 2009 and January 2012, a total of 599 pediatric patients (320 males, 279 females; mean age 5.4±4.7 years; range, 1 day to 21 years) who underwent cardiac catheterization in our cardiac catheterization laboratory were retrospectively analyzed. Demographic and clinical data of the patients including the duration of the procedure, management of anesthesia, the American Society of Anesthesiologists class, and Catheterization Risk Score for Pediatrics, and procedure-related serious adverse events were recorded. Results The incidence of procedure-related serious adverse events was 9.18%. Potential risk factors associated with serious adverse events were identified as interventional heart catheterization, high scores obtained from the Catheterization Risk Score for Pediatrics, the use of endotracheal tube in airway control, and prolonged procedural duration. Conclusion Our study results suggest that prolonged duration of catheterization is a potential risk factor for procedure-related adverse events and the duration of the procedure needs to be included as a variable in the Catheterization Risk Score for Pediatrics scoring system for predicting procedure-related adverse events.
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28
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Kloesel B, Skubas NJ, Belani K. Risk Prediction in Children With Congenital Heart Disease: Business As Usual-Or Not? Anesth Analg 2020; 131:1080-1082. [PMID: 32925327 DOI: 10.1213/ane.0000000000005042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Benjamin Kloesel
- From the Department of Anesthesiology, M Health Fairview, University of Minnesota, Masonic Children's Hospital, Minneapolis, Minnesota
| | - Nikolaos J Skubas
- Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kumar Belani
- From the Department of Anesthesiology, M Health Fairview, University of Minnesota, Masonic Children's Hospital, Minneapolis, Minnesota
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29
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Setiawan CT, Landrigan-Ossar M. Pediatric Anesthesia Outside the Operating Room: Case Management. Anesthesiol Clin 2020; 38:587-604. [PMID: 32792186 DOI: 10.1016/j.anclin.2020.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Anesthesiology teams care for children in diverse locations, including diagnostic and interventional radiology, gastroenterology and pulmonary endoscopy suites, radiation oncology units, and cardiac catheterization laboratories. To provide safe, high-quality care, anesthesiologists working in these environments must understand the unique environmental and perioperative considerations and risks involved with each remote location and patient population. Once these variables are addressed, anesthesia and procedural teams can coordinate to ensure that patients and families receive the same high-quality care that they have come to expect in the operating room. This article also describes some of the considerations for anesthetic care in outfield locations.
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Affiliation(s)
- Christopher Tan Setiawan
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Anesthesiology, Children's Medical Center, 1935 Medical District Drive, Dallas, TX 75235, USA
| | - Mary Landrigan-Ossar
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Harvard Medical School, Boston, MA, USA.
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30
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Brida M, Diller GP, Nashat H, Barracano R, Kempny A, Uebing A, Rigby ML, Gatzoulis MA. Cardiac catheter intervention complexity and safety outcomes in adult congenital heart disease. Heart 2020; 106:1432-1437. [PMID: 32205313 DOI: 10.1136/heartjnl-2019-316148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 01/29/2020] [Accepted: 02/04/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To describe the intervention spectrum, complexity, and safety outcomes of catheter-based interventions in a contemporary adult congenital heart disease (ACHD) tertiary cohort. METHODS All patients over 16 years who underwent a catheter-based intervention for ACHD in our centre between 2000 and 2016 were included. Baseline demographics, clinical characteristics, indications for and complexity of intervention, procedural complications and early and mid-term mortality were analysed. RESULTS Overall, 1644 catheter-based interventions were performed. Intervention complexity ranged from simple (67.5%) to intermediate (26.4%) and to high (6.1%). Commonly performed procedures were atrial septal defect (33.4%) and patent foramen ovale closure (26.1%) followed by coarctation of the aorta (11.1%) and pulmonary artery interventions (7.0%). Age at index intervention was 40±16 years, 758 (46.1%) patients were male, 73.2% in New York Heart Association (NYHA) class I, 20.2% in NYHA class II, whereas 6.6% in NYHA class III/IV. In-hospital mortality was 0.7%. Median postinterventional length of stay was 1 day. Complications occurred in 129 (7.9%) with major adverse events in 21 (1.3%). One-year postintervention survival rates were 98.7% (95% CI 98.2 to 99.2). Over the study period, there was a notable shift in intervention complexity, with a predominance of simple procedures performed in early years and more complex procedures in later years. Furthermore, the case mix during the study broadened (p<0.001) with new catheter-based interventions and a more individualised approach to therapy. CONCLUSION This study shows an increasing complexity and expanding variability of ACHD catheter-based interventions, associated with low major complications, short hospital stays and low early and mid-term mortality. Ongoing investment in ACHD catheter interventions is warranted.
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Affiliation(s)
- Margarita Brida
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK .,Division of Adult Congenital Heart Disease, Department of Cardiovascular Medicine, University Hospital Centre, Zagreb, Croatia.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Gerhard Paul Diller
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK.,Adult Congenital and Valvular Heart Disease Center, Department of Cardiology and Angiology, University Hospital Muenster, Muenster, Germany
| | - Heba Nashat
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
| | - Rosaria Barracano
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
| | - Aleksander Kempny
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Anselm Uebing
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
| | - Michael L Rigby
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
| | - Michael A Gatzoulis
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
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Risk factors for adverse events within one year after atrial septal closure in children: a retrospective follow-up study. Cardiol Young 2020; 30:303-312. [PMID: 31847927 DOI: 10.1017/s1047951119002919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Secundum atrial septal defect is one of the most common congenital heart defects. Previous paediatric studies have mainly addressed echocardiographic and few clinical factors among children associated with adverse events. The aim of this study was to identify neonatal and other clinical risk factors associated with adverse events up to one year after closure of atrial septal defect. METHODS This retrospective case-control study includes children born in Sweden between 2000 and 2014 that were treated surgically or percutaneously for an atrial septal defect. Conditional logistic regression was used to evaluate the association between major and minor adverse events and potential risk factors, adjusting for confounding factors including prematurity, neonatal sepsis, neonatal general ventilatory support, symptomatic atrial septal defects, and pulmonary hypertension. RESULTS Overall, 396 children with 400 atrial septal defect closures were included. The median body weight at closure was 14.5 (3.5-110) kg, and the median age was 3.0 (0.1-17.8) years. Overall, 110 minor adverse events and 68 major events were recorded in 87 and 49 children, respectively. Only symptomatic atrial septal defects were associated with both minor (odds ratio (OR) = 2.18, confidence interval (CI) 95% 1.05-8.06) and major (OR = 2.80 CI 95% 1.23-6.37) adverse events. CONCLUSION There was no association between the investigated neonatal comorbidities and major or minor events after atrial septal defect closure. Patients with symptomatic atrial septal defects had a two to four times increased risk of having a major event, suggesting careful management and follow-up of these children prior to and after closure.
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Holzer RJ, Dayton JD. Registries, Risk Calculators, and Risk-Adjusted Outcomes: Current Usage, Limitations, and Future Prospects. Pediatr Cardiol 2020; 41:443-458. [PMID: 32198591 DOI: 10.1007/s00246-020-02300-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/17/2020] [Indexed: 11/26/2022]
Abstract
Small study sizes are a limiting factor in assessing outcome measures in pediatric cardiology. It is even more difficult to assess the outcomes of congenital catheterizations where the sample sizes are even smaller, particularly on a individual institutional level. The creation of multicenter registries is a method by which investigators can pool data to better assess quality and outcome measures of these procedures. No registry is perfect with several being available today, each with its own strengths and weaknesses. In addition, there are a multitude of methods currently used to assess quality and outcomes from the data contained in these registries, each having its own limitations as well. Nonetheless, multicenter registrities remain one of the best available options to improve the quality of care for pediatric interventional cardiac catheterization. Below, we provide an overview of the current state of quality assessment/improvement in pediatric interventional cardiology including a review of the available registrities and the metrics used to measure quality of care and outcomes.
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Affiliation(s)
- Ralf J Holzer
- NewYork-Presbyterian Komansky Children's Hospital, New York, USA.
- Weill Cornell Medicine, New York, USA.
- David Wallace - Starr Foundation, Division of Pediatric Cardiology, Pediatric Cardiac Catheterization, NewYork-Presbyterian Komansky Children's Hospital, New york, USA.
| | - Jeffrey D Dayton
- NewYork-Presbyterian Komansky Children's Hospital, New York, USA
- Weill Cornell Medicine, New York, USA
- Department of Pediatrics, 525 East 68th Street, Room F-677, New York, NY, 10065, USA
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Abstract
OBJECTIVES Cardiac catheterisation is commonly used for diagnosis and therapeutic interventions in paediatric cardiology. The inherent risk of the procedure can result in unanticipated admissions to critical care. Our goals were to provide a qualitative description of characteristics and evaluation of children admitted unexpectedly to the cardiac critical care unit (CCCU). METHODS A retrospective single centre review of cardiac catheterisation procedures was done between 1 January, 2003 and 30 April, 2013. RESULTS Of 9336 cardiac catheterisations performed, 146 (1.6%) were admitted from the catheterisation laboratory to the CCCU and met inclusion criteria. Of these 146 patients, 117 (1.3%) met criteria for unexpected admission and 29 (0.3%) were planned admissions. The majority admitted unexpectedly were below 1 year of age without co-morbidity aside from heart disease. Patients with planned admissions were significantly more likely to have single ventricle physiology, undergoing angiography or transferred for observation. Most unplanned admissions were triggered by interventional catheterisations or procedure-related complications. Patients received mechanical ventilation as the main CCCU management. Eighteen patients needed either cardiopulmonary resuscitation and/or extracorporeal membrane oxygenation during their catheterisation. About 106/117 (90.6%) patients survived to hospital discharge with no deaths in the planned admission group. CONCLUSIONS Admission to CCCU following cardiac catheterisation was uncommon and tended to occur in younger children undergoing interventional procedures. Outcomes did not differ between patients experiencing planned and unplanned CCCU admission. Ongoing development of risk stratification tools may help to decrease unplanned CCCU admissions. Further studies are needed to determine whether unplanned admission following paediatric cardiac catheterisation should be utilised as a quality indicator.
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Daaboul DG, DiNardo JA, Nasr VG. Anesthesia for high-risk procedures in the catheterization laboratory. Paediatr Anaesth 2019; 29:491-498. [PMID: 30592354 DOI: 10.1111/pan.13571] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 12/18/2018] [Accepted: 12/24/2018] [Indexed: 12/17/2022]
Abstract
Recent advances in catheterization and imaging technology allow for more complex procedures to be performed in the catheterization laboratory. A number of lesions are now amenable to a percutaneous procedure, eliminating or at least postponing the need for a surgical intervention. Due to the increase in the complexity of the procedures performed, the involvement of anesthesiologists and their close collaboration with the interventional cardiologists have increased. It is important to understand the physiology and pathophysiology of the patients and to anticipate the plans and the potential complications in order to manage them. We are witnessing a rise in the number of complex interventions in newborns and infants, such as balloon valvotomy (critical aortic stenosis, pulmonary stenosis), radio frequency perforation (of pulmonary atresia and intact ventricular septum), right ventricular outflow tract stenting (in Tetralogy of Fallot), ductal stenting (in some ductus-dependent pulmonary circulation), and combined with a surgical procedure (hybrid procedure for hypoplastic left heart syndrome). Multiple registries have been created in order to understand and improve outcomes of patients with congenital heart disease undergoing catheterization procedures and to develop performance and quality metrics, from which data regarding anesthetic-related risks can be extrapolated. Experienced personnel and a multidisciplinary team approach with direct communication among the team members is a must to ensure anticipation and management of critical events when they occur.
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Affiliation(s)
- Dima G Daaboul
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - James A DiNardo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Adverse events within 1 year after surgical and percutaneous closure of atrial septal defects in preterm children. Cardiol Young 2019; 29:626-636. [PMID: 31159892 DOI: 10.1017/s1047951119000350] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Atrial septal defect is the third most common CHD. A hemodynamically significant atrial septal defect causes volume overload of the right side of the heart. Preterm children may suffer from both pulmonary and cardiac comorbidities, including altered myocardial function. The aim of this study was to compare the rate of adverse events following atrial septal defect closure in preterm- and term-born children. METHOD We performed a retrospective cohort study including children born in Sweden, who had a surgical or percutaneous atrial septal defect closure at the children's hospitals in Lund and Stockholm, between 2000 and 2014, assessing time to the first event within 1 month or 1 year. We analysed differences in the number of and the time to events between the preterm and term cohort using the Kaplan-Meier survival curve, a generalised model applying zero-inflated Poisson distribution and Gary-Anderson's method. RESULTS Overall, 413 children were included in the study. Of these, 93 (22.5%) were born prematurely. The total number of adverse events was 178 (110 minor and 68 major). There was no difference between the cohorts in the number of events, whether within 1 month or within a year, between major (p = 0.69) and minor (p = 0.84) events or frequencies of multiple events (p = 0.92). CONCLUSION Despite earlier procedural age, larger atrial septal defects, and higher comorbidity than term children, preterm children appear to have comparable risk for complications during the first year after surgical or percutaneous closure.
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A Model for Assessment of Catheterization Risk in Adults With Congenital Heart Disease. Am J Cardiol 2019; 123:1527-1531. [PMID: 30797558 DOI: 10.1016/j.amjcard.2019.01.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/16/2019] [Accepted: 01/21/2019] [Indexed: 11/22/2022]
Abstract
The purpose of this study was to define the risk for adults with congenital heart disease who underwent cardiac catheterization and to propose a precatheterization risk scoring system. Data were prospectively collected using a multicenter registry of the Congenital Cardiovascular Interventional Study Consortium. The occurrence of serious adverse events (SAE) was correlated with 12 predefined variables. Catheterization RISk in Adult patients (CRISA) score was derived using multivariate logistic regression with backward elimination model selection method. The CRISA score was compared with the American Society of Anesthesiology score and a consensus-derived, 20-point risk score based on their ability to predict SAE. From June 2008 to September 2017, 300 adjudicated SAE's occurred in 7317 catheterization procedures (overall SAE rate 4.1%) performed in adults over 18 years of age at 27 contributing centers. Nine of the 12 tested variables were ultimately included in the CRISA score. CRISA score positively correlated with risk of SAE, and was superior to American Society of Anesthesiology and the 20-point risk score in predicting SAE. Minimal (CRISA score 0 to 2), low (3 to 7), moderate (8 to 10) and high (≥11) risk categories were identified, corresponding to 0.5%, 3.2%, 7.9%, and 16.7% risk of SAE, respectfully. In conclusion, the CRISA score reliably predicts risk of SAE in adults with congenital heart disease who underwent cardiac catheterization and may be useful for preprocedural risk assessment.
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Sedation in the Pediatric and Congenital Catheterization Laboratory. JACC Cardiovasc Interv 2019; 12:844-846. [DOI: 10.1016/j.jcin.2019.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 02/05/2019] [Indexed: 11/18/2022]
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Operator-Directed Procedural Sedation in the Congenital Cardiac Catheterization Laboratory. JACC Cardiovasc Interv 2019; 12:835-843. [PMID: 30981573 DOI: 10.1016/j.jcin.2019.01.224] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 12/04/2018] [Accepted: 01/03/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the association between the method of procedural sedation and outcomes for congenital cardiac catheterization procedures. BACKGROUND The safety of operator-directed sedation (ODS) in the pediatric/congenital cardiac catheterization laboratory has been questioned. To our knowledge, the relative safety of ODS versus general anesthesia (GA) in these cases has not to date been critically evaluated. METHODS A single-center retrospective cohort study was performed to compare the relative safety, cost, and times of catheterization procedures performed with ODS and those performed with GA from a cardiac anesthesiologist. The risk of adverse outcomes was compared using propensity-score-adjusted models. Using the same propensity score, procedure times and relative charges were also compared. RESULTS Over the study period, 4,424 procedures in 2,547 patients were studied. Of these, 27% of cases were performed with ODS. ODS procedures were 70% diagnostic procedures, 17% device closure of patent ductus arteriosus, 5% balloon pulmonary valvuloplasty, and 3% pulmonary artery angioplasty. The risk of adverse event in adjusted models for ODS cases was significantly lower than in GA cases (odds ratio: 0.66; 95% confidence interval: 0.45 to 0.95; p = 0.03). Total room time and case time were also significantly shorter (p < 0.001). Professional (charge ratio: 0.88; p < 0.001) and hospital (charge ratio: 0.84; p < 0.001) charges for ODS cases were also lower than those for GA cases. CONCLUSIONS This study demonstrates that clinical judgment can identify subjects in whom ODS is not associated with increased risk of adverse events. The use of ODS was associated with reduced case times and charges. In combination, these findings suggest that the selective use of ODS can allow for greater efficiency and higher value care without sacrificing safety.
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Catheterization Performed in the Early Postoperative Period After Congenital Heart Surgery in Children. Pediatr Cardiol 2019; 40:827-833. [PMID: 30830282 DOI: 10.1007/s00246-019-02078-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 02/23/2019] [Indexed: 10/27/2022]
Abstract
The aim of this study was to describe pediatric patients who underwent early postoperative cardiac catheterization after congenital heart surgery, their clinical indications, findings, interventions, and complications in a cardiovascular center. A descriptive retrospective study was performed. All catheterizations performed within 6 weeks after congenital heart surgery between January 2004 and December 2014 were reviewed. We analyzed 101 early postoperative catheterizations. They were performed on median postoperative day five (IQR: 0-39); the median age was 64 days (IQR: 22-240). The most common diagnoses were single ventricle (53%), left heart obstruction (12%), and tetralogy of fallot or pulmonary atresia with ventricular septal defect (11%). Most common indications were persistent cyanosis (53%), low cardiac output (24%), and residual defect on echocardiogram (20%). Most frequent findings during the catheterization were pulmonary artery stenosis (29%), surgical conduit obstruction (12%), and coarctation or hypoplasia of the aorta (11%). Forty-six (45%) procedures involved intervention. Most frequent interventions were pulmonary artery, aorta, and Blalock-Taussig fistula angioplasty with or without stent implantation. There were adverse effects in 11 cases (11%), and 30-day mortality was 28% (28 patients) with the majority unrelated to the catheterization directly. Although early postoperative catheterizations are high-risk procedures, they are currently a very good option to solve acute problems in critically ill patients. This study provides relevant information for a better understanding and approach to this complex group of patients.
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40
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Amdani SM, Ross RD, Webster PA, Turner DR, Forbes TJ, Kobayashi D. Reducing radiation exposure by lowering frame rate in children undergoing cardiac catheterization: A quality improvement study. CONGENIT HEART DIS 2018; 13:1028-1037. [PMID: 30280489 DOI: 10.1111/chd.12677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 08/10/2018] [Accepted: 08/17/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Reduction of radiation dosage in the pediatric cardiac catheterization laboratory (PCL) is important to reduce the risk of its stochastic effect in children with congenital heart disease. Lowering the frame rate would reduce radiation dosage possibly at the expense of image quality, potentially resulting in higher fluoroscopic time and procedural complication rate. METHODS The data were retrospectively analyzed in three eras: era 1 (n = 234), cineangiography 30 frames/sec (f/s) and fluoroscopy 15 pulse/sec (p/s); era 2 (n = 381), cineangiography 30 f/s and fluoroscopy 6 p/s; and era 3 (n = 328), cineangiography 15 f/s and fluoroscopy 6 p/s. Also, three operators blinded to the frame rate setting evaluated cineangiography image quality. In this study, the impact of lowering the default frame rates on radiation dosage, fluoroscopic time, contrast volume, diagnostic image quality, and complication rates in the PCL was assessed. RESULTS Overall radiation dosage progressively declined during these eras (70.0 vs 64.1 vs 36.6 µGym2 /kg, P < .001) without a difference in significant adverse event rates. There was no significant increase in either fluoroscopy time or contrast volume. There was no difference in the diagnostic image quality between cineangiography 30 and 15 f/s. Lowering the default frame/pulse rates of both fluoroscopy and cineangiography significantly decreased the overall radiation dosage in the PCL. Importantly, fluoroscopy time, contrast volume, and complication rates did not increase while maintaining diagnostic image quality. CONCLUSION This quality improvement project proved successful in lowering radiation dosage without compromising the efficacy and safety of catheterizations.
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Affiliation(s)
- Shahnawaz M Amdani
- Division of Cardiology, Carman and Ann Adams Department of Pediatrics, Children's Hospital, Wayne State University School of Medicine, Detroit, Michigan
| | - Robert D Ross
- Division of Cardiology, Carman and Ann Adams Department of Pediatrics, Children's Hospital, Wayne State University School of Medicine, Detroit, Michigan
| | - Paul A Webster
- Division of Cardiology, Carman and Ann Adams Department of Pediatrics, Children's Hospital, Wayne State University School of Medicine, Detroit, Michigan
| | - Daniel R Turner
- Division of Cardiology, Carman and Ann Adams Department of Pediatrics, Children's Hospital, Wayne State University School of Medicine, Detroit, Michigan
| | - Thomas J Forbes
- Division of Cardiology, Carman and Ann Adams Department of Pediatrics, Children's Hospital, Wayne State University School of Medicine, Detroit, Michigan
| | - Daisuke Kobayashi
- Division of Cardiology, Carman and Ann Adams Department of Pediatrics, Children's Hospital, Wayne State University School of Medicine, Detroit, Michigan
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Whittle R, Peat G, Belcher J, Collins GS, Riley RD. Measurement error and timing of predictor values for multivariable risk prediction models are poorly reported. J Clin Epidemiol 2018; 102:38-49. [PMID: 29782997 DOI: 10.1016/j.jclinepi.2018.05.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 04/26/2018] [Accepted: 05/14/2018] [Indexed: 10/16/2022]
Abstract
OBJECTIVE Measurement error in predictor variables may threaten the validity of clinical prediction models. We sought to evaluate the possible extent of the problem. A secondary objective was to examine whether predictors are measured at the intended moment of model use. METHODS A systematic search of Medline was used to identify a sample of articles reporting the development of a clinical prediction model published in 2015. After screening according to a predefined inclusion criteria, information on predictors, strategies to control for measurement error, and intended moment of model use were extracted. Susceptibility to measurement error for each predictor was classified into low and high risks. RESULTS Thirty-three studies were reviewed, including 151 different predictors in the final prediction models. Fifty-one (33.7%) predictors were categorized as high risk of error; however, this was not accounted for in the model development. Only 8 (24.2%) studies explicitly stated the intended moment of model use and when the predictors were measured. CONCLUSION Reporting of measurement error and intended moment of model use is poor in prediction model studies. There is a need to identify circumstances where ignoring measurement error in prediction models is consequential and whether accounting for the error will improve the predictions.
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Affiliation(s)
- Rebecca Whittle
- Centre for Prognosis Research, Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK.
| | - George Peat
- Centre for Prognosis Research, Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - John Belcher
- Centre for Prognosis Research, Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Richard D Riley
- Centre for Prognosis Research, Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
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Hill KD, Du W, Fleming GA, Forbes TJ, Nykanen DG, Reeves J, Du Y, Kobayashi D. Validation and refinement of the catheterization RISk score for pediatrics (CRISP score): An analysis from the congenital cardiac interventional study consortium. Catheter Cardiovasc Interv 2018; 93:97-104. [DOI: 10.1002/ccd.27837] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 07/23/2018] [Accepted: 07/28/2018] [Indexed: 11/07/2022]
Affiliation(s)
- Kevin D. Hill
- Department of Pediatrics; Duke University Medical Center; Durham North Carolina
- Division of Pediatric Cardiology; Duke University Medical Center; Durham North Carolina
| | - Wei Du
- Department of Pediatrics; Children's Hospital of Michigan; Detroit Michigan
- Division of Pediatric Cardiology; Children's Hospital of Michigan; Detroit Michigan
| | - Gregory A. Fleming
- Department of Pediatrics; Duke University Medical Center; Durham North Carolina
- Division of Pediatric Cardiology; Duke University Medical Center; Durham North Carolina
| | - Thomas J. Forbes
- Department of Pediatrics; Children's Hospital of Michigan; Detroit Michigan
- Division of Pediatric Cardiology; Children's Hospital of Michigan; Detroit Michigan
| | - David G. Nykanen
- Department of Pediatrics; Arnold Palmer Hospital for Children and the University of Central Florida College of Medicine; Orlando Florida
- Division of Pediatric Cardiology; Arnold Palmer Hospital for Children and the University of Central Florida College of Medicine; Orlando Florida
| | - Jaxk Reeves
- Department of Statistics; University of Georgia; Athens Georgia
| | - Yan Du
- Department of Statistics; University of Georgia; Athens Georgia
| | - Daisuke Kobayashi
- Department of Pediatrics; Children's Hospital of Michigan; Detroit Michigan
- Division of Pediatric Cardiology; Children's Hospital of Michigan; Detroit Michigan
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Kenny DP, Hijazi ZM. Going beyond the high-risk patient: the new boundaries for transcatheter device-focused therapy. Expert Rev Med Devices 2018; 15:645-652. [DOI: 10.1080/17434440.2018.1514255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Damien P. Kenny
- Department of Paediatric Cardiology, Our Lady’s Children’s Hospital, Dublin, Ireland
| | - Ziyad M. Hijazi
- Sidra Cardiac Program, Weill Cornell Medical College, Sidra Medicine, Doha, Qatar
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Mossad EB. Outcome Predictors in Congenital Cardiac Care: No More a Hunch or a Curiosity but an Ethical and Financial Necessity. J Cardiothorac Vasc Anesth 2018; 32:2652-2653. [PMID: 29954685 DOI: 10.1053/j.jvca.2018.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Emad B Mossad
- Department of Pediatric Anesthesia, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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Wipf A, Christmann M, Navarini-Meury S, Dave H, Quandt D, Knirsch W, Kretschmar O. Aortopulmonary collaterals in neonates with d-transposition of the great arteries - Clinical significance early after arterial switch operation. Int J Cardiol 2018; 258:237-242. [PMID: 29444748 DOI: 10.1016/j.ijcard.2018.01.132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 12/14/2017] [Accepted: 01/30/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Purpose of this study is to evaluate the clinical significance of major aortopulmonary collateral arteries (MAPCAs) during the early postoperative course after arterial switch operation (ASO) in d-transposition of the great arteries (dTGA). METHODS Clinical data of 98 patients with simple dTGA between January 2007 and December 2016 at the University Children's Hospital Zurich, Switzerland were analyzed retrospectively. RESULTS 37 from 98 patients (38%) required cardiac catheterization (CC) due to an early complicated postoperative course or difficult coronary transfer due to special coronary anatomy. In 15 (15%) patients, hemodynamically relevant MAPCAs were found during CC and coil embolization was performed. Patients with relevant MAPCAs had a significantly longer PICU stay (7 versus 6 days, p = 0.021), longer hospital stay (41 versus 27 days, p = 0.005), longer mechanical ventilation time (5 versus 3 days, p = 0.005), longer need for inotropic support (5 versus 4 days, p = 0.001) and delayed chest closure time (3 versus 2 days, p = 0.030) in those in whom it was left open in comparison to all other patients. In patients having CC, pre-surgery oxygen saturation was significantly lower in patients with relevant MAPCAs (58% vs 70%, p 0.019). Echocardiography had a sensitivity of 53% and a specificity of 100% in detecting relevant MAPCAs, accurately. CONCLUSIONS MAPCAs are frequently found in dTGA patients and can be associated with lower baseline oxygen saturation and a prolonged postoperative course after ASO. Transthoracic echocardiography cannot replace CC as diagnostic tool. If significant MAPCAs are suspected, early CC should be performed for diagnostic and therapeutic reasons.
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Affiliation(s)
- Alexandra Wipf
- Paediatric Cardiology, University Children's Hospital, Zurich, Switzerland; Children's Research Center, University of Zurich, Switzerland
| | - Martin Christmann
- Paediatric Cardiology, University Children's Hospital, Zurich, Switzerland; Children's Research Center, University of Zurich, Switzerland.
| | - Susanne Navarini-Meury
- Paediatric Cardiology, University Children's Hospital, Zurich, Switzerland; Children's Research Center, University of Zurich, Switzerland
| | - Hitendu Dave
- Children's Research Center, University of Zurich, Switzerland; Division of Congenital Cardiovascular Surgery, University Children's Hospital, Zurich, Switzerland
| | - Daniel Quandt
- Paediatric Cardiology, University Children's Hospital, Zurich, Switzerland; Children's Research Center, University of Zurich, Switzerland
| | - Walter Knirsch
- Paediatric Cardiology, University Children's Hospital, Zurich, Switzerland; Children's Research Center, University of Zurich, Switzerland
| | - Oliver Kretschmar
- Paediatric Cardiology, University Children's Hospital, Zurich, Switzerland; Children's Research Center, University of Zurich, Switzerland
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Mowers K, Rockefeller T, Balzer D, Nicolas R, Shahanavaz S. Post-operative Catheterization Interventions at the Site of Surgery: An Application of the CRISP Scoring System. Pediatr Cardiol 2018; 39:674-681. [PMID: 29327147 DOI: 10.1007/s00246-018-1805-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 01/03/2018] [Indexed: 10/18/2022]
Abstract
Catheter-based interventions in the early post-operative period are performed with caution due to concerns for increased procedural risk, particularly across fresh suture lines. The recently published CRISP scoring system provides prospective risk stratification based on pre-procedural criterion. In an effort to refine the assessment of risk in patients undergoing post-operative catheter-based interventions, the predicted risk of an adverse event based on CRISP scores was compared to actual adverse event rates. A single-center, retrospective review of patients undergoing catheterization interventions within 6 weeks of cardiac surgery was conducted between Jan 2004 and Dec 2014. Patients who underwent dilation interventions across fresh suture lines (group 1) were compared to patients who underwent interventional procedures at other sites (group 2), and a CRISP score was calculated for all patients. Patients receiving only surveillance biopsies were excluded. Sixty-eight patients underwent 100 interventional procedures. Group 1 was composed of 44 patients receiving 64 interventions, while group 2 had 24 patients who underwent 36 interventions. Group 1 was comprised significantly more single ventricles and patients were smaller/younger. Group 1 had a significantly higher median CRISP score, but both groups were within Category 4. The rates of adverse events were similar between groups and comparable to predicted rates with the CRISP scoring system. Catheter-based interventions in the early post-operative period can be performed with no significant increase in the risk of serious adverse events when intervening across fresh suture lines. The CRISP scoring system can be a valuable tool in pre-procedural counseling of high-risk post-operative patients.
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Affiliation(s)
- Katie Mowers
- Division of Cardiology, Department of Pediatrics, Washington University School of Medicine/St. Louis Children's Hospital, 1 Children's Place, Saint Louis, MO, 63108, USA
| | - Toby Rockefeller
- Division of Cardiology, Department of Pediatrics, Washington University School of Medicine/St. Louis Children's Hospital, 1 Children's Place, Saint Louis, MO, 63108, USA
| | - David Balzer
- Division of Cardiology, Department of Pediatrics, Washington University School of Medicine/St. Louis Children's Hospital, 1 Children's Place, Saint Louis, MO, 63108, USA
| | - Ramzi Nicolas
- Division of Cardiology, Department of Pediatrics, Washington University School of Medicine/St. Louis Children's Hospital, 1 Children's Place, Saint Louis, MO, 63108, USA
| | - Shabana Shahanavaz
- Division of Cardiology, Department of Pediatrics, Washington University School of Medicine/St. Louis Children's Hospital, 1 Children's Place, Saint Louis, MO, 63108, USA.
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47
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Kenny D. Interventional Cardiology for Congenital Heart Disease. Korean Circ J 2018; 48:350-364. [PMID: 29671282 PMCID: PMC5940641 DOI: 10.4070/kcj.2018.0064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 03/05/2018] [Indexed: 12/22/2022] Open
Abstract
Congenital heart interventions are now replacing surgical palliation and correction in an evolving number of congenital heart defects. Right ventricular outflow tract and ductus arteriosus stenting have demonstrated favorable outcomes compared to surgical systemic to pulmonary artery shunting, and it is likely surgical pulmonary valve replacement will become an uncommon procedure within the next decade, mirroring current practices in the treatment of atrial septal defects. Challenges remain, including the lack of device design focused on smaller infants and the inevitable consequences of somatic growth. Increasing parental and physician expectancy has inevitably lead to higher risk interventions on smaller infants and appreciation of the consequences of these interventions on departmental outcome data needs to be considered. Registry data evaluating congenital heart interventions remain less robust than surgical registries, leading to a lack of insight into the longer-term consequences of our interventions. Increasing collaboration with surgical colleagues has not been met with necessary development of dedicated equipment for hybrid interventions aimed at minimizing the longer-term consequences of scar to the heart. Therefore, great challenges remain to ensure children and adults with congenital heart disease continue to benefit from an exponential growth in minimally invasive interventions and technology. This can only be achieved through a concerted collaborative approach from physicians, industry, academia and regulatory bodies supporting great innovators to continue the philosophy of thinking beyond the limits that has been the foundation of our specialty for the past 50 years.
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Affiliation(s)
- Damien Kenny
- Our Lady's Children's Hospital, Crumlin, Dublin, Ireland.
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48
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Nasr VG, Twite MD, Walker SG, Kussman BD, Motta P, Mittnacht AJC, Mossad EB. Selected 2017 Highlights in Congenital Cardiac Anesthesia. J Cardiothorac Vasc Anesth 2018; 32:1546-1555. [PMID: 29699846 DOI: 10.1053/j.jvca.2018.03.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Vivian G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Mark D Twite
- Department of Anesthesiology, University of Colorado and Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO
| | - Scott G Walker
- Department of Anesthesiology, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - Barry D Kussman
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Pablo Motta
- Division of Pediatric Cardiovascular Anesthesia, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Alexander J C Mittnacht
- Department of Anesthesiology, Perioperative and Pain Medicine, the Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Emad B Mossad
- Division of Pediatric Cardiovascular Anesthesia, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
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49
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Jassal A, Cavus O, Bradley EA. Pediatric and Adolescent Pulmonary Hypertension: What Is the Risk of Undergoing Invasive Hemodynamic Testing? J Am Heart Assoc 2018; 7:JAHA.118.008625. [PMID: 29490974 PMCID: PMC5866344 DOI: 10.1161/jaha.118.008625] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Anudeep Jassal
- Department of Pediatrics, The Heart Center Nationwide Children's Hospital, Columbus, OH
| | - Omer Cavus
- Department of Physiology and Cell Biology, Davis Heart and Lung Research Institute The Ohio State University, Columbus, OH
| | - Elisa A Bradley
- Department of Pediatrics, The Heart Center Nationwide Children's Hospital, Columbus, OH .,Department of Physiology and Cell Biology, Davis Heart and Lung Research Institute The Ohio State University, Columbus, OH.,Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus, OH
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50
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O'Byrne ML, Kennedy KF, Kanter JP, Berger JT, Glatz AC. Risk Factors for Major Early Adverse Events Related to Cardiac Catheterization in Children and Young Adults With Pulmonary Hypertension: An Analysis of Data From the IMPACT (Improving Adult and Congenital Treatment) Registry. J Am Heart Assoc 2018; 7:e008142. [PMID: 29490973 PMCID: PMC5866335 DOI: 10.1161/jaha.117.008142] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 01/03/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiac catheterization is the gold standard for assessment and follow-up of patients with pulmonary hypertension (PH). To date, there are limited data about the factors that influence the risk of catastrophic adverse events after catheterization in this population. METHODS AND RESULTS A retrospective multicenter cohort study was performed to measure risk of catastrophic adverse outcomes after catheterization in children and young adults with PH and identify risk factors for these outcomes. All catheterizations in children and young adults, aged 0 to 21 years, with PH at hospitals submitting data to the IMPACT (Improving Adult and Congenital Treatment) registry between January 1, 2011, and December 31, 2015, were studied. Using mixed-effects multivariable regression, we assessed the association between prespecified subject-, procedure-, and center-level covariates and the risk of death, cardiac arrest, or mechanical circulatory support during or after cardiac catheterization. A total of 8111 procedures performed in 7729 subjects at 77 centers were studied. The observed risk of the composite outcome was 1.4%, and the risk of death before discharge was 5.2%. Catheterization in prematurely born neonates and nonpremature infants was associated with increased risk of catastrophic adverse event, as was precatheterization treatment with inotropes and lower systemic arterial saturation. Secondary analyses demonstrated the following: (1) increasing volumes of catheterization in patients with PH were associated with reduced risk of composite outcome (odds ratio, 0.8 per 10 procedures; P=0.002) and (2) increasing pulmonary vascular resistance and pulmonary artery pressures were associated with increased risk (P<0.0001 for both). CONCLUSIONS Young patients with PH are a high-risk population for diagnostic and interventional cardiac catheterization. Hospital experience with PH is associated with reduced risk, independent of total catheterization case volume.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology and Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute at the University of Pennsylvania, Philadelphia, PA
| | - Kevin F Kennedy
- Mid America Heart Institute, St Luke's Health System, Kansas City, MO
| | - Joshua P Kanter
- Division of Cardiology, Children's National Health System, Washington, DC
- Department of Pediatrics, George Washington University School of Health Sciences, Washington, DC
| | - John T Berger
- Division of Cardiology, Children's National Health System, Washington, DC
- Department of Pediatrics, George Washington University School of Health Sciences, Washington, DC
| | - Andrew C Glatz
- Division of Cardiology and Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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