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Constable MD, Shum HPH, Clark S. Enhancing surgical performance in cardiothoracic surgery with innovations from computer vision and artificial intelligence: a narrative review. J Cardiothorac Surg 2024; 19:94. [PMID: 38355499 PMCID: PMC10865515 DOI: 10.1186/s13019-024-02558-5] [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] [Received: 07/01/2023] [Accepted: 01/30/2024] [Indexed: 02/16/2024] Open
Abstract
When technical requirements are high, and patient outcomes are critical, opportunities for monitoring and improving surgical skills via objective motion analysis feedback may be particularly beneficial. This narrative review synthesises work on technical and non-technical surgical skills, collaborative task performance, and pose estimation to illustrate new opportunities to advance cardiothoracic surgical performance with innovations from computer vision and artificial intelligence. These technological innovations are critically evaluated in terms of the benefits they could offer the cardiothoracic surgical community, and any barriers to the uptake of the technology are elaborated upon. Like some other specialities, cardiothoracic surgery has relatively few opportunities to benefit from tools with data capture technology embedded within them (as is possible with robotic-assisted laparoscopic surgery, for example). In such cases, pose estimation techniques that allow for movement tracking across a conventional operating field without using specialist equipment or markers offer considerable potential. With video data from either simulated or real surgical procedures, these tools can (1) provide insight into the development of expertise and surgical performance over a surgeon's career, (2) provide feedback to trainee surgeons regarding areas for improvement, (3) provide the opportunity to investigate what aspects of skill may be linked to patient outcomes which can (4) inform the aspects of surgical skill which should be focused on within training or mentoring programmes. Classifier or assessment algorithms that use artificial intelligence to 'learn' what expertise is from expert surgical evaluators could further assist educators in determining if trainees meet competency thresholds. With collaborative efforts between surgical teams, medical institutions, computer scientists and researchers to ensure this technology is developed with usability and ethics in mind, the developed feedback tools could improve cardiothoracic surgical practice in a data-driven way.
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Affiliation(s)
- Merryn D Constable
- Department of Psychology, Northumbria University, Newcastle-upon-Tyne, UK.
| | - Hubert P H Shum
- Department of Computer Science, Durham University, Durham, UK
| | - Stephen Clark
- Department of Applied Sciences, Northumbria University, Newcastle-upon-Tyne, UK
- Consultant Cardiothoracic and Transplant Surgeon, Freeman Hospital, Newcastle upon Tyne, UK
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Hartung V, Augustin AM, Grunz JP, Huflage H, Hennes JL, Kleefeldt F, Ergün S, Peter D, Lichthardt S, Bley TA, Gruschwitz P. Training for endovascular therapy of acute arterial disease and procedure-related complication: An extracorporeally-perfused human cadaver model study. PLoS One 2024; 19:e0297800. [PMID: 38330071 PMCID: PMC10852297 DOI: 10.1371/journal.pone.0297800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 01/12/2024] [Indexed: 02/10/2024] Open
Abstract
PURPOSE The aim of this study was to evaluate the usability of a recently developed extracorporeally-perfused cadaver model for training the angiographic management of acute arterial diseases and periprocedural complications that may occur during endovascular therapy of the lower extremity arterial runoff. MATERIALS AND METHODS Continuous extracorporeal perfusion was established in three fresh-frozen body donors via inguinal and infragenicular access. Using digital subtraction angiography for guidance, both arterial embolization (e.g., embolization using coils, vascular plugs, particles, and liquid embolic agents) and endovascular recanalization procedures (e.g., manual aspiration or balloon-assisted embolectomy) as well as various embolism protection devices were tested. Furthermore, the management of complications during percutaneous transluminal angioplasty, such as vessel dissection and rupture, were exercised by implantation of endovascular dissection repair system or covered stents. Interventions were performed by two board-certified interventional radiologists and one resident with only limited angiographic experience. RESULTS Stable extracorporeal perfusion was successfully established on both thighs of all three body donors. Digital subtraction angiography could be performed reliably and resulted in realistic artery depiction. The model allowed for repeatable training of endovascular recanalization and arterial embolization procedures with typical tactile feedback in a controlled environment. Furthermore, the handling of more complex angiographic devices could be exercised. Whereas procedural success was be ascertained for most endovascular interventions, thrombectomies procedures were not feasible in some cases due to the lack of inherent coagulation. CONCLUSION The presented perfusion model is suitable for practicing time-critical endovascular interventions in the lower extremity runoff under realistic but controlled conditions.
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Affiliation(s)
- Viktor Hartung
- Department of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Würzburg, Germany
| | - Anne Marie Augustin
- Department of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Würzburg, Germany
| | - Jan-Peter Grunz
- Department of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Würzburg, Germany
| | - Henner Huflage
- Department of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Würzburg, Germany
| | - Jan-Lucca Hennes
- Department of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Würzburg, Germany
| | - Florian Kleefeldt
- Institute of Anatomy and Cell Biology, University of Würzburg, Würzburg, Germany
| | - Süleyman Ergün
- Institute of Anatomy and Cell Biology, University of Würzburg, Würzburg, Germany
| | - Dominik Peter
- Department of General, Visceral, Transplant, Vascular, and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Sven Lichthardt
- Department of General, Visceral, Transplant, Vascular, and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Thorsten Alexander Bley
- Department of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Würzburg, Germany
| | - Philipp Gruschwitz
- Department of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Würzburg, Germany
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Alifu A, Wang H, Chen R. Technical performance scores associate with early prognosis of tetralogy of Fallot repair. Front Pediatr 2024; 12:1274913. [PMID: 38357504 PMCID: PMC10864547 DOI: 10.3389/fped.2024.1274913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/11/2024] [Indexed: 02/16/2024] Open
Abstract
Objective This study aimed to investigate the relationship between technical performance scores (TPS) and the early prognosis of tetralogy of Fallot repair (TOF). Methods A retrospective study was conducted on TOF repair patients at our center from Oct 2017 to Oct 2022. Patients were classified into Class 1 (no residua), Class 2 (minor residua), or Class 3 (major residua) based on TPS derived from predischarge echocardiograms and need for reintervention. Statistical methods were used to assess the association between TPS and early prognosis. Results A total of 75 TOF repair patients (40% female, 60% male) were analyzed and categorized into TPS1 (24%), TPS2 (53.3%), and TPS3 (22.6%) based on pre-discharge echocardiographic findings. The median follow-up time was 7.0 months. The multivariable Cox regression analysis indicated that TPS3 scores are associated with a 12.68-fold increase in risk compared to TPS1 and TPS2 scores [95% CI = 12.68 (0.9∼179.28), P = 0.06]. The Spearman rank correlation analysis revealed a weak positive correlation between TPS classification and low cardiac output syndrome (r = 0.26, P = 0.03). However, there were no significant differences in ICU stay or duration of mechanical ventilation among the groups. Conclusion TPS3 after intracardiac TOF repair is associated with higher risk of early re-intervention, highlighting the importance of close follow-up and monitoring in this patient population. Patients who develop low cardiac output syndrome in the early postoperative period may have residual defects that require prompt identification.
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Affiliation(s)
| | | | - Renwei Chen
- Department of Cardiothoracic Surgery, Hainan Women and Children’s Medical Center, Haikou, Hainan, China
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Kobayashi K, Higgins T, Liu C, Ayodeji M, Wernovsky G, Jonas RA, Ishibashi N. Defining the optimal historical control group for a phase 1 trial of mesenchymal stromal cell delivery through cardiopulmonary bypass in neonates and infants. Cardiol Young 2023; 33:1523-1528. [PMID: 35989537 PMCID: PMC9995118 DOI: 10.1017/s1047951122002633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Mesenchymal Stromal Cell Delivery through Cardiopulmonary Bypass in Pediatric Cardiac Surgery study is a prospective, open-label, single-centre, dose-escalation phase 1 trial assessing the safety/feasibility of delivering mesenchymal stromal cells to neonates/infants during cardiac surgery. Outcomes will be compared with historical data from a similar population. We aim to define an optimal control group for use in the Mesenchymal Stromal Cell Delivery through Cardiopulmonary Bypass in Pediatric Cardiac Surgery trial. METHODS Consecutive patients who underwent a two-ventricle repair without aortic arch reconstruction within the first 6 months of life between 2015 and 2020 were studied using the same inclusion/exclusion criteria as the Phase 1 Mesenchymal Stromal Cell Delivery through Cardiopulmonary Bypass in Pediatric Cardiac Surgery trial (n = 169). Patients were allocated into one of three diagnostic groups: ventricular septal defect type, Tetralogy of Fallot type, and transposition of the great arteries type. To determine era effect, patients were analysed in two groups: Group A (2015-2017) and B (2018-2020). In addition to biological markers, three post-operative scoring methods (inotropic and vasoactive-inotropic scores and the Pediatric Risk of Mortality-III) were assessed. RESULTS All values for three scoring systems were consistent with complexity of cardiac anomalies. Max inotropic and vasoactive-inotropic scores demonstrated significant differences between all diagnosis groups, confirming high sensitivity. Despite no differences in surgical factors between era groups, we observed lower inotropic and vasoactive-inotropic scores in group B, consistent with improved post-operative course in recent years at our centre. CONCLUSIONS Our studies confirm max inotropic and vasoactive-inotropic scores as important quantitative measures after neonatal/infant cardiac surgery. Clinical outcomes should be compared within diagnostic groupings. The optimal control group should include only patients from a recent era. This initial study will help to determine the sample size of future efficacy/effectiveness studies.
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Affiliation(s)
- Kei Kobayashi
- Center for Neuroscience Research and Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC, USA
- Children’s National Heart Institute, Children’s National Hospital, Washington, DC, USA
| | - Tessa Higgins
- Center for Neuroscience Research and Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC, USA
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Christopher Liu
- Center for Neuroscience Research and Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC, USA
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Mobolanle Ayodeji
- Center for Neuroscience Research and Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC, USA
| | - Gil Wernovsky
- Children’s National Heart Institute, Children’s National Hospital, Washington, DC, USA
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Richard A. Jonas
- Center for Neuroscience Research and Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC, USA
- Children’s National Heart Institute, Children’s National Hospital, Washington, DC, USA
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Nobuyuki Ishibashi
- Center for Neuroscience Research and Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC, USA
- Children’s National Heart Institute, Children’s National Hospital, Washington, DC, USA
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Read J, Ridout D, Johnson S, Hoskote A, Sheehan K, Wellman P, Jones A, Wray J, Brown K. Postoperative morbidities with infant cardiac surgery and toddlers' neurodevelopment. Arch Dis Child 2022; 107:922-928. [PMID: 35793944 DOI: 10.1136/archdischild-2021-322756] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 05/04/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate the relationship between morbidities after infant cardiac surgery and neurodevelopment and behaviour at age 2-3 years. DESIGN/SETTING A prospective cohort follow-up study, in four paediatric cardiac centres. We excluded children with known syndromes. Home-based neurodevelopmental assessments using the Bayley Scales of Infant and Toddler Development 3rd Edition (Bayley-III) were undertaken in 81 children and secondary outcome measures of development and behaviour were completed by parents. A further 41 families completed the secondary outcome measures remotely. RESULTS Children were grouped as multiple morbidities/extracorporeal life support (ECLS) (n=19), single morbidities (n=36) and no morbidities (n=59). Group comparisons found that children with multiple morbidities/ECLS, compared with no morbidities, had: (a) lower adjusted mean scores for core Bayley-III composites (none reached the level of statistical significance), with mean differences of cognitive -6.1 (95% CI -12.4 to 0.1) p=0.06, language -9.1 (95% CI -18.6 to 0.3) p=0.06 and motor -4.4 (95% CI -12.0 to 3.1) p=25; (b) greater adjusted odds of at least one low or borderline Bayley-III composite result 4.0 (95% CI 1.0 to 16.0) (p=0.05); (c) greater adjusted risk of an abnormal Ages and Stages Questionnaire (ASQ) result 5.3 (95% CI 1.3 to 21.1) (p=0.03) and a borderline ASQ result 4.9 (95% CI 1.0 to 25.0) (p=0.05); and no difference in the risk of an abnormal Strengths and Difficulties Questionnaire result 1.7 (95% CI 0.3 to 10.4) p=0.58. These outcomes were not statistically different between the single morbidity and no morbidity groups. CONCLUSIONS Children who experience multiple morbidities/ECLS after infant heart surgery are at a greater risk of neurodevelopmental difficulties than their peers who had no complications and should be prioritised for neurodevelopmental follow-up.
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Affiliation(s)
- Julie Read
- Centre for Outcomes and Experience Research in Child Health, Illness and Disability (ORCHID), Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Deborah Ridout
- Paediatric Epidemiology Biostatistics, University College London Institute of Child Health, London, UK
| | - Samantha Johnson
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Aparna Hoskote
- Heart and Lung Division, Great Ormond Street Hospital National Institute Health Research Biomedical Research Centre, London, UK
| | - Karen Sheehan
- Department of Paediatric Cardiology, Bristol Royal Children's Hospital, Bristol, UK
| | - Paul Wellman
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, London, UK
| | - Alison Jones
- Department of Paediatric Intensive Care, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Jo Wray
- Centre for Outcomes and Experience Research in Child Health, Illness and Disability (ORCHID), Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Katherine Brown
- Heart and Lung Division, Great Ormond Street Hospital National Institute Health Research Biomedical Research Centre, London, UK
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Salna M, Anderson BR, Bacha E, Kurlansky P. Nothing changes if nothing changes. Interact Cardiovasc Thorac Surg 2022; 35:6671255. [PMID: 35980295 PMCID: PMC9403298 DOI: 10.1093/icvts/ivac217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Michael Salna
- Division of Cardiac Surgery, Columbia University Irving Medical Center , New York, NY, USA
| | - Brett R Anderson
- Department of Pediatrics, Columbia University Irving Medical Center , New York, NY, USA
| | - Emile Bacha
- Division of Cardiac Surgery, Columbia University Irving Medical Center , New York, NY, USA
| | - Paul Kurlansky
- Division of Cardiac Surgery, Columbia University Irving Medical Center , New York, NY, USA
- Center for Innovation and Outcomes Research, Columbia University Irving Medical Center , New York, NY, USA
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Miana LA, Nathan M, Tenório DF, Manuel V, Guerreiro G, Fernandes N, Campos CVD, Gaiolla PV, Cassar RS, Turquetto A, Amato L, Canêo LF, Daroda LL, Jatene MB, Jatene FB. Translation and Validation of the Boston Technical Performance Score in a Developing Country. Braz J Cardiovasc Surg 2021; 36:589-598. [PMID: 34787990 PMCID: PMC8597612 DOI: 10.21470/1678-9741-2021-0485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction The Technical Performance Score (TPS) was developed and subsequently refined at the Boston Children's Hospital. Our objective was to translate and validate its application in a developing country. Methods The score was translated into the Portuguese language and approved by the TPS authors. Subsequently, we studied 1,030 surgeries from June 2018 to October 2020. TPS could not be assigned in 58 surgeries, and these were excluded. Surgical risk score was evaluated using Risk Adjustment in Congenital Heart Surgery (or RACHS-1). The impact of TPS on outcomes was studied using multivariable linear and logistic regression adjusting for important perioperative covariates. Results Median age and weight were 2.2 (interquartile range [IQR] = 0.5-13) years and 10.8 (IQR = 5.6-40) kilograms, respectively. In-hospital mortality was 6.58% (n=64), and postoperative complications occurred in 19.7% (n=192) of the cases. TPS was categorized as 1 in 359 cases (37%), 2 in 464 (47.7%), and 3 in 149 (15.3%). Multivariable analysis identified TPS class 3 as a predictor of longer hospital stay (coefficient: 6.6; standard error: 2.2; P=0.003), higher number of complications (odds ratio [OR]: 1.84; 95% confidence interval [CI]: 1.1-3; P=0.01), and higher mortality (OR: 3.2; 95% CI: 1.4-7; P=0.004). Conclusion TPS translated into the Portuguese language was validated and showed to be able to predict higher mortality, complication rate, and prolonged postoperative hospital stay in a high-volume Latin-American congenital heart surgery program. TPS is generalizable and can be used as an outcome assessment tool in resource diverse settings.
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Affiliation(s)
- Leonardo A Miana
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Davi Freitas Tenório
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Valdano Manuel
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil.,Cardiovascular Surgery Division, Clínica Girassol, Luanda, Angola
| | - Gustavo Guerreiro
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Natália Fernandes
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Carolina Vieira de Campos
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Paula V Gaiolla
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Renata Sá Cassar
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Aida Turquetto
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Luciana Amato
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Luiz Fernando Canêo
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | | | - Marcelo Biscegli Jatene
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Fabio B Jatene
- Pediatric Cardiology and Cardiovascular Surgery Division, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), Universidade de São Paulo, São Paulo, São Paulo, Brazil
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Hyperlactataemia as a predictor of adverse outcomes post-cardiac surgery in neonates with congenital heart disease. Cardiol Young 2021; 31:1401-1406. [PMID: 33557993 DOI: 10.1017/s1047951121000263] [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: 11/06/2022]
Abstract
OBJECTIVE To evaluate the discriminative ability of hyperlactataemia for early morbidity and mortality in neonates with CHD following cardiac surgery. METHODS Retrospective, observational study of neonates who underwent cardiac surgery on cardiopulmonary bypass at a tertiary care children's hospital from June 2015 to June 2019. The primary predictor was lactate. The primary composite outcome was defined as ≥1 of the following: cardiac arrest or extracorporeal membrane oxygenation within 72 hours or 30-day mortality post-operatively. The secondary outcome was the presence of major residual lesions, according to the Technical Performance Score. RESULTS Of 432 neonates, 28 (6.5%) sustained the composite outcome. On univariate analysis, peak lactate within 48 hours, increase in lactate from ICU admission through 12 hours, and single ventricle physiology were significantly associated with the composite outcome. The peak lactate occurred at a median of 2.9 hours (interquartile range: 1, 35) before the event. Through multi-variable analysis, a multi-variable risk algorithm was created. Predicted probabilities demonstrated an increasing risk based on single ventricle status and delta lactate, ranging from 1.8% (95% CI: 0.9, 3.9) to 52.4% (95% CI: 32.4, 71.7). The model had good discriminative ability for the composite outcome on receiver operating characteristic analysis (area under the curve = 0.79; 95% CI: 0.75, 0.89). Moreover, a peak lactate of 7.3 mmol/l or greater was significantly associated with the presence of a major residual lesion (odds ratios: 5.16, 95% CI: 3.01, 8.87). CONCLUSIONS We present a simple, two-variable model, including delta lactate in the immediate post-operative period and single ventricle status, to prognosticate the risk of early morbidity and mortality in neonates undergoing cardiac surgery for potential intervention.
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Michalowski AK, Gauvreau K, Kaza A, Quinonez L, Hoganson D, Del Nido P, Nathan M. Technical Performance Score: A Predictor of Outcomes After the Norwood Procedure. Ann Thorac Surg 2020; 112:1290-1297. [PMID: 32987019 DOI: 10.1016/j.athoracsur.2020.07.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 07/12/2020] [Accepted: 07/22/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Technical Performance Score (TPS) can predict outcomes after congenital cardiac surgery. We sought to validate TPS as a predictor of both short- and long-term outcomes of the Norwood procedure. METHODS We conducted a retrospective review of patients who underwent the Norwood procedure from 1997 to 2017. We assigned TPS (class 1, no residua; class 2, minor residua; class 3, major residua or reintervention for major residua before discharge) based on subcomponent scores from discharge echocardiograms or unplanned reinterventions, or both. Multivariable Cox or competing risk analysis, adjusted for preoperative patient- and procedure-related covariates, examined the association of TPS with postoperative hospital length of stay, transplant-free survival, and postdischarge reinterventions. RESULTS Among 500 patients, 319 (64%) were male, 54 (11%) were premature, 56 (11%) had noncardiac anomalies/syndromes, 146 (29%) had preoperative risk factors, and 480 (96%) were assigned TPS. On multivariable analysis, class 3 had greater hazard for reinterventions in transplant-free survivors (class 3: subdistribution hazard ratio [HR], 2.06; 95% confidence interval [CI] 1.34-3.16; P = .001) and was associated with increased hospital length of stay vs class 1 (HR, 0.25; 95% CI, 0.18-0.34; P < .001). Transplant-free survival after Norwood surgery was shorter for both class 2 (HR, 2.48; 95% CI, 1.68-3.66; P < .001) and class 3 (HR, 3.29; 95% CI, 2.18-4.95; P < .001). CONCLUSIONS TPS predicts early and late outcomes after Norwood. Absence of residual lesions results in improved long-term prognosis for single-ventricle patients. TPS may improve outcomes after Norwood by identifying patients warranting closer follow-up and potentially earlier reintervention.
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Affiliation(s)
- Anna K Michalowski
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Aditya Kaza
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Luis Quinonez
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - David Hoganson
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Pedro Del Nido
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Meena Nathan
- Department of Surgery, Harvard Medical School, Boston, Massachusetts.
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Bichell DP. Commentary: Technical excellence is necessary but not sufficient. J Thorac Cardiovasc Surg 2020; 160:225-226. [PMID: 32402381 DOI: 10.1016/j.jtcvs.2019.12.008] [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: 12/02/2019] [Accepted: 12/02/2019] [Indexed: 11/27/2022]
Affiliation(s)
- David P Bichell
- Department of Cardiac Surgery, Monroe Carell, Jr, Children's Hospital, Vanderbilt University Medical Center, Nashville, Tenn.
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Shimada M, Hoashi T, Iida J, Ichikawa H. The Impact of Post-Graduate Year of Primary Surgeon on Technical Performance Score in Tetralogy of Fallot Repair. Circ J 2020; 84:495-500. [PMID: 32023573 DOI: 10.1253/circj.cj-19-0800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of this study was to assess the impact of surgeon years of experience on clinical outcomes of tetralogy of Fallot (TOF) repair using technical performance score (TPS), and to investigate the possibility of safe operations by surgical trainees.Methods and Results:We assessed the cases of 159 consecutive patients who underwent TOF repair between 2001 and 2015. Thirteen different primary surgeons performed operations with 41 different first assistants. The primary surgeon and first assistant mean postgraduate years were 19.1±5.1 years (range, 5.7-31.6 years) and 11.2±6.3 years (range, 3.2-36.3 years), respectively. TPS was assigned using pre-discharge echocardiography based on original criteria. Logistic regression analysis was used to examine the factors associated with TPS. TPS could be scored for all patients, 16 of whom were graded as having optimal (10%), 119 as adequate (75%), and 24 as having inadequate (15%) TPS. None of the preoperative and perioperative variables affected TPS. Although neither the primary surgeon nor the first assistant postgraduate years was associated with TPS independently, total primary surgeon and first assistant postgraduate years correlated with TPS (OR, 1.07; 95% CI: 1.01-1.13, P=0.031). CONCLUSIONS Primary surgeon postgraduate years was not associated with TPS for TOF repair. TOF repair can be performed adequately and safely by surgical trainees under the support of highly experienced supervisors.
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Affiliation(s)
- Masatoshi Shimada
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Takaya Hoashi
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Jun Iida
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
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12
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Karamichalis JM. Commentary: Performance, safety monitoring, and needle counts in the operating room. J Thorac Cardiovasc Surg 2020; 161:S0022-5223(20)30198-7. [PMID: 32067789 DOI: 10.1016/j.jtcvs.2020.01.008] [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: 01/01/2020] [Revised: 01/01/2020] [Accepted: 01/02/2020] [Indexed: 11/25/2022]
Affiliation(s)
- John M Karamichalis
- Cardiac Surgery, LeBonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, Tenn.
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13
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Lushaj EB, Bartlett HL, Lamers LJ, Arndt S, Hermsen J, Ralphe JC, Anagnostopoulos PV. Technical Performance Score Predicts Perioperative Outcomes in Complex Congenital Heart Surgery Performed in a Small-to-Medium-Volume Program. Pediatr Cardiol 2020; 41:88-93. [PMID: 31676956 DOI: 10.1007/s00246-019-02226-9] [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: 07/29/2019] [Accepted: 10/15/2019] [Indexed: 11/29/2022]
Abstract
As the quality of surgical outcomes depend on many factors, the development of validated tools to assess the different aspects of complex multidisciplinary teams' performance is crucial. The Technical Performance Score (TPS) has only been validated to correlate with outcomes in large-volume surgical programs. Here we assess the utility of TPS in correlation to perioperative outcomes for complex congenital heart surgeries (CHS) performed in a small-to-medium-volume program. 673 patients underwent CHS from 4/2012 to 12/2017 at our institution. Of those, 122 were STAT 4 and STAT 5. TPS was determined for each STAT 4 and STAT 5 operation using discharge echocardiogram: 1 = optimal, 2 = adequate, 3 = inadequate. Patient outcomes were compared including mortality, length of stay, ventilation times, and adverse events. 69 patients (57%) were neonates, 32 (26%) were infants, 17 (14%) were children, 4 (3%) were adults. TPS class 1 was assigned to 85 (70%) operations, TPS class 2 was assigned to 25 (20%) operations, and TPS class 3 was assigned to 12 (10%) operations. TPS was associated with re-intubation, ICU length of stay, postoperative length of stay, and mortality. TPS did not correlate with unplanned 30-day readmissions, need for reoperation, and inotropic score. Technical performance score was associated with perioperative outcomes and is a useful tool to assess the adequacy of repair for high complexity CHS in a small-to-medium-volume surgical program. TPS should be a part of program review in congenital heart programs of all sizes to identify strategies that may reduce postoperative morbidity and potentially improve long-term outcomes.
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Affiliation(s)
- Entela B Lushaj
- Department of Surgery-Cardiothoracic, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Heather L Bartlett
- Department of Pediatrics-Cardiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Luke J Lamers
- Department of Pediatrics-Cardiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Shannon Arndt
- University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Joshua Hermsen
- Department of Surgery-Cardiothoracic, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - J Carter Ralphe
- Department of Pediatrics-Cardiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Petros V Anagnostopoulos
- Department of Pediatrics-Cardiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA. .,Division of Cardiothoracic Surgery, School of Medicine and Public Health, University of Wisconsin, 600 Highland Avenue, Madison, WI, 53792, USA.
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14
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Nathan M, Trachtenberg FL, Van Rompay MI, Gaynor W, Kanter K, Ohye R, Bacha EA, Tweddell J, Schwartz SM, Minich LL, Mery CM, Colan SD, Levine J, Lambert LM, Newburger JW. The Pediatric Heart Network Residual Lesion Score Study: Design and objectives. J Thorac Cardiovasc Surg 2019; 160:218-223.e1. [PMID: 31870553 DOI: 10.1016/j.jtcvs.2019.10.146] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 10/28/2019] [Accepted: 10/30/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The Residual Lesion Score (RLS) was developed as a novel tool for assessing residual lesions after congenital heart operations based on widely available clinical and echocardiographic characteristics. The RLS ranks postoperative findings as follows: Class 1 (no/trivial residua), Class 2 (minor residua), or Class 3 (major residua or reintervention before discharge for residua). The multicenter prospective RLS study aims to analyze the influence of residual lesions on outcomes in common congenital cardiac operations. We hypothesize that RLS will predict postoperative adverse events, resource utilization, mortality, and reinterventions by 1 year postoperatively. METHODS The study cohort consisted of infants aged ≤12 months undergoing definitive surgery for complete atrioventricular septal defect, tetralogy of Fallot, dextro-transposition of the great arteries with or without intact ventricular septum, single ventricle (Norwood procedure), and coarctation or interrupted/hypoplastic arch with ventricular septal defect. Children with major congenital or acquired extracardiac anomalies that could independently affect the primary end point, which was number of days alive and out of the hospital within 30 days of surgery (60 days for Norwood procedure), were excluded. Secondary outcomes included ≥1 early major postoperative adverse event; days of intensive care unit and hospital stay, and initial and total ventilator time; mortality/transplant after discharge; unplanned reinterventions after discharge; and cost. All analyses will be performed separately by surgical operation. CONCLUSIONS This is the first multicenter prospective validation of a tool for surgical outcome assessment and quality improvement specific to congenital heart surgery.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass.
| | | | | | - William Gaynor
- Division of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Kirk Kanter
- Division of Pediatric Cardiac Surgery, Children's Health Care of Atlanta, Atlanta, Ga
| | - Richard Ohye
- Division of Pediatric Cardiac Surgery, C. S. Mott Children's Hospital, Ann Arbor, Mich
| | - Emile A Bacha
- Division of Cardiothoracic Surgery, New York Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - James Tweddell
- Division of Pediatric Cardiac Surgery, Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
| | - Steven M Schwartz
- Division of Cardiac Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - L LuAnn Minich
- Division of Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School/ Dell Children's Medical Center, Austin, Tex
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Jami Levine
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Linda M Lambert
- Division of Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
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Bellsham-Revell HR, Deri A, Caroli S, Durward A, Miller OI, Mathur S, Saundankar J, Anderson DR, Austin BC, Salih C, Pushparajah K, Simpson JM. Application of the Boston Technical Performance Score to intraoperative echocardiography. Echo Res Pract 2019; 6:63-70. [PMID: 31413860 PMCID: PMC6689121 DOI: 10.1530/erp-19-0032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 07/09/2019] [Indexed: 11/11/2022] Open
Abstract
Background The Technical Performance Score (TPS) developed by Boston Children’s Hospital showed surgical outcomes correlate with adequacy of technical repair when implemented on pre-discharge echocardiograms. We applied this scoring system to intraoperative imaging in a tertiary UK congenital heart surgical centre. Methods After a period of training, intraoperative TPS (epicardial and/or transesophageal echocardiography) was instituted. TPS was used to inform intraoperative discussions and recorded on a custom-made database using the previously published scoring system. After a year, we reviewed the feasibility, results and relationship between the TPS and mortality, extubation time and length of stay. Results From 01 September 2015 to 04 July 2016, there were 272 TPS procedures in 251 operations with 208 TPS recorded. Seven patients had surgery with no documented TPS, three had operations with no current TPS score template available. Patients left the operating theatre with TPS optimal in 156 (75%), adequate 34 (16%) and inadequate 18 (9%). Of those with an optimal score on leaving theatre, ten had more than one period of cardiopulmonary bypass. All four deaths <30 days after surgery (1.9%) had optimal TPS. There was a statistically significant difference in extubation times in the RACHS category 4 patients (3 days vs 5 days, P < 0.05) and in PICU and total length of stay in the RACHS category three patients (2 and 8 days vs 12.5 and 21.5 days respectively) if leaving theatre with an inadequate result. Conclusions Application of intraoperative TPS is feasible and provides a way of objectively recording intraoperative imaging assessment of surgery. An ‘inadequate’ TPS did not predict mortality but correlated with a longer ventilation time and longer length of stay compared to those with optimal or adequate scores.
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Affiliation(s)
| | - Antigoni Deri
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - Silvia Caroli
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - Andrew Durward
- Paediatric Airway Service, Evelina London Children's Hospital, London, UK
| | - Owen I Miller
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - Sujeev Mathur
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - Jelena Saundankar
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - David R Anderson
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - B Conal Austin
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - Caner Salih
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - Kuberan Pushparajah
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK.,Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - John M Simpson
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK.,Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
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16
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Are surgeons reluctant to accurately report intraoperative adverse events? A prospective study of 1,989 patients. Surgery 2018; 164:525-529. [PMID: 29945783 DOI: 10.1016/j.surg.2018.04.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 04/30/2018] [Accepted: 04/30/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND The true incidence of intraoperative adverse events (iAEs) remains unknown. METHODS All patients undergoing abdominal surgery at an academic institution between January and July 2016 were included in a prospective fashion. At the end of surgery, using a secure REDCap database, the surgeon was given the Institute of Medicine definition of intraoperative adverse events and asked whether an intraoperative adverse event had occurred. Blinded reviewers systematically examined all operative reports for intraoperative adverse events and their severity. The response rate and the intraoperative adverse event rate reported by surgeons were calculated. The latter was compared with the rate of intraoperative adverse events detected by operative report review. The severity of intraoperative adverse events was assessed based on a previously validated intraoperative adverse event classification system. RESULTS A total of 1,989 operations were included. The surgeons' response rate was 71.9%, reporting intraoperative adverse events in 107 operations (7.5%). Of those intraoperative adverse events, 26 (24.3%) were not described in the operative report. Operative report review revealed intraoperative adverse events in 417 operations (21.0%). Most injuries were of lower severity (85.8% were either class I or II). The surgeons' response rate was similar in operations with and without intraoperative adverse events (69.8% versus 72.5%, P=.28), but they underreported low severity intraoperative adverse events-only 13.2% of class I compared with 35.3%, 36.8%, and 55.6% of injury classes II, III, and IV respectively (P<.001). CONCLUSION Surgeons are willing to report intraoperative adverse events, but systematically and significantly underreport them, especially if they are of lower severity. This is potentially related to the absence of a clear intraoperative adverse event definition or their personal interpretation of their clinical significance.
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17
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Martin E, Del Nido PJ, Nathan M. Technical performance scores are predictors of midterm mortality and reinterventions following congenital mitral valve repair. Eur J Cardiothorac Surg 2018; 52:218-224. [PMID: 28398542 DOI: 10.1093/ejcts/ezx074] [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: 10/03/2016] [Accepted: 02/25/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The Technical Performance Score (TPS) has been shown to be predictive of postoperative mortality, morbidities and reinterventions following various cardiac procedures in children. We hypothesized that TPS is also a predictor of mitral valve repair outcomes. METHODS A review of patients who underwent mitral valve repair from January 2000 to December 2013 was performed. Primary repair of complete atrioventricular defect was excluded. The scores were determined according to previously published criteria based on the need for reintervention and predischarge echocardiograms: Class 1 (no residua), Class 2 (minor residua) or Class 3 (pacemaker implantation, major residua or reintervention for major residua prior to discharge). Cox proportional hazard models and Kaplan-Meier estimator were used. RESULTS A total of 587 patients underwent mitral repair (median age 2.6 years). Median follow-up duration was 3 years. There were 125 (21.3%) post-discharge mitral reinterventions and freedom from reintervention was 85.2%, 78.2% and 69.4% at 1, 2 and 5 years, respectively. Both TPS Class 2 [hazard ratio (HR) 3.6, 95% confidence interval (CI) 1.4-10.0; P = 0.02] and Class 3 (HR 8.7, 95% CI 3.0-25.1; P < 0.001) were associated with post-discharge reinterventions. There were 31 late deaths/transplantations, and transplant-free survival at 1, 2 and 5 years was 97.8%, 95.3% and 93.2%. TPS 3 was associated with decreased post-discharge transplant-free survival (HR 5.5, 95% CI 1.2-25.0; P = 0.03). Post-discharge mitral reintervention was not associated with increased mortality. CONCLUSIONS The TPS is a strong predictor of midterm mortality and post-discharge mitral reintervention in congenital patients who underwent mitral repair.
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Affiliation(s)
- Elisabeth Martin
- Division of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Université Laval, Quebec City, Quebec, Canada.,Department of Cardiac Surgery, Children's Hospital Boston and Harvard Medical School, Boston, MA, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Children's Hospital Boston and Harvard Medical School, Boston, MA, USA
| | - Meena Nathan
- Department of Cardiac Surgery, Children's Hospital Boston and Harvard Medical School, Boston, MA, USA
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18
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IJsselhof R, Gauvreau K, Del Nido P, Nathan M. Technical Performance Score: Predictor of Outcomes in Complete Atrioventricular Septal Defect Repair. Ann Thorac Surg 2017. [PMID: 28648535 DOI: 10.1016/j.athoracsur.2017.03.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Technical performance score (TPS) has been associated with both early and late outcomes across a wide range of congenital cardiac procedures. We sought to validate TPS as predictor of outcomes for complete atrioventricular septal defect (CAVSD) repair. METHODS This was a single-center retrospective review of patients after balanced CAVSD repair between January 1, 2000, and March 1, 2016. We assigned TPS (class 1, no residua; class 2, minor residua; class 3, major residua or reintervention before discharge for residua) based on summation of subcomponent scores from discharge echocardiograms. Outcomes of interest were in-hospital complications, postoperative days on ventilator, and postdischarge reintervention. RESULTS Among 350 patients, median age was 3.2 months (interquartile range [IQR], 2.4 to 4.2 months). Fifty-four patients (16%) had class 1 TPS, 218 (62%) class 2, 63 (18%) class 3, and 15 (4%) were unscorable. There were 36 complications (10%), and median postoperative days on ventilator were 2 (IQR, 1 to 3) days. There were 34 postdischarge reinterventions (10%). Median follow-up was 2.6 years (IQR, 0.09 to 7.9) years. On multivariable modeling, class 3 TPS was associated with complications (odds ratio 5.45, 95% confidence interval [CI]: 1.06 to 28.1, p = 0.04), prolonged postoperative ventilator days (hazard ratio [HR] 0.54, 95% CI: 0.37 to 0.80, p = 0.002), and postdischarge reintervention (HR 5.61, 95% CI: 1.28 to 24.5, p = 0.02) after adjusting for covariates such as age, weight, genetic abnormality, concomitant procedure, prematurity, and second bypass run. CONCLUSIONS At our center, CAVSD repair was associated with low morbidity. TPS may identify patients with complications, prolonged days on ventilator, and who require postdischarge reinterventions; thus, it provides feedback on areas of improvement and allows identification of patients who warrant closer follow-up.
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Affiliation(s)
| | - Kim Gauvreau
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pedro Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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19
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Lodin D, Mavrothalassitis O, Haberer K, Sunderji S, Quek RGW, Peyvandi S, Moon-Grady A, Karamlou T. Revisiting the utility of technical performance scores following tetralogy of Fallot repair. J Thorac Cardiovasc Surg 2017; 154:585-595.e3. [PMID: 28461051 DOI: 10.1016/j.jtcvs.2017.02.066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 01/18/2017] [Accepted: 02/08/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Although an important quality metric, current technical performance scores may not be generalizable and may omit operative factors that influence outcomes. We examined factors not included in current technical performance scores that may contribute to increased postoperative length of stay, major complications, and cost after primary repair of tetralogy of Fallot. METHODS This is a retrospective single site study of patients younger than age 2 years with tetralogy of Fallot undergoing complete repair between 2007 and 2015. Medical record data and discharge echocardiograms were reviewed to ascertain component and composite technical performance scores. Primary outcomes included postoperative length of stay, major complications, and total hospital costs. Multivariable logistic and linear regression identified determinants of each outcome. RESULTS Patient population (n = 115) had a median postoperative length of stay of 8 days (interquartile range, 6-10 days), and a median total cost of $71,147. Major complications occurred in 33 patients (29%) with 1 death. Technical performance scores assigned were optimum in 28 patients (25%), adequate in 59 patients (52%), and inadequate in 26 patients (23%). Neither technical performance score components nor composite scores were associated with increased postoperative length of stay. Optimum or adequate repairs versus inadequate had equal risk of a complication (P = .79), and equivalent mean total cost ($100,000 vs $187,000; P = .25). Longer cardiopulmonary bypass time per 1-minute increase (P < .01) was associated with longer postoperative length of stay and reintervention (P = .02). The need to return to bypass also increased total cost (P < .01). CONCLUSIONS Current tetralogy of Fallot technical performance scores were not associated with selected outcomes in our postoperative population. Although returning to bypass and bypass length are not included as components in the current score, these are important factors influencing complications and resource use in our population. Revisions anticipated from a prospective trial should consider including these variables.
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Affiliation(s)
- Daud Lodin
- San Juan Bautista School of Medicine, Caguas, Puerto Rico
| | | | - Kim Haberer
- Division of Pediatric Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, Calif
| | - Sherzana Sunderji
- Division of Pediatric Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, Calif
| | - Ruben G W Quek
- Global Health Economics, Amgen Inc, Thousand Oaks, Calif
| | - Shabnam Peyvandi
- Division of Pediatric Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, Calif
| | - Anita Moon-Grady
- Division of Pediatric Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, Calif
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery, Phoenix Children's Hospital, Phoenix, Ariz.
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20
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Vedula SS, Ishii M, Hager GD. Objective Assessment of Surgical Technical Skill and Competency in the Operating Room. Annu Rev Biomed Eng 2017; 19:301-325. [PMID: 28375649 DOI: 10.1146/annurev-bioeng-071516-044435] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Training skillful and competent surgeons is critical to ensure high quality of care and to minimize disparities in access to effective care. Traditional models to train surgeons are being challenged by rapid advances in technology, an intensified patient-safety culture, and a need for value-driven health systems. Simultaneously, technological developments are enabling capture and analysis of large amounts of complex surgical data. These developments are motivating a "surgical data science" approach to objective computer-aided technical skill evaluation (OCASE-T) for scalable, accurate assessment; individualized feedback; and automated coaching. We define the problem space for OCASE-T and summarize 45 publications representing recent research in this domain. We find that most studies on OCASE-T are simulation based; very few are in the operating room. The algorithms and validation methodologies used for OCASE-T are highly varied; there is no uniform consensus. Future research should emphasize competency assessment in the operating room, validation against patient outcomes, and effectiveness for surgical training.
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Affiliation(s)
- S Swaroop Vedula
- Malone Center for Engineering in Healthcare, Department of Computer Science, The Johns Hopkins University Whiting School of Engineering, Baltimore, Maryland 21218;
| | - Masaru Ishii
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287
| | - Gregory D Hager
- Malone Center for Engineering in Healthcare, Department of Computer Science, The Johns Hopkins University Whiting School of Engineering, Baltimore, Maryland 21218;
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22
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Association of Extracorporeal Membrane Oxygenation Support Adequacy and Residual Lesions With Outcomes in Neonates Supported After Cardiac Surgery. Pediatr Crit Care Med 2016; 17:1045-1054. [PMID: 27648896 DOI: 10.1097/pcc.0000000000000943] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES There is a paucity of data regarding the impact of extracorporeal membrane oxygenation support, adequacy of surgical repair, and timing of intervention for residual structural lesions in neonates cannulated to extracorporeal membrane oxygenation after cardiac surgery. Our goal was to determine how these factors were associated with survival. DESIGN Retrospective study. SETTING Cardiovascular ICU. SUBJECTS Neonates (≤ 28 d old) with congenital heart disease cannulated to extracorporeal membrane oxygenation after cardiac surgery during 2006-2013. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eighty-four neonates were cannulated to venoarterial extracorporeal membrane oxygenation after cardiac surgery. Survival to discharge was 50%. There was no difference in survival based on surgical complexity and those with single or biventricular congenital heart disease. Prematurity (≤ 36 wk gestation; odds ratio, 2.33; p = 0.01), preextracorporeal membrane oxygenation pH less than or equal to 7.17 (odds ratio, 2.01; p = 0.04), need for inotrope support during extracorporeal membrane oxygenation (odds ratio, 3.99; p = 0.03), and extracorporeal membrane oxygenation duration greater than 168 hours (odds ratio, 2.04; p = 0.04) were all associated with increased mortality. Although preextracorporeal membrane oxygenation lactate was not significantly different between survivors and nonsurvivors, unresolved lactic acidosis greater than or equal to 72 hours after cannulation (odds ratio, 2.77; p = 0.002) was associated with increased mortality. Finally, many patients (n = 70; 83%) were noted to have residual lesions after cardiac surgery, and time to diagnosis or correction of residual lesions was significantly shorter in survivors (1 vs 2 d; p = 0.02). CONCLUSIONS Our data suggest that clearance of lactate is an important therapeutic target for patients cannulated to extracorporeal membrane oxygenation. In addition, timely identification of residual lesions and expedient interventions on those lesions may improve survival.
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23
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Outcomes of neonates requiring prolonged stay in the intensive care unit after surgical repair of congenital heart disease. J Thorac Cardiovasc Surg 2016; 152:720-727.e1. [DOI: 10.1016/j.jtcvs.2016.04.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 04/08/2016] [Accepted: 04/13/2016] [Indexed: 12/31/2022]
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24
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Overman DM. Neonatal outcomes and length of stay: A firm grasp of the obvious? J Thorac Cardiovasc Surg 2016; 152:727-8. [PMID: 27378735 DOI: 10.1016/j.jtcvs.2016.05.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 05/31/2016] [Indexed: 10/21/2022]
Affiliation(s)
- David M Overman
- Division of Cardiac Surgery, The Children's Heart Clinic and Division of Cardiovascular Surgery, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minn.
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25
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Cunningham MEA, Donofrio MT, Peer SM, Zurakowski D, Jonas R, Sinha P. Influence of Age and Weight on Technical Repair of Tetralogy of Fallot. Ann Thorac Surg 2016; 102:864-869. [PMID: 27154147 DOI: 10.1016/j.athoracsur.2016.02.087] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 02/21/2016] [Accepted: 02/25/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND We have previously shown that early primary repair of tetralogy of Fallot can be performed without increased morbidity or resource utilization. The technical performance score (TPS) is a self-assessment tool used to identify patients at risk of poor postoperative outcomes. We hypothesized that adequate technical repair can be obtained regardless of the patient's preoperative age or size. METHODS A retrospective review of all tetralogy of Fallot patients repaired between September 2004 and December 2013 was performed. The postoperative predischarge echocardiogram was reviewed to assign a TPS rating of optimal, adequate, or inadequate. The TPS groups were compared by univariate analysis using the Kruskal-Wallis test for continuous variables and χ(2) analysis for categoric variables. Multivariable logistic regression analysis was performed to identify independent predictors of inadequate TPS. RESULTS Among 167 patients (1 operative mortality), TPS was optimal in 88, adequate in 62, and inadequate in 17. Patients with worse TPS had longer ventilation time (p = 0.031), hospital length of stay (p = 0.036), and higher hospital charges (p = 0.005). Multivariable regression analysis revealed discontinuous branch pulmonary arteries (odds ratio 18.24, 95% confidence interval: 1.42 to 234, p = 0.015) as the only independent predictor of inadequate TPS. Younger age at repair (p = 0.245) and smaller weight (p = 0.260) were not associated with inadequate TPS. CONCLUSIONS Technical adequacy of tetralogy of Fallot repair is affected by anatomic subsets (discontinuous branch pulmonary arteries) and not by the patient's age or size. Worse TPS is associated with higher postoperative morbidity and hospital charges. Younger age and size should not be a deterrent for early primary repair.
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Affiliation(s)
| | - Mary T Donofrio
- Department of Cardiology, Children's National Health System, Washington, DC
| | - Syed Murfad Peer
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC
| | - David Zurakowski
- Departments of Anesthesia and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Richard Jonas
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC
| | - Pranava Sinha
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC.
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Parthiban A, Levine JC, Nathan M, Marshall JA, Shirali GS, Simon SD, Colan SD, Newburger JW, Raghuveer G. Impact of Variability in Echocardiographic Interpretation on Assessment of Adequacy of Repair Following Congenital Heart Surgery: A Pilot Study. Pediatr Cardiol 2016; 37:144-50. [PMID: 26358473 DOI: 10.1007/s00246-015-1256-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 08/24/2015] [Indexed: 10/23/2022]
Abstract
Technical Performance Score (TPS) is based largely on the presence and magnitude of residual lesions on postoperative echocardiograms; this score correlates with outcomes following repair of congenital heart defects. We evaluated reader variability for echocardiographic components of TPS for complete repair of tetralogy of Fallot (TOF) and arterial switch operation (ASO) in two centers and measured its effect on TPS. Postoperative echocardiograms were evaluated in 67 children (39 TOF and 28 ASO). Two readers (one per center) interpreted each echocardiogram. Reader variability in image quality assessments and measurements was compared using weighted kappa (κ), percent agreement, and intra-class correlation. TPS class (1 optimal-no residua, 2 adequate-minor residua, 3 inadequate-major residua) was assigned for each echocardiographic review by an independent investigator. The effect of reader interpretation variability on TPS classification was measured. There was strong agreement for TPS between the two readers (κ = 0.88). The readers were concordant for TPS classes for 57 children (85%) and discordant for classes 2 (minor residua) versus 3 (major residua) in six (9%). Coronary arteries and branch pulmonary arteries were frequently suboptimally visualized. Although inter-reader agreement for TPS was strong, inter-reader variation in echocardiographic interpretations had a small, but important effect on TPS for TOF and ASO, particularly for the distinction between minor and major residua. Further studies of generalizability and reproducibility of TPS and refinement of scoring modules may be needed before it can be used as a tool to assess pediatric cardiac surgical performance and outcomes.
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Affiliation(s)
- Anitha Parthiban
- Heart Center, Children's Mercy Hospital, University of Missouri Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO, 64108, USA.
| | - Jami C Levine
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA.,Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Meena Nathan
- Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA.,Department of Cardiac Surgery, Boston Children's Hospital, Bader 665, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Jennifer A Marshall
- Heart Center, Children's Mercy Hospital, University of Missouri Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Girish S Shirali
- Heart Center, Children's Mercy Hospital, University of Missouri Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Stephen D Simon
- Department of Biostatistics, University of Missouri Kansas City School of Medicine, 2411 Holmes street, Kansas City, MO, 64108, USA
| | - Steve D Colan
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA.,Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA.,Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Geetha Raghuveer
- Heart Center, Children's Mercy Hospital, University of Missouri Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO, 64108, USA
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Fraser J. The morbidity and mortality meeting: time for a different approach? Arch Dis Child 2016; 101:4-8. [PMID: 26566689 DOI: 10.1136/archdischild-2015-309536] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 10/17/2015] [Indexed: 11/04/2022]
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Affiliation(s)
- James A DiNardo
- Division of Cardiac Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA.
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Nathan M, Sleeper LA, Ohye RG, Frommelt PC, Caldarone CA, Tweddell JS, Lu M, Pearson GD, Gaynor JW, Pizarro C, Williams IA, Colan SD, Dunbar-Masterson C, Gruber PJ, Hill K, Hirsch-Romano J, Jacobs JP, Kaltman JR, Kumar SR, Morales D, Bradley SM, Kanter K, Newburger JW. Technical performance score is associated with outcomes after the Norwood procedure. J Thorac Cardiovasc Surg 2014; 148:2208-13, 2214.e1-6. [PMID: 25037617 PMCID: PMC4253672 DOI: 10.1016/j.jtcvs.2014.05.076] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 04/30/2014] [Accepted: 05/29/2014] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The technical performance score (TPS) has been reported in a single center study to predict the outcomes after congenital cardiac surgery. We sought to determine the association of the TPS with outcomes in patients undergoing the Norwood procedure in the Single Ventricle Reconstruction trial. METHODS We calculated the TPS (class 1, optimal; class 2, adequate; class 3, inadequate) according to the predischarge echocardiograms analyzed in a core laboratory and unplanned reinterventions that occurred before discharge from the Norwood hospitalization. Multivariable regression examined the association of the TPS with interval to first extubation, Norwood length of stay, death or transplantation, unplanned postdischarge reinterventions, and neurodevelopment at 14 months old. RESULTS Of 549 patients undergoing a Norwood procedure, 356 (65%) had an echocardiogram adequate to assess atrial septal restriction or arch obstruction or an unplanned reintervention, enabling calculation of the TPS. On multivariable regression, adjusting for preoperative variables, a better TPS was an independent predictor of a shorter interval to first extubation (P=.019), better transplant-free survival before Norwood discharge (P<.001; odds ratio, 9.1 for inadequate vs optimal), shorter hospital length of stay (P<.001), fewer unplanned reinterventions between Norwood discharge and stage II (P=.004), and a higher Bayley II psychomotor development index at 14 months (P=.031). The TPS was not associated with transplant-free survival after Norwood discharge, unplanned reinterventions after stage II, or the Bayley II mental development index at 14 months. CONCLUSIONS TPS is an independent predictor of important outcomes after Norwood and could serve as a tool for quality improvement.
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Affiliation(s)
- Meena Nathan
- Children's Hospital Boston and Harvard Medical School, Boston, Mass.
| | | | | | - Peter C Frommelt
- Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wis
| | | | - James S Tweddell
- Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wis
| | - Minmin Lu
- New England Research Institutes, Watertown, Mass
| | - Gail D Pearson
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | - J William Gaynor
- Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia, Pa
| | | | - Ismee A Williams
- Morgan Stanley Children's Hospital of NewYork-Presbyterian, New York, NY
| | - Steven D Colan
- Children's Hospital Boston and Harvard Medical School, Boston, Mass; New England Research Institutes, Watertown, Mass
| | | | - Peter J Gruber
- University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | | | - Jeffrey P Jacobs
- Johns Hopkins All Children's Heart Institute, St Petersburg, Fla
| | - Jonathan R Kaltman
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | - S Ram Kumar
- Children's Hospital Los Angeles, Los Angeles, Calif
| | - David Morales
- Cincinnati Children's Medical Center, Cincinnati, Ohio
| | | | | | - Jane W Newburger
- Children's Hospital Boston and Harvard Medical School, Boston, Mass
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Nathan M, Gauvreau K, Liu H, Pigula FA, Mayer JE, Colan SD, Del Nido PJ. Outcomes differ in patients who undergo immediate intraoperative revision versus patients with delayed postoperative revision of residual lesions in congenital heart operations. J Thorac Cardiovasc Surg 2014; 148:2540-6.e1-5. [PMID: 25173124 DOI: 10.1016/j.jtcvs.2014.07.073] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 07/07/2014] [Accepted: 07/20/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVES In a previous study of infants less than 6 month old, we found that delayed revision of residual lesions resulted in worse patient outcomes compared with intraoperative revision. We explored a larger cohort to determine if this finding persisted. METHODS A prospective cohort followed from index surgery to discharge from January 2011 to September 2013 were divided into 4 groups: (1) intraoperative revisions (IO) of residual lesions, (2) delayed postoperative revision (PO) of residual lesions during the same hospital stay, (3) both intraoperative and delayed (BOTH) revision of residual lesions, (4) no intraoperative or postoperative revision (NO). Linear and logistic regression analyses were used to compare outcomes of postoperative hospital length of stay, postoperative adverse events (AE), hospital costs, and mortality, after adjusting for age, prematurity, presence of extracardiac anomalies, and RACHS-1 (Risk Adjustment for Congenital Heart Surgery-1) risk category known to affect outcomes. RESULTS Of the 2427 patients discharged after a congenital cardiac operation, 1886 were eligible for this study after exclusion of adults, procedures performed off cardiopulmonary bypass, and transplants and assist devices. On multivariable modeling adjusting for other significant patient factors, the NO group fared better than the other 3 groups. The IO group had significantly lower postoperative length of stay, AE rate, and hospital costs compared with the PO and BOTH groups, but showed no significant differences in mortality. CONCLUSIONS Intraoperative correction of residual lesions results in shorter length of stay, and lower postoperative AE and costs compared with delayed postoperative revision of residual lesions.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Mass.
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Mass
| | - Hua Liu
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Mass
| | - Frank A Pigula
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Mass
| | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Mass
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Mass
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Mass
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Chen JM. Editorial Commentary: Technical Performance Anxiety: Utility of the Technical Performance Scale in Predicting Later Intervention After Repair of Tetralogy of Fallot. Semin Thorac Cardiovasc Surg 2014; 26:304-5. [DOI: 10.1053/j.semtcvs.2015.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2015] [Indexed: 11/11/2022]
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Association between Technical Performance Scores and neurodevelopmental outcomes after congenital cardiac surgery. J Thorac Cardiovasc Surg 2013; 148:232-237.e3. [PMID: 24084277 DOI: 10.1016/j.jtcvs.2013.08.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 07/29/2013] [Accepted: 08/11/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Technical Performance Score (TPS) has been shown to have a strong association with early and late outcomes after congenital cardiac surgery, with greater morbidity and reintervention in children with major residual lesions (TPS class 3). We sought to explore the effect of TPS on the neurodevelopmental outcomes. METHODS All infants undergoing cardiac surgery, excluding those with trisomy 21, were offered neurodevelopmental testing at 1 year of age using the Bayley Scales of Infant Development, 3rd edition. TPSs from the discharge echocardiograms were graded as class 1 (optimal), class 2 (minor residual), or class 3 (major residual). Multivariate regression analysis was performed using patient characteristics and preoperative variables. RESULTS Neurodevelopmental testing was performed in 140 patients at a median age of 16 months. Of these, 28 (20%) had single ventricle palliation; 39 (28%) were in Risk Adjustment for Congenital Heart Surgery category 4 to 6. Significant differences between the groups were found in the cognitive (P = .01) and motor (P = .05) domains, with subjects in TPS class 3 having significantly lower cognitive and motor composite scores. The scores did not vary significantly according to single ventricle versus biventricular repair or Risk Adjustment for Congenital Heart Surgery categorization. In multivariate modeling, class 3 TPS remained significantly associated with a lower Bayley cognitive score (P = .02), with a trend toward a lower Bayley motor score (P = .08). CONCLUSIONS We found that TPS is an independent predictor of neurodevelopmental outcomes after infant heart surgery. Future research should explore whether a structured program of intraoperative recognition and intervention on residual lesions can improve the TPS and neurodevelopmental outcomes.
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Nathan M, Karamichalis J, Liu H, Gauvreau K, Colan S, Saia M, Pigula F, Fynn-Thompson F, Emani S, Baird C, Mayer JE, del Nido PJ. Technical Performance Scores are strongly associated with early mortality, postoperative adverse events, and intensive care unit length of stay-analysis of consecutive discharges for 2 years. J Thorac Cardiovasc Surg 2013; 147:389-94, 396.e1-396.e3. [PMID: 24035318 DOI: 10.1016/j.jtcvs.2013.07.044] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Revised: 06/20/2013] [Accepted: 07/16/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Previous work in our institution has indicated that the Technical Performance Score (TPS) is highly associated with early outcomes in select subsets of procedures and age groups. We hypothesized that the TPS could predict early outcomes in a wide range of diagnoses and age groups. METHODS Consecutive patients discharged from January 2011 to March 2013 were prospectively evaluated. The TPS was assigned according to the discharge echocardiographic findings and the need for reinterventions in the anatomic area of interest. Case complexity was determined using Risk Adjustment for Congenital Heart Surgery (RACHS-1) categories. Early mortality and postoperative adverse events were recorded. Relationships between the TPS and outcomes were assessed after adjusting for the baseline patient characteristics. RESULTS The median age of the 1926 patients was 1.8 years (range, 0 days to 68 years). Bypass was used in 1740 (90%); 322 (17%) were neonates, 520 (27%) infants, 873 (45%) children, 211 (11%) adults. TPS was class 1 (optimal) in 956 (50%), class 2 (adequate) in 584 (30%), and class 3 (inadequate) in 226 (12%); 160 patients (8%) could not be scored. A total of 51 early deaths (2.6%) and 111 adverse events (5.7%) occurred. On univariate analysis, age, RACHS-1 category, and TPS were significantly associated with mortality and the occurrence of adverse events. On multivariate modeling, class 3 (inadequate) TPS was strongly associated with mortality (odds ratio, 16.9; 95% confidence interval, 6.7-42.9; P < .001), adverse events (odds ratio, 6.9; 95% confidence interval, 4.1-11.6; P < .001), and postoperative intensive care unit length of stay (coefficient, 2.3; 95% confidence interval, 2.0-2.6; P < .001) after adjusting for other covariates. CONCLUSIONS The TPS is strongly associated with early outcomes across a wide range of ages and disease complexity and can serve as important tool for self-assessment and quality improvement.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass.
| | - John Karamichalis
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Hua Liu
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Kimberley Gauvreau
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Steven Colan
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Matthew Saia
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Frank Pigula
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Francis Fynn-Thompson
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Christopher Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - John E Mayer
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Pedro J del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
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Nathan M, Pigula FA, Liu H, Gauvreau K, Colan SD, Fynn-Thompson F, Emani S, Baird CA, Mayer JE, Del Nido PJ. Inadequate technical performance scores are associated with late mortality and late reintervention. Ann Thorac Surg 2013; 96:664-9. [PMID: 23782646 DOI: 10.1016/j.athoracsur.2013.04.043] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 04/10/2013] [Accepted: 04/15/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND We have shown previously that technical performance score (TPS) is strongly associated with early mortality and major postoperative adverse events in a diverse group of patients. We now report evaluation of the validity of TPS in predicting late outcomes in the same group of patients. METHODS Patients who underwent surgery between June 1, 2005 and June 30, 2006 were included. The TPS were assigned based on discharge echocardiograms and certain clinical criteria as previously described. Follow-up data for up to 4 years were retrospectively collected. Cox proportional hazards models were used for analysis. RESULTS A total of 679 patients were included in the analysis. One hundred twenty-three (18%) were neonates, 213 (31%) infants, 291 (435) children, and 52 (8%) adults. Four hundred ninety-one (72%) were in low-risk adjustment in congenital heart surgery (RACHS; 1 to 3), 109 (16%) in high risk (4 to 6), and 27 (4%) were less than 18 years and could not be assigned a RACHS score. Three hundred thirty-one (48%) had an optimal TPS, 283 (42%) adequate, 61 (9%) inadequate, and 4 (1%) could not be scored. There were 34 (5%) late deaths and 149 (22%) late unplanned reinterventions. By univariate analysis, age, RACHS-1 categories, and TPS were all significantly associated with late reintervention (p < 0.001 for all), while TPS and RACHS-1 were significant factors for mortality (p < 0.001). On multivariable modeling, inadequate TPS was strongly associated with both late mortality (p = 0.001; HR [hazard ratio] 3.8, CI [confidence interval] 1.7 to 8.4) and late reintervention (p = 0.002, HR 2.1, CI 1.3 to 3.3) after controlling for RACHS-1 and age. CONCLUSIONS The TPS has a strong association with late outcomes across a wide range of age and disease complexity and may serve as a tool to identify patients who are at a higher risk for late reintervention or mortality.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts 02215, USA.
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Jacques F, Anand V, Hickey EJ, Kotani Y, Yadava M, Alghamdi A, Caldarone CA, Redington AN, Schwartz S, Van Arsdell GS. Medical errors: The performance gap in hypoplastic left heart syndrome and physiologic equivalents? J Thorac Cardiovasc Surg 2013; 145:1465-73; discussion 1473-5. [DOI: 10.1016/j.jtcvs.2012.12.065] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 11/26/2012] [Accepted: 12/18/2012] [Indexed: 10/27/2022]
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Nathan M, Karamichalis JM, Liu H, Emani S, Baird C, Pigula F, Colan S, Thiagarajan RR, Bacha EA, Del Nido P. Surgical technical performance scores are predictors of late mortality and unplanned reinterventions in infants after cardiac surgery. J Thorac Cardiovasc Surg 2012; 144:1095-1101.e7. [PMID: 22939862 DOI: 10.1016/j.jtcvs.2012.07.081] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Revised: 05/29/2012] [Accepted: 07/30/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We have previously shown that surgical Technical Performance Scores (TPS) are important predictors of early postoperative morbidity across a wide spectrum of procedures and that intraoperative recognition and intervention of residual defects resulted in improved outcomes. We hypothesized that these scores would also be important predictors of midterm outcomes. METHODS Neonates and infants aged younger 6 months were prospectively followed from the index surgery for a minimum of 1 year. The TPS were calculated using previously published criteria, including intraoperative course, predischarge echocardiograms or catheterizations, and clinical data, and graded as optimal, adequate, or inadequate. Case complexity was determined by the Risk Adjustment for Congenital Heart Surgery-1 category. The primary outcome was mortality, and the secondary outcome was the need for unplanned reinterventions. Outcomes were analyzed using nonparametric methods and a logistic regression model. RESULTS A total of 166 patients were included in our study, with 7 early deaths. The remaining 159 patients (Risk Adjustment for Congenital Heart Surgery-1 category 4-6, 76 [48%]; neonates, 78 [49%]) were followed for a minimum of 1 year after surgery. There were 14 late deaths or late transplantations and 55 late reinterventions. On univariate analysis, the TPS were associated with mortality (P < .001) and reintervention (P = .04). On logistic regression analysis, inadequate TPS was associated with late mortality (P < .001; odds ratio, 7.2; 95% confidence interval, 2.2-23.6), and Risk Adjustment for Congenital Heart Surgery-1 category (P = .004; odds ratio, 3.7; 1.5-8.8) at index surgery was associated with need for late unplanned reintervention. CONCLUSIONS Technical performance affects midterm survival after infant heart surgery. Inadequate TPS can be used to prospectively identify patients at ongoing risk of demise and the need for reintervention. An aggressive approach to diagnosing and treating residual lesions at the initial operation is warranted.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Children's Hospital Boston and Harvard Medical School, Boston, MA, USA.
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Karamichalis JM, Colan SD, Nathan M, Pigula FA, Baird C, Marx G, Emani SM, Geva T, Fynn-Thompson FE, Liu H, Mayer JE, del Nido PJ. Technical performance scores in congenital cardiac operations: a quality assessment initiative. Ann Thorac Surg 2012; 94:1317-23; discussion 1323. [PMID: 22795058 DOI: 10.1016/j.athoracsur.2012.05.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Revised: 04/27/2012] [Accepted: 05/02/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Technical performance in congenital cardiac operations and its association with clinical outcomes was previously examined in infants and neonates. The purpose of this study was the development and implementation of a system for measuring technical performance in the majority of congenital cardiac operations to be used as a surgeon's self-assessment tool. METHODS Using the methodologic framework piloted at our institution, measures of technical performance were created for more than 90% of all congenital cardiac operations. Each operation was divided into multiple subprocedures to be assessed separately. Criteria for technical scores were created using a consensus panel of senior clinicians and were based primarily on the predischarge echocardiographic findings and need for early postoperative reinterventions. This system of procedure modules was then piloted by prospectively assigning technical scores to all patients undergoing operations. RESULTS Thirty modules were created covering more than 90% of the cardiac operations performed. One hundred eighty-five patients were enlisted. One hundred one (54.6%) cases were scored as class 1 (highest), 46 (24.9%) cases as class 2, 22 (11.9%) cases as class 3 (lowest); 16 cases (8.6%) could not be scored. The results were further analyzed by RACHS (Risk Adjustment for Congenital Heart Surgery) categories and outcomes. Valve-procedure-specific criteria were calibrated to reflect specific echocardiographic measurements. CONCLUSIONS The development and implementation of a broad technical performance self-assessment system for congenital cardiac operations is possible. Based on this scoring system, the impact of a less than optimal (2 or 3) technical score depends on case risk category, with higher mortality in the higher risk group, and increased resource use for lower risk procedures.
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Affiliation(s)
- John M Karamichalis
- Department of Cardiac Surgery, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts, USA.
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