1
|
Schneider K, de Loizaga S, Beck AF, Morales DLS, Seo J, Divanovic A. Socioeconomic Influences on Outcomes Following Congenital Heart Disease Surgery. Pediatr Cardiol 2024; 45:1072-1078. [PMID: 38472658 PMCID: PMC11056327 DOI: 10.1007/s00246-024-03451-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/12/2024] [Indexed: 03/14/2024]
Abstract
Associations between social determinants of health (SDOH) and adverse outcomes for children with congenital heart disease (CHD) are starting to be recognized; however, such links remain understudied. We examined the relationship between community-level material deprivation on mortality, readmission, and length of stay (LOS) for children undergoing surgery for CHD. We performed a retrospective cohort study of patients who underwent cardiac surgery at our institution from 2015 to 2018. A community-level deprivation index (DI), a marker of community material deprivation, was generated to contextualize the lived experience of children with CHD. Generalized mixed-effects models were used to assess links between the DI and outcomes of mortality, readmission, and LOS following cardiac surgery. The DI and components were scaled to provide mean differences for a one standard deviation (SD) increase in deprivation. We identified 1,187 unique patients with surgical admissions. The median LOS was 11 days, with an overall mortality rate of 4.6% and readmission rate of 7.6%. The DI ranged from 0.08 to 0.85 with a mean of 0.37 (SD 0.12). The DI was associated with increased LOS for patients with more complex heart disease (STAT 3, 4, and 5), which persisted after adjusting for factors that could prolong LOS (all p < 0.05). The DI approached but did not meet a significant association with mortality (p = 0.0528); it was not associated with readmission (p = 0.36). Community-level deprivation is associated with increased LOS for patients undergoing cardiac surgery. Future work to identify the specific health-related social needs contributing to LOS and identify targets for intervention is needed.
Collapse
Affiliation(s)
- Kristin Schneider
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Sarah de Loizaga
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew F Beck
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Divisions of General & Community Pediatrics and Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David L S Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - JangDong Seo
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA
| | - Allison Divanovic
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| |
Collapse
|
2
|
Kim AY, Woo W, Saxena A, Tanidir IC, Yao A, Kurniawati Y, Thakur V, Shin YR, Shin JI, Jung JW, Barron DJ. Treatment of hypoplastic left heart syndrome: a systematic review and meta-analysis of randomised controlled trials. Cardiol Young 2024; 34:659-666. [PMID: 37724575 DOI: 10.1017/s1047951123002986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
BACKGROUND This meta-analysis aimed to consolidate existing data from randomised controlled trials on hypoplastic left heart syndrome. METHODS Hypoplastic left heart syndrome specific randomised controlled trials published between January 2005 and September 2021 in MEDLINE, EMBASE, and Cochrane databases were included. Regardless of clinical outcomes, we included all randomised controlled trials about hypoplastic left heart syndrome and categorised them according to their results. Two reviewers independently assessed for eligibility, relevance, and data extraction. The primary outcome was mortality after Norwood surgery. Study quality and heterogeneity were assessed. A random-effects model was used for analysis. RESULTS Of the 33 included randomised controlled trials, 21 compared right ventricle-to-pulmonary artery shunt and modified Blalock-Taussig-Thomas shunt during the Norwood procedure, and 12 regarded medication, surgical strategy, cardiopulmonary bypass tactics, and ICU management. Survival rates up to 1 year were superior in the right ventricle-to-pulmonary artery shunt group; this difference began to disappear at 3 years and remained unchanged until 6 years. The right ventricle-to-pulmonary artery shunt group had a significantly higher reintervention rate from the interstage to the 6-year follow-up period. Right ventricular function was better in the modified Blalock-Taussig-Thomas shunt group 1-3 years after the Norwood procedure, but its superiority diminished in the 6-year follow-up. Randomised controlled trials regarding medical treatment, surgical strategy during cardiopulmonary bypass, and ICU management yielded insignificant results. CONCLUSIONS Although right ventricle-to-pulmonary artery shunt appeared to be superior in the early period, the two shunts applied during the Norwood procedure demonstrated comparable long-term prognosis despite high reintervention rates in right ventricle-to-pulmonary artery shunt due to pulmonary artery stenosis. For medical/perioperative management of hypoplastic left heart syndrome, further randomised controlled trials are needed to deliver specific evidence-based recommendations.
Collapse
Affiliation(s)
- A Y Kim
- Division of Pediatric Cardiology, Department of Pediatrics, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - W Woo
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - A Saxena
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - I C Tanidir
- Department of Pediatric Cardiology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - A Yao
- Department of Health Service Promotion, University of Tokyo, Japan
| | - Y Kurniawati
- Department of Pediatric Cardiology, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - V Thakur
- Department of Pediatrics, Labatt Family Heart Center, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Y R Shin
- Department of Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - J I Shin
- Department of Pediatrics, Labatt Family Heart Center, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Severance Underwood Meta-research Center, Institute of Convergence Science, Yonsei University, Seoul, South Korea
| | - J W Jung
- Division of Pediatric Cardiology, Department of Pediatrics, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - D J Barron
- Division of Cardiovascular Surgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
3
|
Zaidi AH, Saleeb SF, Gurvitz M, Bucholz E, Gauvreau K, Jenkins KJ, de Ferranti SD. Social Determinants of Health Including Child Opportunity Index Leading to Gaps in Care for Patients With Significant Congenital Heart Disease. J Am Heart Assoc 2024; 13:e028883. [PMID: 38353239 PMCID: PMC11010070 DOI: 10.1161/jaha.122.028883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 10/11/2023] [Indexed: 02/21/2024]
Abstract
BACKGROUND Gaps in care (GIC) are common for patients with congenital heart disease (CHD) and can lead to worsening clinical status, unplanned hospitalization, and mortality. Understanding of how social determinants of health (SDOH) contribute to GIC in CHD is incomplete. We hypothesize that SDOH, including Child Opportunity Index (COI), are associated with GIC in patients with significant CHD. METHODS AND RESULTS A total of 8554 patients followed at a regional specialty pediatric hospital with moderate to severe CHD seen in cardiology clinic between January 2013 and December 2015 were retrospectively reviewed. SDOH factors including race, ethnicity, language, and COI calculated based on home address and zip code were analyzed. GIC of >3.25 years were identified in 32% (2709) of patients. GIC were associated with ages 14 to 29 years (P<0.001), Black race or Hispanic ethnicity (P<0.001), living ≥150 miles from the hospital (P=0.017), public health insurance (P<0.001), a maternal education level of high school or less (P<0.001), and a low COI (P<0.001). Multivariable analysis showed that GIC were associated with age ≥14 years, Black race or Hispanic ethnicity, documenting <3 caregivers as contacts, mother's education level being high school or less, a very low/low COI, and insurance status (C statistic 0.66). CONCLUSIONS One-third of patients followed in a regional referral center with significant CHD experienced a substantial GIC (>3.25 years). Several SDOH, including a low COI, were associated with GIC. Hospitals should adopt formal GIC improvement programs focusing on SDOH to improve continuity of care and ultimately overall outcomes for patients with CHD.
Collapse
Affiliation(s)
- Abbas H. Zaidi
- Department of CardiologyBoston Children’s HospitalBostonMA
- Department of PediatricsHarvard Medical SchoolBostonMA
- Present address:
Nemours Children's Hospital‐DelawareWilmingtonDE
| | - Susan F. Saleeb
- Department of CardiologyBoston Children’s HospitalBostonMA
- Department of PediatricsHarvard Medical SchoolBostonMA
| | - Michelle Gurvitz
- Department of CardiologyBoston Children’s HospitalBostonMA
- Department of PediatricsHarvard Medical SchoolBostonMA
| | - Emily Bucholz
- Department of CardiologyBoston Children’s HospitalBostonMA
- Department of PediatricsHarvard Medical SchoolBostonMA
- Present address:
University of Colorado DenverDenverCO
- Present address:
Children’s Hospital ColoradoAuroraCO
| | - Kimberlee Gauvreau
- Department of CardiologyBoston Children’s HospitalBostonMA
- Department of PediatricsHarvard Medical SchoolBostonMA
| | - Kathy J. Jenkins
- Department of CardiologyBoston Children’s HospitalBostonMA
- Department of PediatricsHarvard Medical SchoolBostonMA
| | - Sarah D. de Ferranti
- Department of CardiologyBoston Children’s HospitalBostonMA
- Department of PediatricsHarvard Medical SchoolBostonMA
| |
Collapse
|
4
|
Cherestal B, Erickson LA, Noel‐MacDonnell JR, Shirali G, Graue Hancock HS, Aly D, Files M, Clauss S, Jayaram N. Association Between Remote Monitoring and Interstage Morbidity and Death in Patients With Single-Ventricle Heart Disease Across Socioeconomic Groups. J Am Heart Assoc 2023; 12:e031069. [PMID: 38014668 PMCID: PMC10727312 DOI: 10.1161/jaha.123.031069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 10/24/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Despite improvements in survival over time, the mortality rate for infants with single-ventricle heart disease remains high. Infants of low socioeconomic status (SES) are particularly vulnerable. We sought to determine whether use of a novel remote monitoring program, the Cardiac High Acuity Monitoring Program, mitigates differences in outcomes by SES. METHODS AND RESULTS Within the Cardiac High Acuity Monitoring Program, we identified 610 infants across 11 centers from 2014 to 2021. All enrolled families had access to a mobile application allowing for near-instantaneous transfer of patient information to the care team. Patients were divided into SES tertiles on the basis of 6 variables relating to SES. Hierarchical logistic regression, adjusted for potential confounding characteristics, was used to determine the association between SES and death or transplant listing during the interstage period. Of 610 infants, 39 (6.4%) died or were listed for transplant. In unadjusted analysis, the rate of reaching the primary outcome between SES tertiles was similar (P=0.24). Even after multivariable adjustment, the odds of death or transplant listing were no different for those in the middle (odds ratio, 1.7 [95% CI, 0.73-3.94) or highest (odds ratio, 0.997 [95% CI, 0.30, 3.36]) SES tertile compared with patients in the lowest (overall P value 0.4). CONCLUSIONS In a large multicenter cohort of infants with single-ventricle heart disease enrolled in a digital remote monitoring program during the interstage period, we found no difference in outcomes based on SES. Our study suggests that this novel technology could help mitigate differences in outcomes for this fragile population of patients.
Collapse
Affiliation(s)
| | | | | | | | | | - Doaa Aly
- UCSF Benioff Children’s HospitalSan FranciscoCA
| | | | | | | |
Collapse
|
5
|
Shustak RJ, Huang J, Tam V, Stagg A, Giglia TM, Ravishankar C, Mercer‐Rosa L, Guevara JP, Gardner MM. Neighborhood Social Vulnerability and Interstage Weight Gain: Evaluating the Role of a Home Monitoring Program. J Am Heart Assoc 2023; 12:e030029. [PMID: 37702068 PMCID: PMC10547291 DOI: 10.1161/jaha.123.030029] [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] [Received: 03/12/2023] [Accepted: 08/08/2023] [Indexed: 09/14/2023]
Abstract
Background Poor interstage weight gain is a risk factor for adverse outcomes in infants with hypoplastic left heart syndrome. We sought to examine the association of neighborhood social vulnerability and interstage weight gain and determine if this association is modified by enrollment in our institution's Infant Single Ventricle Management and Monitoring Program (ISVMP). Methods and Results We performed a retrospective single-center study of infants with hypoplastic left heart syndrome before (2007-2010) and after (2011-2020) introduction of the ISVMP. The primary outcome was interstage weight gain, and the secondary outcome was interstage growth failure. Multivariable linear and logistic regression models were used to examine the association between the Social Vulnerability Index and the outcomes. We introduced an interaction term into the models to test for effect modification by the ISVMP. We evaluated 217 ISVMP infants and 111 pre-ISVMP historical controls. The Social Vulnerability Index was associated with interstage growth failure (P=0.001); however, enrollment in the ISVMP strongly attenuated this association (P=0.04). Pre-ISVMP, as well as high- and middle-vulnerability infants gained 4 g/d less and were significantly more likely to experience growth failure than low-vulnerability infants (high versus low: adjusted odds ratio [aOR], 12.5 [95% CI, 2.5-62.2]; middle versus low: aOR, 7.8 [95% CI, 2.0-31.2]). After the introduction of the ISVMP, outcomes did not differ by Social Vulnerability Index tertile. Infants with middle and high Social Vulnerability Index scores who were enrolled in the ISVMP gained 4 g/d and 2 g/d more, respectively, than pre-ISVMP controls. Conclusions In infants with hypoplastic left heart syndrome, high social vulnerability is a risk factor for poor interstage weight gain. However, enrollment in the ISVMP significantly reduces growth disparities.
Collapse
Affiliation(s)
- Rachel J. Shustak
- Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia and Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Jing Huang
- Department of Biomedical and Health Informatics, Data Science and Biostatistics UnitThe Children’s Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Vicky Tam
- Cartographic Modeling LabUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Alyson Stagg
- Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia and Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Therese M. Giglia
- Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia and Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Chitra Ravishankar
- Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia and Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Laura Mercer‐Rosa
- Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia and Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - James P. Guevara
- Division of General Pediatrics, Department of Pediatrics, The Children’s Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPAUSA
| | - Monique M. Gardner
- Division of Cardiac Critical Care Medicine, The Children’s Hospital of Philadelphia and Department of Anesthesiology and Critical CarePerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPAUSA
| |
Collapse
|
6
|
Vashist S, Dudeck BS, Sherfy B, Rosenthal GL, Chaves AH. Neighborhood socioeconomic status and length of stay after congenital heart disease surgery. Front Pediatr 2023; 11:1167064. [PMID: 37534195 PMCID: PMC10390779 DOI: 10.3389/fped.2023.1167064] [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: 02/15/2023] [Accepted: 06/05/2023] [Indexed: 08/04/2023] Open
Abstract
Background and Objectives Socioeconomic factors are associated with health outcomes and can affect postoperative length of stay after congenital heart disease (CHD) surgery. The hypothesis of this study is that patients from neighborhoods with a disadvantaged socioeconomic status (SES) have a prolonged length of hospital stay after CHD surgery. Methods Pre- and postoperative data were collected on patients who underwent CHD surgery at the University of Maryland Medical Center between 2011 and 2019. A neighborhood SES score was calculated for each patient using data from the United States Census Bureau and patients were grouped by high vs. low SES neighborhoods. The difference of patient length of stay (LOS) from the Society for Thoracic Surgeons median LOS for that surgery was the primary outcome measure. Linear regression was performed to examine the association between the difference from the median LOS and SES, as well as other third variables. Results The difference from the median LOS was -4.8 vs. -2.2 days in high vs. low SES groups (p = 0.003). SES category was a significant predictor of LOS in unadjusted and adjusted regression analyses. There was a significant interaction between Norwood operation and SES-patients with a low neighborhood SES who underwent Norwood operation had a longer LOS, but there was no difference in LOS by SES in patients who underwent other operations. Conclusions Neighborhood SES is a significant predictor of the LOS after congenital heart disease surgery. This effect was seen primarily in patients undergoing Norwood operation.
Collapse
Affiliation(s)
- Sudhir Vashist
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Brandon S. Dudeck
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Beth Sherfy
- University of Maryland Medical Center, Baltimore, MD, United States
| | - Geoffrey L. Rosenthal
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Alicia H. Chaves
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, United States
| |
Collapse
|
7
|
Ramonfaur D, Zhang X, Garza AP, García-Pons JF, Britton-Robles SC. Hypoplastic Left Heart Syndrome: A Review. Cardiol Rev 2023; 31:149-154. [PMID: 35349498 DOI: 10.1097/crd.0000000000000435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Hypoplastic left heart syndrome is a rare and poorly understood congenital disorder featuring a univentricular myocardium, invariably resulting in early childhood death if left untreated. The process to palliate this congenital cardiomyopathy is of high complexity and may include invasive interventions in the first week of life. The preferred treatment strategy involves a staged correction with 3 surgical procedures at different points in time. The Norwood procedure is usually performed within the first weeks of life and aims to increase systemic circulation and relieve pulmonary vascular pressure. This procedure is followed by the bidirectional Glenn and the Fontan procedures in later life, which offer to decrease stress in the ventricular chamber. The prognosis of children with this disease has greatly improved in the past decades; however, it is still largely driven by multiple modifiable and nonmodifiable variables. Novel and clever alternatives have been proposed to improve the survival and neurodevelopment of these patients, although they are not used as standard of care in all centers. The neurodevelopmental outcomes among these patients have received particular attention in the last decade in light to improve this very limiting associated comorbidity that compromises quality of life.
Collapse
Affiliation(s)
- Diego Ramonfaur
- From the Division of Postgraduate Medical Education, Harvard Medical School, Boston, MA
| | - Xiaoya Zhang
- From the Division of Postgraduate Medical Education, Harvard Medical School, Boston, MA
| | - Abraham P Garza
- Departamento de Medicina, Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, México
| | - José Fernando García-Pons
- División de Ciencias de la Salud, Departamento de Medicina y Nutrición, Universidad de Guanajuato, Guanajuato, México
| | - Sylvia C Britton-Robles
- Departamento de Medicina, Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, México
| |
Collapse
|
8
|
Zaleski KL, Valencia E, Matte GS, Kaza AK, Nasr VG. How We Would Treat Our Own Hypoplastic Left Heart Syndrome Neonate for Stage 1 Surgery. J Cardiothorac Vasc Anesth 2023; 37:504-512. [PMID: 36717315 DOI: 10.1053/j.jvca.2023.01.003] [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: 10/17/2022] [Revised: 12/26/2022] [Accepted: 01/02/2023] [Indexed: 01/09/2023]
Affiliation(s)
- Katherine L Zaleski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Eleonore Valencia
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Gregory S Matte
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Aditya K Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| |
Collapse
|
9
|
Vodiskar J, Mertin J, Heinisch PP, Burri M, Kido T, Strbad M, Hager A, Ewert P, Hörer J, Ono M. Impact of Extracardiac Anomalies on Mortality and Morbidity in Staged Single Ventricle Palliation. Ann Thorac Surg 2023; 115:1197-1204. [PMID: 36646244 DOI: 10.1016/j.athoracsur.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 12/20/2022] [Accepted: 01/09/2023] [Indexed: 01/14/2023]
Abstract
BACKGROUND This study was intended to determine the impact of extracardiac anomalies on outcomes in patients with functional single ventricle who underwent staged palliation. METHODS We reviewed medical records of patients who underwent first-stage palliation at our center between 2001 and 2020. The prevalence and type of extracardiac anomalies were evaluated, and their impact on outcomes during staged palliation was analyzed. RESULTS Among 602 patients who underwent first-stage palliation, 81 (14%) patients had associated with extracardiac anomalies. They were more frequently associated with prematurity (P = .03) and low birth weight below 2.5 kg (P < .01). Mortality between first-stage palliation and stage II was similar in patients with and without extracardiac anomalies (24.7% vs 17.1%, P = .10). However, mortality between stage II and stage III was significantly higher in patients with extracardiac anomalies compared with those without (22.2% vs 12.5%, P = .02). Mortality after stage III was also higher in patients with extracardiac anomalies compared with those without (4.9% vs 1.5%, P = .04). In the subgroup analysis of 81 patients with extracardiac anomalies, renal anomalies were identified as a significant risk factor for mortality (P = .03, hazard ratio 2.44). CONCLUSIONS The incidence of extracardiac anomalies in this study was 14%, and patients with extracardiac anomalies were highly associated with prematurity and low birth weight. Presence of extracardiac anomalies was associated with higher mortality between stage II and stage III palliation and after stage III phase, but not before stage II. Among extracardiac anomalies, renal anomalies were identified as a risk factor for mortality.
Collapse
Affiliation(s)
- Janez Vodiskar
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany; Division of Congenital and Pediatric Heart Surgery, Department of Cardiac Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany.
| | - Jannik Mertin
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany; Division of Congenital and Pediatric Heart Surgery, Department of Cardiac Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Paul Philipp Heinisch
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany; Division of Congenital and Pediatric Heart Surgery, Department of Cardiac Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Takashi Kido
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany; Division of Congenital and Pediatric Heart Surgery, Department of Cardiac Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Martina Strbad
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany; Division of Congenital and Pediatric Heart Surgery, Department of Cardiac Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany; Division of Congenital and Pediatric Heart Surgery, Department of Cardiac Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany; Division of Congenital and Pediatric Heart Surgery, Department of Cardiac Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| |
Collapse
|
10
|
Backes ER, Afonso NS, Guffey D, Tweddell JS, Tabbutt S, Rudd NA, O'Harrow G, Molossi S, Hoffman GM, Hill G, Heinle JS, Bhat P, Anderson JB, Ghanayem NS. Cumulative comorbid conditions influence mortality risk after staged palliation for hypoplastic left heart syndrome and variants. J Thorac Cardiovasc Surg 2023; 165:287-298.e4. [PMID: 35599210 DOI: 10.1016/j.jtcvs.2022.01.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 12/29/2021] [Accepted: 01/27/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Prematurity, low birth weight, genetic syndromes, extracardiac conditions, and secondary cardiac lesions are considered high-risk conditions associated with mortality after stage 1 palliation. We report the impact of these conditions on outcomes from a prospective multicenter improvement collaborative. METHODS The National Pediatric Cardiology Quality Improvement Collaborative Phase II registry was queried. Comorbid conditions were categorized and quantified to determine the cumulative burden of high-risk diagnoses on survival to the first birthday. Logistic regression was applied to evaluate factors associated with mortality. RESULTS Of the 1421 participants, 40% (575) had at least 1 high-risk condition. The aggregate high-risk group had lower survival to the first birthday compared with standard risk (76.2% vs 88.1%, P < .001). Presence of a single high-risk diagnosis was not associated with reduced survival to the first birthday (odds ratio, 0.71; confidence interval, 0.49-1.02, P = .066). Incremental increases in high-risk diagnoses were associated with reduced survival to first birthday (odds ratio, 0.23; confidence interval, 0.15-0.36, P < .001) for 2 and 0.17 (confidence interval, 0.10-0.30, P < .001) for 3 to 5 high-risk diagnoses. Additional analysis that included prestage 1 palliation characteristics and stage 1 palliation perioperative variables identified multiple high-risk diagnoses, poststage 1 palliation extracorporeal membrane oxygenation support (odds ratio, 0.14; confidence interval, 0.10-0.22, P < .001), and cardiac reoperation (odds ratio, 0.66; confidence interval, 0.45-0.98, P = .037) to be associated with reduced survival odds to the first birthday. CONCLUSIONS The presence of 1 high-risk diagnostic category was not associated with decreased survival at 1 year. Cumulative diagnoses across multiple high-risk diagnostic categories were associated with decreased odds of survival. Further patient accrual is needed to evaluate the impact of specific comorbid conditions within the broader high-risk categories.
Collapse
Affiliation(s)
- Emily R Backes
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex.
| | - Natasha S Afonso
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - Danielle Guffey
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - James S Tweddell
- Division of Cardiology, Department of Surgery, Department of Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sarah Tabbutt
- Divisions of Critical Care and Cardiology, Department of Pediatrics, University of California San Francisco and Benioff Children's Hospital, San Francisco, Calif
| | - Nancy A Rudd
- Division of Cardiology, Department of Pediatrics, Department of Anesthesia, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Ginny O'Harrow
- Division of Critical Care, Department of Pediatrics, University of Chicago Medicine and Comer Children's Hospital, Chicago, Ill
| | - Silvana Molossi
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - George M Hoffman
- Division of Cardiology, Department of Pediatrics, Department of Anesthesia, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Garick Hill
- Division of Cardiology, Department of Surgery, Department of Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey S Heinle
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - Priya Bhat
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - Jeffrey B Anderson
- Division of Cardiology, Department of Surgery, Department of Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nancy S Ghanayem
- Division of Critical Care, Department of Pediatrics, University of Chicago Medicine and Comer Children's Hospital, Chicago, Ill; Advocate Children's Hospital, Oak Lawn, Ill
| |
Collapse
|
11
|
Schuermans A, Van den Eynde J, Jacquemyn X, Van De Bruaene A, Lewandowski AJ, Kutty S, Geva T, Budts W, Gewillig M, Roest AAW. Preterm Birth Is Associated With Adverse Cardiac Remodeling and Worse Outcomes in Patients With a Functional Single Right Ventricle. J Pediatr 2022; 255:198-206.e4. [PMID: 36470462 DOI: 10.1016/j.jpeds.2022.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/04/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess the effects of preterm birth on cardiac structure and function and transplant-free survival in patients with hypoplastic left heart syndrome and associated anomalies throughout the staged palliation process. STUDY DESIGN Data from the Single Ventricle Reconstruction trial were used to assess the impact of prematurity on echocardiographic measures at birth, Norwood, Stage II, and 14 months in 549 patients with a single functional right ventricle. Medical history was recorded once a year using medical records or telephone interviews. Cox regression models were applied to analyze transplant-free survival to age 6 years. Causal mediation analysis was performed to estimate the mediating effect of birth weight within this relationship. RESULTS Of the 549 participants, 64 (11.7%) were born preterm. Preterm-born participants had lower indexed right ventricle end-diastolic volumes at birth but higher volumes than term-born participants by age 14 months. Preterm-born participants had an increased risk of death or heart transplantation from birth to age 6 years, with an almost linear increase in the observed risk as gestational age decreased below 37 weeks. Of the total effect of preterm birth on transplant-free survival, 27.3% (95% CI 2.5-59.0%) was mediated through birth weight. CONCLUSIONS Preterm birth is associated with adverse right ventricle remodeling and worse transplant-free survival throughout the palliation process, in part independently of low birth weight. Further investigation into this vulnerable group may allow development of strategies that mitigate the impact of prematurity on outcomes in patients with hypoplastic left heart syndrome.
Collapse
Affiliation(s)
- Art Schuermans
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Jef Van den Eynde
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, MD
| | - Xander Jacquemyn
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Alexander Van De Bruaene
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Adam J Lewandowski
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Shelby Kutty
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, MD
| | - Tal Geva
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Werner Budts
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Marc Gewillig
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Pediatric Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Arno A W Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
| |
Collapse
|
12
|
Segar DE, Frommelt PC, Woods RK. Is native aortic valvuloplasty at time of Norwood operation in infants with hypoplastic left heart syndrome and aortic stenosis safe? Cardiol Young 2022; 33:1-2. [PMID: 36259095 DOI: 10.1017/s1047951122003225] [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
In hypoplastic left heart syndrome, the size and function of the left ventricle vary and are dependent on the patency of the aortic valve. A patent native aortic valve, permitting left ventricular ejection, can augment cardiac output. We performed a retrospective chart review of patients with hypoplastic left heart syndrome and a stenotic aortic valve who underwent native aortic valvuloplasty at the time of Norwood and found that none of the eight patients identified had clinically significant aortic insufficiency. This case series suggests that surgical aortic valvuloplasty at Norwood is associated with aortic valve patency/augmented systemic cardiac output without the development of clinically significant aortic regurgitation at intermediate follow-up in a limited cohort.
Collapse
Affiliation(s)
- David E Segar
- Pediatric Cardiology, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, WI, USA
| | - Peter C Frommelt
- Pediatric Cardiology, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, WI, USA
| | - Ronald K Woods
- Congenital Heart Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| |
Collapse
|
13
|
Geoffrion TR, Fuller SM. High-Risk Anatomic Subsets in Hypoplastic Left Heart Syndrome. World J Pediatr Congenit Heart Surg 2022; 13:593-599. [PMID: 36053102 DOI: 10.1177/21501351221111390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite overall improvements in outcomes for patients with hypoplastic left heart syndrome, there remain anatomic features that can place these patients at higher risk throughout their treatment course. These include severe preoperative obstruction to pulmonary venous return, restrictive atrial septum, coronary fistulae, severe tricuspid regurgitation, smaller ascending aorta diameter (especially if <2 mm), and poor ventricular function. The risk of traditional staged palliation has led to the development of alternative strategies for such patients. To further improve the outcomes, we must continue to diligently examine and study anatomic details in HLHS patients.
Collapse
Affiliation(s)
- Tracy R Geoffrion
- Division of Cardiothoracic Surgery, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stephanie M Fuller
- Division of Cardiothoracic Surgery, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Division of Cardiothoracic Surgery, Department of Surgery, 14640Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
14
|
Purkey NJ, Ma C, Lee HC, Hintz SR, Shaw GM, McElhinney DB, Carmichael SL. Distance from home to birth hospital, transfer, and mortality in neonates with hypoplastic left heart syndrome in California. Birth Defects Res 2022; 114:662-673. [PMID: 35488460 DOI: 10.1002/bdr2.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 04/04/2022] [Accepted: 04/11/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Prior studies report a lower risk of mortality among neonates with hypoplastic left heart syndrome (HLHS) who are born at a cardiac surgical center, but many neonates with HLHS are born elsewhere and transferred for repair. We investigated the associations between the distance from maternal home to birth hospital, the need for transfer after birth, sociodemographic factors, and mortality in infants with HLHS in California from 2006 to 2011. METHODS We used linked data from two statewide databases to identify neonates for this study. Three groups were included in the analysis: "lived close/not transferred," "lived close/transferred," and "lived far/not transferred." We defined "lived close" versus "lived far" as 11 miles, the median distance from maternal residence to birth hospital. Log-binomial regression models were used to identify the association between sociodemographic variables, distance to birth hospital and transfer. Cox proportional hazards models were used to identify the association between mortality and distance to birth hospital and transfer. Models were adjusted for sociodemographic variables. RESULTS Infants in the lived close/not transferred and the lived close/transferred groups (vs. the lived far/not transferred group) were more likely to live in census tracts above the 75th percentile for poverty with relative risks 1.94 (95% confidence interval [CI] 1.41-2.68) and 1.21 (95% CI 1.05-1.40), respectively. Neonatal mortality was higher among the lived close/not transferred group compared with the lived far/not transferred group (hazard ratio 1.77, 95% CI 1.17-2.67). CONCLUSIONS Infants born to mothers experiencing poverty were more likely to be born close to home. Infants with HLHS who were born close to home and not transferred to a cardiac center had a higher risk of neonatal mortality than infants who were delivered far from home and not transferred. Future studies should identify the barriers to delivery at a cardiac center for mothers experiencing poverty.
Collapse
Affiliation(s)
- Neha J Purkey
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Chen Ma
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Henry C Lee
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Susan R Hintz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Gary M Shaw
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Doff B McElhinney
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA.,Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Suzan L Carmichael
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA.,Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California, USA
| |
Collapse
|
15
|
Cain N, Saul JP, Gongwer R, Trachtenberg F, Czosek RJ, Kim JJ, Kaltman JR, LaPage MJ, Janson CM, Singh AK, Hill AC, Landstrom AP, Thacker D, Niu MC, DeWitt ES, Bulic A, Silver ES, Whitehill RD, Decker J, Newburger JW. Relation of Norwood Shunt Type and Frequency of Arrhythmias at 6 Years (from the Single Ventricle Reconstruction Trial). Am J Cardiol 2022; 169:107-112. [PMID: 35101270 DOI: 10.1016/j.amjcard.2021.12.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/16/2021] [Accepted: 12/20/2021] [Indexed: 01/21/2023]
Abstract
The Norwood procedure with a right ventricular to pulmonary artery shunt (RVPAS) decreases early mortality, but requires a ventriculotomy, possibly increasing risk of ventricular arrhythmias (VAs) compared with the modified Blalock-Taussig shunt (MBTS). The effect of shunt and Fontan type on arrhythmias by 6 years of age in the SVRII (Single Ventricle Reconstruction Extension Study) was assessed. SVRII data collected on 324 patients pre-/post-Fontan and annually at 2 to 6 years included antiarrhythmic medications, electrocardiography (ECG) at Fontan, and Holter/ECG at 6 years. ECGs and Holters were reviewed for morphology, intervals, atrioventricular conduction, and arrhythmias. Isolated VA were seen on 6-year Holter in >50% of both cohorts (MBTS 54% vs RVPAS 60%), whereas nonsustained ventricular tachycardia was rare and observed in RVPAS only (2.7%). First-degree atrioventricular block was more common in RVPAS than MBTS (21% vs 8%, p = 0.01), whereas right bundle branch block, QRS duration, and QTc were similar. Antiarrhythmic medication usage was common in both groups, but most agents also supported ventricular function (e.g., digoxin, carvedilol). Of the 7 patients with death or transplant between 2 and 6 years, none had documented VAs, but compared with transplant-free survivors, they had somewhat longer QRS (106 vs 93 ms, p = 0.05). Atrial tachyarrhythmias varied little between MBTS and RVPAS but did vary by Fontan type (lateral tunnel 41% vs extracardiac conduit 29%). VAs did not vary by Fontan type. In conclusion, at 6-year follow-up, benign VAs were common in the SVRII population. However, despite the potential for increased VAs and sudden death in the RVPAS cohort, these data do not support significant differences or increased risk at 6 years. The findings highlight the need for ongoing surveillance for arrhythmias in the SVR population.
Collapse
Affiliation(s)
- Nicole Cain
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina.
| | - J Philip Saul
- Department of Pediatrics, West Virginia University School of Medicine, Morgantown, West Virginia
| | | | | | - Richard J Czosek
- The Heart Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey J Kim
- Department of Pediatric, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Jonathon R Kaltman
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Martin J LaPage
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Christopher M Janson
- Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia, Pennsylvania
| | - Anoop K Singh
- Department of Pediatrics, Medical College of Wisconsin, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin
| | - Allison C Hill
- Department of Pediatrics, Children's Hospital Los Angeles, and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Andrew P Landstrom
- Department of Pediatrics; Department of Cell Biology, Duke University School of Medicine, Durham, North Carolina
| | - Deepika Thacker
- Department of Pediatrics, Nemours Cardiac Center, Alfred I duPont Hospital for Children, Wilmington, Delaware
| | - Mary C Niu
- Department of Pediatrics, Primary Children's Hospital and the University of Utah, Salt Lake City, Utah
| | - Elizabeth S DeWitt
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Anica Bulic
- Department of Pediatrics, University of Toronto, SickKids Children's Hospital, Toronto, Ontario, Canada
| | - Eric S Silver
- Department of Pediatrics, Children's Hospital of New York, Columbia University Irving Medical Center, New York, New York
| | - Robert D Whitehill
- Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta Sibley Heart Center, Atlanta, Georgia
| | - Jamie Decker
- Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
16
|
Fricke K, Mellander M, Hanséus K, Tran P, Synnergren M, Johansson Ramgren J, Rydberg A, Sunnegårdh J, Dalén M, Sjöberg G, Weismann CG, Liuba, P. Impact of Left Ventricular Morphology on Adverse Outcomes Following Stage 1 Palliation for Hypoplastic Left Heart Syndrome: 20 Years of National Data From Sweden. J Am Heart Assoc 2022; 11:e022929. [PMID: 35348003 PMCID: PMC9075443 DOI: 10.1161/jaha.121.022929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
Hypoplastic left heart syndrome is associated with significant morbidity and mortality. We aimed to assess the influence of left ventricular morphology and choice of shunt on adverse outcome in patients with hypoplastic left heart syndrome and stage 1 palliation.
Methods and Results
This was a retrospective analysis of patients with hypoplastic left heart syndrome with stage 1 palliation between 1999 and 2018 in Sweden. Patients (n=167) were grouped based on the anatomic subtypes aortic‐mitral atresia, aortic atresia‐mitral stenosis (AA‐MS), and aortic‐mitral stenosis. The left ventricular phenotypes including globular left ventricle (Glob‐LV), miniaturized and slit‐like left ventricle (LV), and the incidence of major adverse events (MAEs) including mortality were assessed. The overall mortality and MAEs were 31% and 41%, respectively. AA‐MS (35%) was associated with both mortality (all other subtypes versus AA‐MS: interstage‐I: hazard ratio [HR], 2.7;
P
=0.006; overall: HR, 2.2;
P
=0.005) and MAEs (HR, 2.4;
P
=0.0009). Glob‐LV (57%), noticed in all patients with AA‐MS, 61% of patients with aortic stenosis‐mitral stenosis, and 19% of patients with aortic atresia‐mitral atresia, was associated with both mortality (all other left ventricular phenotypes versus Glob‐LV: interstage‐I: HR, 4.5;
P
=0.004; overall: HR, 3.4;
P
=0.0007) and MAEs (HR, 2.7;
P
=0.0007). There was no difference in mortality and MAEs between patients with AA‐MS and without AA‐MS with Glob‐LV (
P
>0.15). Patients with AA‐MS (35%) or Glob‐LV (38%) palliated with a Blalock‐Taussig shunt had higher overall mortality compared with those palliated with Sano shunts, irrespective of the stage 1 palliation year (AA‐MS: HR, 2.6;
P
=0.04; Glob‐ LV: HR, 2.1;
P
=0.03).
Conclusions
Glob‐LV and AA‐MS are independent morphological risk factors for adverse short‐ and long‐ term outcome, especially if a Blalock‐Taussig shunt is used as part of stage 1 palliation. These findings are important for the clinical management of patients with hypoplastic left heart syndrome.
Collapse
Affiliation(s)
- Katrin Fricke
- Cardiology Pediatric Heart Centre Skåne University Hospital Lund Sweden
- Pediatrics Department of Clinical Sciences Lund University Lund Sweden
| | - Mats Mellander
- Department of Pediatrics Institute of Clinical SciencesSahlgrenska Academy Gothenburg Sweden
- Children´s Heart Centre Sahlgrenska University Hospital Gothenburg Sweden
| | - Katarina Hanséus
- Cardiology Pediatric Heart Centre Skåne University Hospital Lund Sweden
- Pediatrics Department of Clinical Sciences Lund University Lund Sweden
| | - Phan‐Kiet Tran
- Pediatrics Department of Clinical Sciences Lund University Lund Sweden
- Cardiac Surgery Pediatric Heart Centre Skåne University Hospital Lund Sweden
| | - Mats Synnergren
- Department of Pediatrics Institute of Clinical SciencesSahlgrenska Academy Gothenburg Sweden
- Children´s Heart Centre Sahlgrenska University Hospital Gothenburg Sweden
| | - Jens Johansson Ramgren
- Pediatrics Department of Clinical Sciences Lund University Lund Sweden
- Cardiac Surgery Pediatric Heart Centre Skåne University Hospital Lund Sweden
| | - Annika Rydberg
- Department of Clinical Sciences, Pediatrics Umeå University Umeå Sweden
| | - Jan Sunnegårdh
- Department of Pediatrics Institute of Clinical SciencesSahlgrenska Academy Gothenburg Sweden
- Children´s Heart Centre Sahlgrenska University Hospital Gothenburg Sweden
| | - Magnus Dalén
- Department of Cardiothoracic Surgery Karolinska University Hospital Stockholm Sweden
- Department of Molecular Medicine and Surgery Karolinska Institute Stockholm Sweden
| | - Gunnar Sjöberg
- Department of Women's and Children's Health Karolinska Institute Stockholm Sweden
| | - Constance G. Weismann
- Cardiology Pediatric Heart Centre Skåne University Hospital Lund Sweden
- Pediatrics Department of Clinical Sciences Lund University Lund Sweden
| | - Petru Liuba,
- Cardiology Pediatric Heart Centre Skåne University Hospital Lund Sweden
- Pediatrics Department of Clinical Sciences Lund University Lund Sweden
| |
Collapse
|
17
|
Global longitudinal strain analysis of the singe right ventricle: leveling the playing field. J Am Soc Echocardiogr 2022; 35:657-663. [PMID: 35271990 DOI: 10.1016/j.echo.2022.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/04/2022] [Accepted: 03/01/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND All available echocardiographic methods to assess single, systemic right ventricle (sRV) systolic function have limitations. Subjective grading is prone to bias and varies among readers. Quantitative methods that require significant manual input, such as fractional area change (FAC), are often not reproducible. The aim of this study is to determine whether global longitudinal strain (GLS) is more reproducible than FAC and subjective grading in sRV patients among individual readers and across different levels of experience. METHODS Clinically indicated echocardiograms for 40 patients with functional systemic right ventricles were assessed by 5 readers with varying reading experience: one sonographer, one cardiology fellow, and three attending cardiologists at different career stages. All readers were blinded to patient data and other reader responses. Each reader reviewed the same images for subjective grade (scale 1-8, normal to severely depressed), RV end-diastolic and end-systolic area measurements, and longitudinal strain analysis. A repeat analysis was performed under identical conditions after at least 2 weeks on all 40 patients. Inter- and intra-reader reproducibility was assessed with intraclass correlation coefficient (ICC). Correlations between responses were assessed with Spearman's correlation coefficient. RESULTS The subjective method had fair to good reproducibility (ICC 0.7, interquartile range (IQR) 0.60,0.72) while the FAC method was poor (ICC 0.46, IQR 0.39,0.51) between readers. Reproducibility for GLS was excellent (ICC 0.88, IQR 0.88,0.89). Intra-reader reproducibility was excellent by subjective grading (ICC 0.85, IQR 0.73,0.88), poor by FAC (ICC = 0.63, IQR 0.35,0.66) and excellent by GLS (ICC 0.93, IQR 0.88,0.96). Attending-level readers were more consistent with their subjective grading, while all readers were excellent with GLS. CONCLUSION GLS is more reproducible than conventional methods at assessing sRV systolic function between readers with different levels of experience. For most readers it was more consistent than their own subjective grade of RV function. Laboratories staffed by multiple readers are likely to be more consistent in grading systemic RV systolic function using GLS.
Collapse
|
18
|
Socioeconomic Impact on Outcomes During the First Year of Life of Patients with Single Ventricle Heart Disease: An Analysis of the National Pediatric Cardiology Quality Improvement Collaborative Registry. Pediatr Cardiol 2022; 43:605-615. [PMID: 34718855 DOI: 10.1007/s00246-021-02763-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/22/2021] [Indexed: 10/19/2022]
Abstract
Socioeconomic status (SES) affects a range of health outcomes but has not been extensively explored in the single ventricle population. We investigate the impact of community-level deprivation on morbidity and mortality for infants with single ventricle heart disease in the first year of life. Retrospective cohort analysis of infants enrolled in the National Pediatric Cardiology Improvement Collaborative who underwent staged single ventricle palliation examining mortality and length of stay (LOS) using a community-level deprivation index (DI). 974 patients met inclusion criteria. Overall mortality was 20.5%, with 15.7% of deaths occurring between the first and second palliations. After adjusting for clinical risk factors, the DI was associated with death (log relative hazard [Formula: see text] = 8.92, p = 0.030) and death or transplant (log relative hazard [Formula: see text] = 8.62, p = 0.035) in a non-linear fashion, impacting those near the mean DI. Deprivation was associated with LOS following the first surgical palliation (S1P) (p = 0.031) and overall hospitalization during the first year of life (p = 0.018). For every 0.1 increase in the DI, LOS following S1P increased by 3.35 days (95% confidence interval 0.31-6.38) and total hospitalized days by 5.08 days (95% CI 0.88-9.27). Community deprivation is associated with mortality and LOS for patients with single ventricle congenital heart disease. While patients near the mean DI had a higher hazard of one year mortality compared to those at the extremes of the DI, LOS and DI were linearly associated, demonstrating the complex nature of SES factors.
Collapse
|
19
|
Wirth SH, Heydarian HC, Marcuccio E, Tepe BE, Stein LH, Hill GD. Increasing Use of the Right Ventricle to Pulmonary Artery Shunt for Stage 1 Palliation. Ann Thorac Surg 2022; 115:1229-1236. [PMID: 35033509 DOI: 10.1016/j.athoracsur.2021.12.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 11/14/2021] [Accepted: 12/10/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Stage 1 palliation of hypoplastic left heart syndrome entails use of the Norwood operation with either a modified Blalock-Taussig shunt or a right ventricle-to-pulmonary artery shunt, or the Hybrid procedure. Utilization trends and factors influencing palliation selection remain unclear. We aimed to evaluate these questions and to compare outcomes between types of stage 1 palliation. METHODS The National Pediatric Cardiology Quality Improvement Collaborative phase 1 (6/2008-8/2016) and phase 2 (8/2016-9/2019) databases were used. Procedure type was assessed by operation year. Baseline characteristics and annual hospital volume were evaluated. Post-surgical admission duration and outcomes were compared. RESULTS 3,497 patients were included, 30.8% with modified Blalock-Taussig shunt, 59.7% with right-ventricle-to-pulmonary-artery shunt, and 9.5% with Hybrid. Use of the right-ventricle-to-pulmonary-artery shunt increased over time (p=0.02). This increase was similar among all hospital volumes. Higher hospital volume (OR 1.2 [95% CI 1.1-1.4], p=0.003), male sex (OR 1.3 [95% CI 1.1-1.6], p=0.01), and isolated cardiac disease (OR 1.33 [95% CI 1.01-1.55], p=0.05) were associated with relatively higher likelihoods of a modified Blalock-Taussig shunt. Mortality/transplant rates before stage 2 palliation were higher with the modified Blalock-Taussig shunt than the right-ventricle-to-pulmonary-artery shunt (12.3% vs 9.6%, p=0.03). CONCLUSIONS In stage one palliation, use of right-ventricle-to-pulmonary-artery shunts has increased over time, use of modified Blalock-Taussig shunts has decreased, and use of Hybrids was unchanged. The modified Blalock-Taussig shunt has a higher likelihood of use in higher volume centers, males, and less complex patients, but is associated with longer hospitalizations and lower transplant-free survival to stage 2 palliation.
Collapse
Affiliation(s)
- Scott H Wirth
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229.
| | - Haleh C Heydarian
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229
| | - Elisa Marcuccio
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229
| | - Brooke E Tepe
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229
| | - Laurel H Stein
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229
| | - Garick D Hill
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229
| |
Collapse
|
20
|
Cho HJ, Choi I, Kwak Y, Kim DW, Habimana R, Jeong IS. The Outcome of Post-cardiotomy Extracorporeal Membrane Oxygenation in Neonates and Pediatric Patients: A Systematic Review and Meta-Analysis. Front Pediatr 2022; 10:869283. [PMID: 35547551 PMCID: PMC9083359 DOI: 10.3389/fped.2022.869283] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Post-cardiotomy extracorporeal membrane oxygenation (PC-ECMO) is a known rescue therapy for neonates and pediatric patients who failed to wean from cardiopulmonary bypass (CPB) or who deteriorate in intensive care unit (ICU) due to various reasons such as low cardiac output syndrome (LCOS), cardiac arrest and respiratory failure. We conducted a systematic review and meta-analysis to assess the survival in neonates and pediatric patients who require PC-ECMO and sought the difference in survivals by each indication for PC-ECMO. DESIGN Systematic review and meta-analysis. SETTING Multi-institutional analysis. PARTICIPANTS Neonates and pediatric patients who requires PC- ECMO. INTERVENTIONS ECMO after open-heart surgery. RESULTS Twenty-six studies were included in the analysis with a total of 186,648 patients and the proportion of the population who underwent PC-ECMO was 2.5% (2,683 patients). The overall pooled proportion of survival in this population was 43.3% [95% Confidence interval (CI): 41.3-45.3%; I 2: 1%]. The survival by indications of PC-ECMO were 44.6% (95% CI: 42.6-46.6; I 2: 0%) for CPB weaning failure, 47.3% (95% CI: 39.9-54.7%; I 2: 5%) for LCOS, 37.6% (95% CI: 31.0-44.3%; I 2: 32%) for cardiac arrest and 47.7% (95% CI: 32.5-63.1%; I 2: 0%) for respiratory failure. Survival from PC-ECMO for single ventricle or biventricular physiology, was reported by 12 studies. The risk ratio (RR) was 0.74 for survival in patients with single ventricle physiology (95% CI: 0.63-0.86; I 2: 40%, P < 0.001). Eight studies reported on the survival after PC-ECMO for genetic conditions. The RR was 0.93 for survival in patients with genetic condition (95% CI: 0.52-1.65; I 2: 65%, P = 0.812). CONCLUSIONS PC-ECMO is an effective modality to support neonates and pediatric patients in case of failed CPB weaning and deterioration in ICU. Even though ECMO seems to improve survival, mortality and morbidity remain high, especially in neonates and pediatric patients with single ventricle physiology. Most genetic conditions alone should not be considered a contraindication to ECMO support, further studies are needed to determine which genetic abnormalities are associated with favorable outcome.
Collapse
Affiliation(s)
- Hwa Jin Cho
- Division of Pediatric Cardiology and Cardiac Critical Care, Department of Pediatrics, Chonnam National University Children's Hospital and Medical School, Gwangju, South Korea.,Cardiovascular and Respiratory Research Team, Chonnam National University Hospital, Gwangju, South Korea
| | - Insu Choi
- Division of Pediatric Cardiology and Cardiac Critical Care, Department of Pediatrics, Chonnam National University Children's Hospital and Medical School, Gwangju, South Korea
| | - Yujin Kwak
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital and Medical School, Gwangju, South Korea
| | - Do Wan Kim
- Cardiovascular and Respiratory Research Team, Chonnam National University Hospital, Gwangju, South Korea.,Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital and Medical School, Gwangju, South Korea
| | - Reverien Habimana
- Cardiovascular and Respiratory Research Team, Chonnam National University Hospital, Gwangju, South Korea.,Department of Biomedical Sciences, College of Medicine, Chonnam National University Graduate School, Gwangju, South Korea
| | - In-Seok Jeong
- Cardiovascular and Respiratory Research Team, Chonnam National University Hospital, Gwangju, South Korea.,Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital and Medical School, Gwangju, South Korea
| |
Collapse
|
21
|
Piber N, Ono M, Palm J, Kido T, Burri M, Röhlig C, Strbad M, Cleuziou J, Lemmer J, Dilber D, Klawonn F, Ewert P, Hager A, Hörer J. Influence of Shunt Type on Survival and Right Heart Function after the Norwood Procedure for Aortic Atresia. Semin Thorac Cardiovasc Surg 2021; 34:1300-1310. [PMID: 34838954 DOI: 10.1053/j.semtcvs.2021.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 11/18/2021] [Indexed: 12/28/2022]
Abstract
The study objective was to compare the results after Norwood procedure between modified Blalock-Taussig shunt (MBTS) and right ventricle-to-pulmonary artery conduit (RVPAC) according to Sano in patients with hypoplastic left heart syndrome (HLHS) and aortic atresia (AA). A total of 146 neonates with HLHS and AA who underwent the Norwood procedure at our institution between 2001 and 2020 were divided into 2 groups according to shunt type (MBTS or RVPAC). Survival after the Norwood procedure was compared between the groups. Longitudinal right ventricular and tricuspid valve function in each group were evaluated using cubic splines method. RVPAC was performed in 103 patients and MBTS in 43 according to surgeon preference. There were no differences in the 30-day mortality rates (16.5% vs 16.3%, P = 0.973). Survival at 0.5, 1 and 3 years was 79.6%, 74.6%, and 68.9% in RVPAC and 66.8%, 64.3%, and 58.5% in MBTS (P = 0.293). Among 23 patients undergoing tricuspid valve procedure, different mechanisms of tricuspid regurgitation were observed between the groups. Longitudinal analysis revealed greater prevalence of late right ventricular dysfunction in RVPAC patients. In 77 patients who completed Fontan procedure, the postoperative N-terminal pro B-type natriuretic peptide value was significantly higher in RVPAC vs MBTS (554 vs 276 ng/L, P = 0.007). No survival advantage of RVPAC over MBTS was observed in neonates with HLHS and AA undergoing the Norwood procedure. Longitudinal analysis demonstrated a greater prevalence of right ventricular dysfunction and higher N-terminal pro B-type natriuretic peptide values during late follow-up in patients with RVPAC.
Collapse
Affiliation(s)
- Nicole Piber
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany.
| | - Jonas Palm
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich Technische Universität München, Munich, Germany
| | - Takashi Kido
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Christoph Röhlig
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich Technische Universität München, Munich, Germany
| | - Martina Strbad
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Julie Cleuziou
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Julia Lemmer
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich Technische Universität München, Munich, Germany
| | - Daniel Dilber
- Department of Pediatrics, University Hospital Centre Zagreb, School of medicine Zagreb, Zagreb, Croatia
| | - Frank Klawonn
- Biostatistics, Helmholtz Center for Infection Research, Braunschweig, Germany; Department of Computer Science, Ostfalia University, Wolfenbüttel, Germany
| | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich Technische Universität München, Munich, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich Technische Universität München, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| |
Collapse
|
22
|
Chamberlain RC, Andersen ND, McCrary AW, Hornik CP, Hill KD. Post-operative Renal Failure, Shunt Type and Mortality after Norwood Palliation. Ann Thorac Surg 2021; 113:2046-2053. [PMID: 34534529 DOI: 10.1016/j.athoracsur.2021.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 08/02/2021] [Accepted: 08/09/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND The Single Ventricle Reconstruction (SVR) trial demonstrated increased risk of death or heart transplant one year post-Norwood in subjects randomized to Blalock-Taussig shunts (mBTS) compared to right ventricle-to-pulmonary artery (RV-PA) shunts. We used the SVR public use database to evaluate incidence and risk factors for post-operative renal failure and relationships between renal failure, shunt type and outcomes post-Norwood. METHODS Post-operative renal failure was defined a-priori as a 3-fold rise in creatinine from baseline, or dialysis use, within 7 days of Norwood. We used multivariate logistic regression to evaluate risk factors for post-operative renal failure and Cox hazard regression to determine the association between post-operative renal failure and one-year post-Norwood mortality. RESULTS Overall, post-operative renal failure occurred in 8.4% (46/544) with risk factors including receipt of a mBTS (aOR 3.3, p=0.02), low center volume (aOR 2.7, p=0.005), presence of ≥2 pre-op complications (aOR 4.0, p<0.001), low birth weight (aOR 3.2, p=0.002), post-operative heart block (aOR 8.5, p=0.001), and delayed sternal closure (aOR 5.3, p=0.026). Renal failure was an independent risk factor for one-year mortality (aHR 1.9, p=0.019). Assessing interaction by shunt type, mortality risk associated with renal failure was greatest in the RV-PA shunt group (aHR 3.3 versus RV-PA shunt without renal failure, p=0.001), but was also increased in the mBTS group (aHR 1.9, p=0.03). CONCLUSIONS Post-operative renal failure is common after Norwood and is independently associated with mortality. Although renal failure is more common after mBTS, the highest mortality risk with renal failure occurs after RV-PA shunt.
Collapse
Affiliation(s)
- Reid C Chamberlain
- Department of Pediatrics, Duke University Medical Center, 2301 Erwin Road, Durham, North Carolina 27710.
| | - Nicholas D Andersen
- Department of Surgery, Duke University Medical Center, 2301 Erwin Road, Durham, North Carolina 27710
| | - Andrew W McCrary
- Department of Pediatrics, Duke University Medical Center, 2301 Erwin Road, Durham, North Carolina 27710
| | - Christoph P Hornik
- Department of Pediatrics, Duke University Medical Center, 2301 Erwin Road, Durham, North Carolina 27710; Duke Clinical Research Institute, Duke University Medical Center, 2301 Erwin Road, Durham, North Carolina 27710
| | - Kevin D Hill
- Department of Pediatrics, Duke University Medical Center, 2301 Erwin Road, Durham, North Carolina 27710; Duke Clinical Research Institute, Duke University Medical Center, 2301 Erwin Road, Durham, North Carolina 27710
| |
Collapse
|
23
|
Ono M, Kido T, Wallner M, Burri M, Lemmer J, Ewert P, Strbad M, Cleuziou J, Hager A, Hörer J. Preoperative risk factors influencing inter-stage mortality after the Norwood procedure. Interact Cardiovasc Thorac Surg 2021; 33:218-226. [PMID: 33948647 PMCID: PMC8691571 DOI: 10.1093/icvts/ivab073] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/29/2021] [Accepted: 02/18/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES With improvements in early survival after the stage I palliation (S1P) Norwood procedure for hypoplastic left heart syndrome (HLHS) and its variants, inter-stage death accounts for an increasing proportion of mortality. Our aim was to identify the risk factors for inter-stage mortality. METHODS The records of 322 neonates with HLHS or a variant who underwent the Norwood procedure at our centre between 2001 and 2019 were retrospectively analysed. RESULTS The diagnoses included 271 neonates with HLHS (84%) and 51 with variants (16%). Aortic atresia was observed in 138 (43%) patients, mitral atresia in 91 (28%), extracardiac anomalies in 42 (13%) and genetic disorder in 14 (4%). The median age and weight of the patients at the S1P Norwood procedure were 9 (interquartile range: 7-12) days and 3.2 (2.9-3.5) kg, respectively. The median cardiopulmonary bypass time was 137 (107-163) min. Modified Blalock-Taussig shunts were used in 159 (49%) and unvalved right ventricle-to-pulmonary artery shunts in 163 (51%) patients. The number of inter-stage deaths was as follows: between S1P and stage II palliation (S2P), 61 including 38 early (<30 days) and 23 late (>30 days) deaths, and between S2P and stage III palliation, 32 deaths. Low birth weight (<2.5 kg) (odds ratio 4.37, P = 0.020) and restrictive atrial septum (odds ratio 2.97, P = 0.013) were identified as risks for early mortality. Low birth weight [hazard ratio (HR) 0.99/g, P = 0.002] was a risk for inter-stage mortality between S1P and S2P. Extracardiac anomalies (HR 4.75, P = 0.049) and significant pre-S1P atrioventricular valve regurgitation (HR: 7.72, P = 0.016) were risks for inter-stage mortality between S2P and stage III palliation. Other anatomical variables including aortic atresia, anatomical subtypes and the diameter of the ascending aorta nor shunt type were not identified as risk factors for mortality during any inter-stage period. CONCLUSIONS The risk factors for inter-stage attrition after the Norwood procedure were different between each stage. Preoperative factors, including birth weight, restrictive atrial septum and extracardiac anomalies, adversely affected the inter-stage mortality.
Collapse
Affiliation(s)
- Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Takashi Kido
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Marie Wallner
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Julia Lemmer
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Martina Strbad
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Julie Cleuziou
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| |
Collapse
|
24
|
Hoganson DM, Piekarski BL, Quinonez LG, Kheir JJ, Kaza AK, Zurakowski D, Emani SM, Baird CW. Patch augmentation of small ascending aorta during stage I procedure reduces the risk of morbidity and mortality. Eur J Cardiothorac Surg 2021; 61:555-561. [PMID: 34269379 DOI: 10.1093/ejcts/ezab312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 04/26/2021] [Accepted: 05/21/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Hypoplastic left heart syndrome (HLHS) with aortic atresia (AA) patients are prone to coronary insufficiency due to a small ascending aorta. Prophylactic patch augmentation of the small ascending aorta during the stage I procedure (S1P) may reduce the risk of coronary insufficiency as marked by ventricular dysfunction, need for extracorporeal membrane oxygenator (ECMO) support or mortality. METHODS Retrospective analysis of patients with HLHS with AA who underwent an S1P was completed. Baseline ascending aorta size, right ventricular (RV) function and outcome variables of transplant-free survival, ECMO support after the stage 1 operation and RV function at the time of the bidirectional Glenn and latest follow-up were collected. RESULTS Between January 2010 and April 2020, 11 patients underwent prophylactic ascending aorta augmentation at the time of the S1P as a planned portion of the procedure. A total of 125 patients underwent S1P during this period as a comparison. Overall survival was 100% for the augmented group and 74% for the control group (P = 0.66). A composite end point of transplant-free survival, no post-S1P ECMO and less than moderate RV dysfunction was created. At the time of BDG, this composite end point was 100% for the augmented group and 61.8% for the control group (P = 0.008) and at most recent follow-up was 100% for the augmented group and 59.3% for control (P = 0.007). Eight patients required a rescue procedure for the clinical evidence of coronary insufficiency following S1P that included ascending aorta patch augmentation or stent placement. When comparing these rescue versus prophylactic ascending aortic augmentations, there were also differences in the composite outcome 100% for augmented and 60% for rescue (P = 0.009) and at the time of most recent follow-up 100% for augmented and 50% for rescue (P = 0.029). CONCLUSIONS Prophylactic patch augmentation of the ascending aorta in HLHS patients with AA may reduce the risk of mortality, ECMO and reduced RV function. Patients not initially undergoing augmentation but then requiring a rescue procedure have particularly poor outcomes. Patch augmentation for smaller ascending aortic diameters should be considered and further clinical experience may help delineate aorta diameter threshold for augmentation.
Collapse
Affiliation(s)
- David M Hoganson
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Breanna L Piekarski
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Luis G Quinonez
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA, USA
| | - John J Kheir
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Aditya K Kaza
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA, USA
| | - David Zurakowski
- Department of Anesthesiology, Critical Care, and Pain Management, Boston Children's Hospital, Boston, MA, USA
| | - Sitaram M Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Chris W Baird
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA, USA
| |
Collapse
|
25
|
Ono M, Kido T, Wallner M, Burri M, Lemmer J, Ewert P, Strbad M, Cleuziou J, Hager A, Hörer J. Comparison of shunt types in the neonatal Norwood procedure for single ventricle. Eur J Cardiothorac Surg 2021; 60:1084-1091. [PMID: 34050665 DOI: 10.1093/ejcts/ezab163] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 02/01/2021] [Accepted: 02/22/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The ideal shunt for pulmonary blood flow, modified Blalock-Taussig shunt (MBTS) or right ventricular-pulmonary artery conduit (RVPAC) is yet to be determined. This study aimed to evaluate outcomes after the Norwood procedure according to the type of shunt. METHODS A total of 322 neonates with hypoplastic left heart syndrome and related anomalies who underwent the Norwood procedure at our institution between 2001 and 2019 were divided into MBTS and RVPAC groups and the outcomes after the Norwood procedure were compared between the groups with respect to mortality after each staged procedure. RESULTS We identified 322 consequent patients who underwent neonatal Norwood procedure for hypoplastic left heart syndrome (271 patients, 84.2%) and its variant (51 patients, 15.8%). RVPAC was performed in 163 (50.6%) patients and MBTS was performed in 159 (49.4%). There were no differences in the rate of early death (11.0% vs 12.6%, P = 0.69) or late death (7.4% vs 6.9%, P = 0.87) between the 2 groups after the Norwood procedure, and no significant difference in the number of patients who reached bidirectional cavopulmonary shunt (77.9% vs 76.1%, P = 0.69), and there was no difference in mortality after bidirectional cavopulmonary shunt (12.3% vs 7.5%, P = 0.15) or Fontan completion rate (54.0% vs 52.2%, P = 0.42) between the 2 groups. Survival at 0.5, 1, 3 and 6 years after the Norwood procedure was 81.0%, 73.8%, 67.9% and 67.0% in patients with RVPAC and 77.1%, 73.3%, 69.1% and 67.9% in patients with MBTS. There was no significant difference in the survival between the 2 groups during the median follow-up of 2.6 (interquartile ranges: 0.3-8.4, maximal 18.8) years (P = 0.97). CONCLUSIONS In neonates undergoing the Norwood procedure, our available data of maximal 18.8 years follow-up showed no significant difference in early mortality, inter-stage attritions, or overall survival, between MBTS and RVPAC.
Collapse
Affiliation(s)
- Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Takashi Kido
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Marie Wallner
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Julia Lemmer
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Martina Strbad
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Julie Cleuziou
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| |
Collapse
|
26
|
Bhatla P, Kumar TS, Makadia L, Winston B, Bull C, Nielsen JC, Williams D, Chakravarti S, Ohye RG, Mosca RS. Periscopic technique in Norwood operation is associated with better preservation of early ventricular function. JTCVS Tech 2021; 8:116-123. [PMID: 34401829 PMCID: PMC8350951 DOI: 10.1016/j.xjtc.2021.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 05/13/2021] [Indexed: 11/16/2022] Open
Abstract
Objective Although the right ventricle (RV) to pulmonary artery conduit in stage 1 Norwood operation results in improved interstage survival, the long-term effects of the ventriculotomy used in the traditional technique remain a concern. The periscopic technique (PT) of RV to pulmonary artery conduit placement has been described as an alternative technique to minimize RV injury. A retrospective study was performed to compare the effects of traditional technique and PT on ventricular function following Norwood operation. Methods A retrospective study of all patients who underwent Norwood operation from 2012 to 2019 was performed. Patients with baseline RV dysfunction and significant tricuspid valve regurgitation were excluded. Prestage 2 echocardiograms were reviewed by a blinded experienced imager for quantification of RV function (sinus and infundibular RV fractional area change) as well as for regional conduit site wall dysfunction (normal or abnormal, including hypokinesia, akinesia, or dyskinesia). Wilcoxon rank-sum tests were used to assess differences in RV infundibular and RV sinus ejection fraction and the Fisher exact test was used to assess differences in regional wall dysfunction. Results Twenty-two patients met inclusion criteria. Eight underwent traditional technique and 14 underwent PT. Median infundibular RV fractional area change was 49% and 37% (P = .02) and sinus RV fractional area change was 50% and 41% for PT and traditional technique (P = .007) respectively. Similarly qualitative regional RV wall function was better preserved in PT (P = .002). Conclusions The PT for RV to pulmonary artery conduit in Norwood operation results in better preservation of early RV global and regional systolic function. Whether or not this benefit translates to improved clinical outcome still needs to be studied.
Collapse
Affiliation(s)
- Puneet Bhatla
- Division of Pediatric Cardiology, New York University Langone Medical Center, New York, NY.,Department of Radiology, New York University Langone Medical Center, New York, NY
| | - Tk Susheel Kumar
- Department of Cardiac Surgery, New York University Langone Medical Center, New York, NY
| | - Luv Makadia
- Department of Pediatrics, New York University Langone Medical Center, New York, NY
| | - Brandon Winston
- Department of Cardiac Surgery, New York University Langone Medical Center, New York, NY
| | - Catherine Bull
- Department of Cardiac Surgery, New York University Langone Medical Center, New York, NY
| | - James C Nielsen
- Division of Pediatric Cardiology, New York University Langone Medical Center, New York, NY
| | - David Williams
- Department of Cardiac Surgery, New York University Langone Medical Center, New York, NY
| | - Sujata Chakravarti
- Division of Pediatric Cardiology, New York University Langone Medical Center, New York, NY
| | - Richard G Ohye
- Department of Cardiac Surgery, Mott Children's Hospital, Ann Arbor, Mich
| | - Ralph S Mosca
- Department of Cardiac Surgery, New York University Langone Medical Center, New York, NY
| |
Collapse
|
27
|
Social determinants of health and outcomes for children and adults with congenital heart disease: a systematic review. Pediatr Res 2021; 89:275-294. [PMID: 33069160 DOI: 10.1038/s41390-020-01196-6] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/02/2020] [Accepted: 09/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Social determinants of health (SDH) can substantially impact health outcomes. A systematic review, however, has never been conducted on associations of SDH with congenital heart disease (CHD) outcomes. The aim, therefore, was to conduct such a systematic review. METHODS Seven databases were searched through May 2020 to identify articles on SDH associations with CHD. SDH examined included poverty, uninsurance, housing instability, parental educational attainment, immigration status, food insecurity, and transportation barriers. Studies were independently selected and coded by two researchers based on the PICO statement. RESULTS The search generated 3992 citations; 88 were included in the final database. SDH were significantly associated with a lower likelihood of fetal CHD diagnosis, higher CHD incidence and prevalence, increased infant mortality, adverse post-surgical outcomes (including hospital readmission and death), decreased healthcare access (including missed appointments, no shows, and loss to follow-up), impaired neurodevelopmental outcomes (including IQ and school performance) and quality of life, and adverse outcomes for adults with CHD (including endocarditis, hospitalization, and death). CONCLUSIONS SDH are associated with a wide range of adverse outcomes for fetuses, children, and adults with CHD. SDH screening and referral to appropriate services has the potential to improve outcomes for CHD patients across the lifespan. IMPACT Social determinants of health (SDH) are associated with a wide range of adverse outcomes for fetuses, children, and adults with congenital heart disease (CHD). This is the first systematic review (to our knowledge) on associations of SDH with congenital heart disease CHD outcomes. SDH screening and referral to appropriate services has the potential to improve outcomes for CHD patients across the lifespan.
Collapse
|
28
|
Carvajal HG, Canter MW, Abarbanell AM, Eghtesady P. Does Ascending Aorta Size Affect Norwood Outcomes in Hypoplastic Left Heart With Aortic Atresia? Ann Thorac Surg 2020; 110:1651-1658. [DOI: 10.1016/j.athoracsur.2020.02.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/24/2020] [Accepted: 02/09/2020] [Indexed: 02/07/2023]
|
29
|
Lawrence KM, Ittenbach RF, Hunt ML, Kaplinski M, Ravishankar C, Rychik J, Steven JM, Fuller SM, Nicolson SC, Gaynor JW, Spray TL, Mascio CE. Attrition between the superior cavopulmonary connection and the Fontan procedure in hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2020; 162:385-393. [PMID: 33581902 DOI: 10.1016/j.jtcvs.2020.10.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 10/11/2020] [Accepted: 10/16/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We investigated the incidence and predictors of failure to undergo the Fontan in children with hypoplastic left heart syndrome who survived superior cavopulmonary connection. METHODS The cohort consists of all patients with hypoplastic left heart syndrome who survived to hospital discharge after superior cavopulmonary connection between 1988 and 2017. The primary outcome was attrition, which was defined as death, nonsuitability for the Fontan, or cardiac transplantation before the Fontan. Subjects were excluded if they were awaiting the Fontan, were lost to follow-up, or underwent biventricular repair. The study period was divided into 4 eras based on changes in operative or medical management. Attrition was estimated with 95% confidence intervals, and predictors were identified using adjusted, logistic regression models. RESULTS Of the 856 hospital survivors after superior cavopulmonary connection, 52 died, 7 were deemed unsuitable for Fontan, and 12 underwent or were awaiting heart transplant. Overall attrition was 8.3% (71/856). Attrition rate did not change significantly across eras. A best-fitting multiple logistic regression model was used, adjusting for superior cavopulmonary connection year and other influential covariates: right ventricle to pulmonary artery shunt at Norwood (P < .01), total support time at superior cavopulmonary connection (P < .01), atrioventricular valve reconstruction at superior cavopulmonary connection (P = .02), performance of other procedures at superior cavopulmonary connection (P = .01), and length of stay after superior cavopulmonary connection (P < .01). CONCLUSIONS In this study spanning more than 3 decades, 8.3% of children with hypoplastic left heart syndrome failed to undergo the Fontan after superior cavopulmonary connection. This attrition rate has not decreased over 30 years. Use of a right ventricle to pulmonary artery shunt at the Norwood procedure was associated with increased attrition.
Collapse
Affiliation(s)
- Kendall M Lawrence
- Department of Surgery, Weill Cornell New York Presbyterian, New York, NY
| | - Richard F Ittenbach
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mallory L Hunt
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Michelle Kaplinski
- Division of Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, Calif
| | - Chitra Ravishankar
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Jack Rychik
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - James M Steven
- Division of Cardiac Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Stephanie M Fuller
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Susan C Nicolson
- Division of Cardiac Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa.
| |
Collapse
|
30
|
Global Leadership in Paediatric and Congenital Cardiac Care: "Using data to improve outcomes - an interview with Jennifer S. Li, MD, MHS". Cardiol Young 2020; 30:1226-1230. [PMID: 32921334 DOI: 10.1017/s1047951120002875] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Dr. Jennifer Li is the focus of our second in a planned series of interviews in Cardiology in the Young entitled, "Global Leadership in Paediatric and Congenital Cardiac Care". Dr. Li was born in Boston, Massachusetts, United States of America, and moved to Indianapolis, Indiana where she completed her secondary education. She then attended Stanford University, majoring in Chemistry and English and graduating with distinction in 1983. Dr. Li then attended Duke University School of Medicine, graduating in 1987. She then completed her internship at Children's Hospital of Philadelphia in 1987-1989, returning to Duke University Medical Center to complete both her residency in general paediatrics in 1989-1990 followed by her fellowship in paediatric cardiology in 1990-1993. She would later complete her Master's Degree in Health Sciences at Duke University in 2005.Dr. Li has spent her entire career as a paediatric cardiologist at Duke University Medical Center, where she was appointed a Professor of Pediatrics and Professor of Medicine in 2008 and has held the position as Beverly C. Morgan Endowed Professor of Pediatrics since 2012. She has served as the Chief of Paediatric Cardiology at Duke University Medical Center since 2006. She also was the Director of Paediatric Research at Duke Clinical Research Institute from 2001-2015. Dr. Li has played an instrumental role in evaluating the safety and efficacy of drugs in children, as well as in analysing and linking large multicentric databases to evaluate the outcomes, quality, and cost of paediatric and congenital cardiac care. Dr. Li has received funding from the National Institute of Health of the United States of America, as well as from industry and foundation grants. This article presents our interview with Dr. Li, an interview that covers her experience collaborating with governmental organizations and industry in the pursuit of common interests to design clinical drug trials, link and analyse large, multicentric databases, and improve paediatric health care.
Collapse
|
31
|
Standardization of the Perioperative Management for Neonates Undergoing the Norwood Operation for Hypoplastic Left Heart Syndrome and Related Heart Defects. Pediatr Crit Care Med 2020; 21:e848-e857. [PMID: 32701749 DOI: 10.1097/pcc.0000000000002478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In-hospital complications after the Norwood operation for single ventricle heart defects account for the majority of morbidity and mortality. Inpatient care variation occurs within and across centers. This multidisciplinary quality improvement project standardized perioperative management in a large referral center. DESIGN Quality improvement project. SETTING High volume cardiac center, tertiary care children's hospital. PATIENTS Neonates undergoing Norwood operation. INTERVENTIONS The quality improvement team developed and implemented a clinical guideline (preoperative admission to 48 hr after surgery). The composite process metric, Guideline Adherence Score, contained 13 recommendations in the guideline that reflected consistent care for all patients. MEASUREMENTS AND MAIN RESULTS One-hundred two consecutive neonates who underwent Norwood operation (January 1, 2013, to July 12, 2016) before guideline implementation were compared with 50 consecutive neonates after guideline implementation (July 13, 2016, to May 4, 2018). No preguideline operations met the goal Guideline Adherence Score. In the first 6 months after guideline implementation, 10 of 12 operations achieved goal Guideline Adherence Score and continued through implementation, reaching 100% for the last 10 operations. Statistical process control analysis demonstrated less variability and decreased hours of postoperative mechanical ventilation and cardiac ICU length of stay during implementation. There were no statistically significant differences in major hospital complications or in 30-day mortality. A higher percentage of patients were extubated by postoperative day 2 after guideline implementation (67% [30/47] vs 41% [41/99], respectively; p = 0.01). Of these patients, reintubation within 72 hours of extubation significantly decreased after guideline implementation (0% [0/30] vs 17% [7/41] patients, respectively; p = 0.02). CONCLUSIONS This initiative successfully implemented a standardized perioperative care guideline for neonates undergoing the Norwood operation at a large center. Positive statistical process control centerline shifts in Guideline Adherence Score, length of postoperative mechanical ventilation, and cardiac ICU length of stay were demonstrated. A higher percentage were successfully extubated by postoperative day 2. Establishment of standard processes can lead to best practices to decrease major adverse events.
Collapse
|
32
|
Alphonso N, Angelini A, Barron DJ, Bellsham-Revell H, Blom NA, Brown K, Davis D, Duncan D, Fedrigo M, Galletti L, Hehir D, Herberg U, Jacobs JP, Januszewska K, Karl TR, Malec E, Maruszewski B, Montgomerie J, Pizzaro C, Schranz D, Shillingford AJ, Simpson JM. Guidelines for the management of neonates and infants with hypoplastic left heart syndrome: The European Association for Cardio-Thoracic Surgery (EACTS) and the Association for European Paediatric and Congenital Cardiology (AEPC) Hypoplastic Left Heart Syndrome Guidelines Task Force. Eur J Cardiothorac Surg 2020; 58:416-499. [DOI: 10.1093/ejcts/ezaa188] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Nelson Alphonso
- Queensland Pediatric Cardiac Service, Queensland Children’s Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Annalisa Angelini
- Department of Cardiac, Thoracic Vascular Sciences and Public health, University of Padua Medical School, Padua, Italy
| | - David J Barron
- Department of Cardiovascular Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Katherine Brown
- Paediatric Intensive Care, Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah Davis
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, USA
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Daniel Duncan
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Marny Fedrigo
- Department of Cardiac, Thoracic Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Lorenzo Galletti
- Unit of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - David Hehir
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | | | - Katarzyna Januszewska
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | | | - Edward Malec
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | - Bohdan Maruszewski
- Department for Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - James Montgomerie
- Department of Anesthesia, Birmingham Children’s Hospital, Birmingham, UK
| | - Christian Pizzaro
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University, Giessen, Germany
| | - Amanda J Shillingford
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | | |
Collapse
|
33
|
Vitanova K, Georgiev S, Lange R, Cleuziou J. Choice of shunt type for the Norwood I procedure: does it make a difference? Interact Cardiovasc Thorac Surg 2020; 30:630-635. [PMID: 31821450 DOI: 10.1093/icvts/ivz294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/06/2019] [Accepted: 11/14/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES This study aimed to compare pulmonary artery (PA) growth between patients who received a right ventricle-to-PA (RV-PA) shunt and those who received a modified Blalock-Taussig shunt (mBTS). METHODS All consecutive patients with hypoplastic left heart syndrome who underwent the Norwood I procedure between 2001 and 2017 were included in the study. Pre-stage 2 angiograms were analysed to measure the size of the PA. The Nakata index was calculated to estimate PA growth. The ratio of the right PA to left PA cross-sectional area (RPA/LPA) was used to calculate the difference in growth between the 2 branches. Study end points were shunt failure, shunt-related mortality and growth of the PAs. RESULTS A total of 223 patients with hypoplastic left heart syndrome (RV-PA group = 137, mBTS group = 86) underwent the Norwood I procedure, and 186 patients (RV-PA n = 116, mBTS n = 70) achieved the stage 2 procedure. PA growth was better in patients with mBTS (Nakata index: RV-PA = 282, mBTS = 315 mm2/m2, P = 0.021). LPA growth was worse compared to RPA growth in both groups (RPA/LPA: RV-PA = 1.21, mBTS = 1.29, P = 1.0). Patients with RV-PA shunts experienced more frequent shunt stenosis compared to patients with mBTS (26 vs 2, P < 0.010). Freedom from shunt failure was 83.3 ± 3.2% and 94 ± 2% at 6 months in the RV-PA and mBTS groups, respectively (P = 0.003). CONCLUSIONS PA growth is significantly better in patients who received an mBTS. Moreover, patients with an RV-PA shunt more frequently experienced shunt failure due to shunt stenosis. However, survival after the NW procedure is not shunt dependent and growth of the LPA is less pronounced than RPA, regardless of the shunt type.
Collapse
Affiliation(s)
- Keti Vitanova
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technische Universität München, Munich, Germany.,Department of Cardiovascular Surgery, Insure (Institute for Translational Cardiac Surgery), German Heart Centre Munich, Technische Universität München, Munich, Germany
| | - Stanimir Georgiev
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich, Technische Universität München, Munich, Germany
| | - Rüdiger Lange
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technische Universität München, Munich, Germany.,Department of Cardiovascular Surgery, Insure (Institute for Translational Cardiac Surgery), German Heart Centre Munich, Technische Universität München, Munich, Germany.,German Heart Center Munich - DZHK Partner Site Munich Heart Alliance, Munich, Germany
| | - Julie Cleuziou
- Department of Cardiovascular Surgery, Insure (Institute for Translational Cardiac Surgery), German Heart Centre Munich, Technische Universität München, Munich, Germany.,Department of Congenital and Paediatric Cardiac Surgery, German Heart Centre Munich, Technische Universität München, Munich, Germany
| |
Collapse
|
34
|
Karamlou T, Najm HK. Evolution of care pathways for babies with hypoplastic left heart syndrome: integrating mechanistic and clinical process investigation, standardization, and collaborative study. J Thorac Dis 2020; 12:1174-1183. [PMID: 32274198 PMCID: PMC7139006 DOI: 10.21037/jtd.2019.10.75] [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: 12/13/2022]
Abstract
Since initial descriptions of staged palliation for hypoplastic left heart syndrome (HLHS) in the 1980’s, much has been learned about the pathophysiology of the single ventricle circulation. New therapies that leverage systems biology and clinical derivatives have been developed. While in-hospital mortality and morbidity for babies with HLHS have continued to improve, there remains a long (and daresay winding) road ahead to achieve ideal outcomes. Important variation in even these abbreviated in-hospital metrics persists among institutions and currently utilized prediction models explain only a small amount of this variation. Moreover, long-term survival and neurodevelopmental health for patients with HLHS are infrequently reported and remain suboptimal despite improved in-hospital outcomes. This focused review will describe the evolution of national outcomes for HLHS over time and the potential factors motivating improved time-related mortality. Emerging modifiable risk-factors that hold promise in terms of moving the needle for long-term success, including social determinants of health and the delineation of genetic profiles, will be discussed. Specifically, this review will integrate contemporary data based on the first murine HLHS models that suggest a genetically elicited modular phenotype with environmental factors known to impact the initial durability of surgical therapies. A comprehensive approach to the management of HLHS, which leverages both proactive transplantation and hybrid palliation, in addition to traditional Norwood palliation, will be emphasized to extend and match management to the complete spectrum of patient risk-profiles. Finally, we will explore the critical role that national collaboratives and quality reporting initiatives have played in improving outcomes and shifting the focus to more meaningful long-term survival and neurodevelopment.
Collapse
Affiliation(s)
- Tara Karamlou
- Division of Pediatric Cardiac Surgery, Cleveland Clinic Heart Vascular Institute, Cleveland, OH, USA
| | - Hani K Najm
- Division of Pediatric Cardiac Surgery, Cleveland Clinic Heart Vascular Institute, Cleveland, OH, USA
| |
Collapse
|
35
|
Frommelt PC, Hu C, Trachtenberg F, Baffa JM, Boruta RJ, Chowdhury S, Cnota JF, Dragulescu A, Levine JC, Lu J, Mercer-Rosa L, Miller TA, Shah A, Slesnick TC, Stapleton G, Stelter J, Wong P, Newburger JW. Impact of Initial Shunt Type on Echocardiographic Indices in Children After Single Right Ventricle Palliations. Circ Cardiovasc Imaging 2019; 12:e007865. [PMID: 30755054 DOI: 10.1161/circimaging.118.007865] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Heart size and function in children with single right ventricle (RV) anomalies may be influenced by shunt type at the Norwood procedure. We sought to identify shunt-related differences during early childhood after staged surgical palliations using echocardiography. Methods We compared echocardiographic indices of RV, neoaortic, and tricuspid valve size and function at 14 months, pre-Fontan, and 6 years in 241 subjects randomized to a Norwood procedure using either the modified Blalock-Taussig shunt or RV-to-pulmonary-artery shunt. Results At 6 years, the shunt groups did not differ significantly in any measure except for increased indexed neoaortic area in the modified Blalock-Taussig shunt. RV ejection fraction improved between pre-Fontan and 6 years in the RV-to-pulmonary artery shunt group but was stable in the modified Blalock-Taussig shunt group. For the entire cohort, RV diastolic and systolic size and functional indices were improved at 6 years compared with earlier measurements, and indexed tricuspid and neoaortic annular area decreased from 14 months to 6 years. The prevalence of ≥moderate tricuspid and neoaortic regurgitation was uncommon and did not vary by group or time period. Diminished RV ejection fraction at the 14-month study was predictive of late death/transplant; the hazard of late death/transplant when RV ejection fraction was <40% was tripled (hazard ratio, 3.18; 95% CI, 1.41-7.17). Conclusions By 6 years after staged palliation, shunt type has not impacted RV size and function, and RV and valvar size and function show beneficial remodeling. Poor RV systolic function at 14 months predicts worse late survival independent of the initial shunt type. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT00115934.
Collapse
Affiliation(s)
- Peter C Frommelt
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Hospital of Wisconsin, Milwaukee (P.C.F., J.S.).,Department of Pediatrics, Division of Pediatric Cardiology, Medical College of Wisconsin, Milwaukee (P.C.F., J.S.)
| | - Chenwei Hu
- Department of Pediatrics, Division of Pediatric Cardiology, New England Research Institutes, Waterford, MA (C.H., F.T.)
| | - Felicia Trachtenberg
- Department of Pediatrics, Division of Pediatric Cardiology, New England Research Institutes, Waterford, MA (C.H., F.T.)
| | - Jeanne Marie Baffa
- Department of Pediatrics, Division of Pediatric Cardiology, The Nemours Cardiac Center, Wilmington, DE (J.M.B.)
| | - Richard J Boruta
- Department of Pediatrics, Division of Pediatric Cardiology, Duke University Hospital, Durham, NC (R.J.B.)
| | - Shahryar Chowdhury
- Department of Pediatrics, Division of Pediatric Cardiology, Medical University of South Carolina, Charleston (S.C.)
| | - James F Cnota
- Department of Pediatrics, Division of Pediatric Cardiology, Cincinnati Children's Hospital and Medical Center, OH (J.F.C.)
| | - Andreea Dragulescu
- Department of Pediatrics, Division of Pediatric Cardiology, Hospital of Sick Children, Toronto, Canada (A.D.)
| | - Jami C Levine
- Department of Pediatrics, Division of Pediatric Cardiology, Boston Children's Hospital, Harvard Medical School, MA (J.C.L., J.W.N.)
| | - Jimmy Lu
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan Medical School, Ann Arbor (J.L.)
| | - Laura Mercer-Rosa
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania Medical School (L.M.-R.)
| | - Thomas A Miller
- Department of Pediatrics, Division of Pediatric Cardiology, Primary Children's Medical Center, University of Utah, Salt Lake City (T.A.M.)
| | - Amee Shah
- Department of Pediatrics, Division of Pediatric Cardiology, Morgan Stanley Children's Hospital of New York-Presbyterian (A.S.).,Department of Pediatrics, Division of Pediatric Cardiology, Columbia College of Physicians and Surgeons, New York, NY (A.S.)
| | - Timothy C Slesnick
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA (T.C.S.)
| | - Gary Stapleton
- Department of Pediatrics, Division of Pediatric Cardiology, John Hopkins All Children's Health Institute, Baltimore, MD (G.S.)
| | - Jessica Stelter
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Hospital of Wisconsin, Milwaukee (P.C.F., J.S.).,Department of Pediatrics, Division of Pediatric Cardiology, Medical College of Wisconsin, Milwaukee (P.C.F., J.S.)
| | - Pierre Wong
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Hospital Los Angeles, CA (P.W.)
| | - Jane W Newburger
- Department of Pediatrics, Division of Pediatric Cardiology, Boston Children's Hospital, Harvard Medical School, MA (J.C.L., J.W.N.)
| |
Collapse
|
36
|
Parker DM, Owens SL, Ramkumar N, Likosky D, DiScipio AW, Malenka DJ, MacKenzie TA, Brown JR. Galectin-3 as a Predictor of Long-term Survival After Isolated Coronary Artery Bypass Grafting Surgery. Ann Thorac Surg 2019; 109:132-138. [PMID: 31336070 DOI: 10.1016/j.athoracsur.2019.05.072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 05/02/2019] [Accepted: 05/21/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Galectin-3 (Gal-3) is a well-established biomarker of adverse clinical outcomes, but its prognostic value for long-term survival after cardiac surgery is not well understood. Elevated levels of Gal-3 have been found to be remarkably associated with higher risk of death in both acute decompensated and chronic heart failure populations. Its prognostic value for long-term survival after cardiac surgery is not known. METHODS A sample of patients contributing to the Northern New England Cardiovascular Disease Study Group Cardiac Surgery Registry from 2004 to 2007 were enrolled in a prospective biomarker cohort (N = 1690). Preoperative Gal-3 levels were measured and categorized by quartile. We used Kaplan-Meier survival analysis and Cox regression models, adjusting for variables in The Society of Thoracic Surgeons Collaboration on the Comparative Effectiveness of Revascularization Strategy probability calculator to evaluate the association between elevated Gal-3 levels and survival to 6 years. RESULTS Preoperative Gal-3 levels ranged from 1.72 to 28.89 ng/mL (mean, 8.96 ng/mL; median, 8.06 ng/mL; interquartile range, 5.42-11.08 ng/mL). Crude survival decreased by increasing quartile. After adjustment, serum levels of Gal-3 in the highest quartile of the cohort were associated with significantly decreased survival compared with the lowest quartile (hazard ratio [HR] 2.22; 95% confidence interval [CI], 1.40-3.54; P = .001). No decrease in survival was found for the middle quartiles (HR 1.36; 95% CI, 0.87-2.12; P = .177). CONCLUSIONS A substantial association was found between elevated preoperative Gal-3 levels and risk of mortality after isolated coronary artery bypass grafting surgery. An assessment of the relationship between preoperative serum biomarkers and long-term survival can be used for risk stratification or estimating postsurgical prognosis.
Collapse
Affiliation(s)
- Devin M Parker
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
| | - Sherry L Owens
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
| | - Niveditta Ramkumar
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
| | - Donald Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | | | | | - Todd A MacKenzie
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
| | - Jeremiah R Brown
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire; Department of Epidemiology, Geisel School of Medicine, Lebanon, New Hampshire; Department of Biomedical Data Science, Geisel School of Medicine, Lebanon, New Hampshire.
| |
Collapse
|
37
|
Best KE, Vieira R, Glinianaia SV, Rankin J. Socio-economic inequalities in mortality in children with congenital heart disease: A systematic review and meta-analysis. Paediatr Perinat Epidemiol 2019; 33:291-309. [PMID: 31347722 DOI: 10.1111/ppe.12564] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 05/02/2019] [Accepted: 05/27/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND The impact of socio-economic status (SES) on congenital heart disease (CHD)-related mortality in children is not well established. OBJECTIVES We aimed to systematically review and appraise the existing evidence on the association between SES (including poverty, parental education, health insurance, and income) and mortality among children with CHD. DATA SOURCES Seven electronic databases (Medline, Embase, Scopus, PsycINFO, CINAHL, ProQuest Natural, and Biological Science Collections), reference lists, citations, and key journals were searched. STUDY SELECTION AND DATA EXTRACTION We included articles reporting original research on the association between SES and mortality in children with CHD if they were full papers published in the English language and regardless of (a) timing of mortality; (b) individual or area-based measures of SES; (c) CHD subtype; (d) age at ascertainment; (e) study period examined. Screening for eligibility, data extraction, and quality appraisal were performed in duplicate. SYNTHESIS Meta-analyses were performed to estimate pooled ORs for in-hospital mortality according to health insurance status. RESULTS Of 1388 identified articles, 28 met the inclusion criteria. Increased area-based poverty was associated with increased odds/risk of postoperative (n = 1), neonatal (n = 1), post-discharge (n = 1), infant (n = 1), and long-term mortality (n = 2). Higher parental education was associated with decreased odds/risk of neonatal (n = 1) and infant mortality (n = 5), but not with long-term mortality (n = 1). A meta-analysis of four US articles showed increased unadjusted odds of in-hospital mortality in those with government/public versus private health insurance (OR 1.40, 95% CI 1.24, 1.56). The association between area-based income and CHD-related mortality was conflicting, with three of eight articles reporting significant associations. CONCLUSION This systematic review provides evidence that children of lower SES are at increased risk of CHD-related mortality. As these children are over-represented in the CHD population, interventions targeting socio-economic inequalities could have a large impact on improving CHD survival.
Collapse
Affiliation(s)
- Kate E Best
- Institute of Health & Society, Newcastle University, Newcastle Upon Tyne, UK
| | - Rute Vieira
- Institute of Health & Society, Newcastle University, Newcastle Upon Tyne, UK.,The Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | - Judith Rankin
- Institute of Health & Society, Newcastle University, Newcastle Upon Tyne, UK
| |
Collapse
|
38
|
Miller TA, Ghanayem NS, Newburger JW, McCrindle BW, Hu C, DeWitt AG, Cnota JF, Tractenberg FL, Pemberton VL, Wolf MJ, Votava-Smith JK, Fifer CG, Lambert LM, Shah A, Graham EM, Pizarro C, Jacobs JP, Miller SG, Minich LL. Gestational Age, Birth Weight, and Outcomes Six Years After the Norwood Procedure. Pediatrics 2019; 143:peds.2018-2577. [PMID: 30979811 PMCID: PMC6564065 DOI: 10.1542/peds.2018-2577] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Preterm delivery and low birth weight (LBW) are generally associated with worse outcomes in hypoplastic left heart syndrome (HLHS), but an individual preterm or small neonate may do well. We sought to explore the interactions between gestational age, birth weight, and birth weight for gestational age with intermediate outcomes in HLHS. METHODS We analyzed survival, growth, neurodevelopment, length of stay, and complications to age 6 years in subjects with HLHS from the Single Ventricle Reconstruction trial. Univariate and multivariable survival and regression analyses examined the effects and interactions of LBW (<2500 g), weight for gestational age, and gestational age category. RESULTS Early-term delivery (n = 234) was more common than term (n = 219) delivery. Small for gestational age (SGA) was present in 41% of subjects, but only 14% had LBW. Preterm, compared with term, delivery was associated with an increased risk of death or transplant at age 6 years (all: hazard ratio = 2.58, confidence interval = 1.43-4.67; Norwood survivors: hazard ratio = 1.96, confidence interval = 1.10-3.49) independent of LBW and weight for gestational age. Preterm delivery, early-term delivery, LBW, and SGA were each associated with lower weight at 6 years. Neurodevelopmental outcomes were worst in the LBW cohort. CONCLUSIONS Preterm delivery in HLHS was associated with worse survival, even beyond Norwood hospitalization. LBW, SGA, and early-term delivery were associated with worse growth but not survival. LBW was associated with worse neurodevelopment, despite similar length of stay and complications. These data suggest that preterm birth and LBW (although often concomitant) are not equivalent, impacting clinical outcomes through mechanisms independent of perioperative course complexity.
Collapse
Affiliation(s)
- Thomas A. Miller
- Department of Pediatrics, The University of Utah, Salt Lake City, Utah
| | - Nancy S. Ghanayem
- Department of Pediatrics, Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Brian W. McCrindle
- Department of Pediatrics, University of Toronto and Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Canada
| | - Chenwei Hu
- New England Research Institute, Watertown, Massachusetts
| | - Aaron G. DeWitt
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - James F. Cnota
- Heart Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | | | - Victoria L. Pemberton
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Michael J. Wolf
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia
| | - Jodie K. Votava-Smith
- Department of Pediatrics, Children’s Hospital of Los Angeles, Los Angeles, California
| | - Carlen G. Fifer
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Linda M. Lambert
- Department of Pediatrics, The University of Utah, Salt Lake City, Utah
| | - Amee Shah
- Department of Pediatrics, Columbia University, New York, New York
| | - Eric M. Graham
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Christian Pizarro
- Departments of Surgery and Pediatrics, Thomas Jefferson University, Wilmington, Delaware
| | - Jeffrey P. Jacobs
- The Congenital Heart Institute of Florida, St. Petersburg, Florida; and
| | - Stephen G. Miller
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - L. LuAnn Minich
- Department of Pediatrics, The University of Utah, Salt Lake City, Utah
| | | |
Collapse
|
39
|
Alsoufi B, McCracken C, Kochilas LK, Clabby M, Kanter K. Factors Associated With Interstage Mortality Following Neonatal Single Ventricle Palliation. World J Pediatr Congenit Heart Surg 2018; 9:616-623. [DOI: 10.1177/2150135118787723] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background: Several advances have led to improved hospital survival following neonatal palliation (NP) of single ventricle (SV) anomalies. Nonetheless, a number of patients continue to suffer from interstage mortality (ISM) prior to subsequent Glenn. We aim to study patients’ characteristics and anatomic, surgical, and clinical details associated with ISM. Methods: A total of 453 SV neonates survived to hospital discharge following NP. Competing risk analysis modeled events after NP (Glenn, transplantation, or death) and examined variables associated with ISM. Results: Competing risk analysis showed that one year following NP, 10% of patients had died, 87% had progressed to Glenn, 1% had received heart transplantation, and 2% were alive without subsequent surgery. On multivariable analysis, factors associated with ISM were as follows: weight ≤2.5 kg (hazard ratio, HR = 2.4 [1.2-4.6], P = .013), premature birth ≤36 weeks (HR = 2.0 [1.0-4.0], P = .05), genetic syndromes (HR = 3.2 [1.7-6.1], P < .001), unplanned cardiac reoperation (HR = 2.1 [1.0-4.4], P = .05), and prolonged intensive care unit (ICU) stay >30 days following NP (HR = 2.5 [1.4-4.5], P < .001). Palliative surgery type (shunt, Norwood, band) was not associated with ISM, although aortopulmonary shunt circulation after Norwood was (HR = 5.4 [1.5-19.2] P = .01). Of interest, underlying SV anatomy was not associated with ISM (HR = 1.1 [0.6-2.2], P = .749). Conclusions: In our series, ISM following NP occurred in 10% of hospital survivors. As opposed to hospital death, underlying SV anomaly was not associated with ISM. Conversely, several patient factors (prematurity, low weight, and genetic syndromes) and clinical factors (unplanned reoperation and prolonged ICU stay following NP) were associated with ISM. Vigilant outpatient management that is individualized to specific clinical and social needs, taking into account all associated factors, is warranted to improve survival in high-risk patients.
Collapse
Affiliation(s)
- Bahaaldin Alsoufi
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Courtney McCracken
- Sibley Heart Center, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Lazaros K. Kochilas
- Sibley Heart Center, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Martha Clabby
- Sibley Heart Center, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Kirk Kanter
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
40
|
Alsoufi B, McCracken C, Oster M, Shashidharan S, Kanter K. Genetic and Extracardiac Anomalies Are Associated With Inferior Single Ventricle Palliation Outcomes. Ann Thorac Surg 2018; 106:1204-1212. [DOI: 10.1016/j.athoracsur.2018.04.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 04/10/2018] [Accepted: 04/18/2018] [Indexed: 12/20/2022]
|
41
|
Meza JM, Slieker M, Blackstone EH, Mertens L, DeCampli WM, Kirklin JK, Karimi M, Eghtesady P, Pourmoghadam K, Kim RW, Burch PT, Jacobs ML, Karamlou T, McCrindle BW. A novel, data-driven conceptualization for critical left heart obstruction. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2018; 165:107-116. [PMID: 30337065 DOI: 10.1016/j.cmpb.2018.08.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/11/2018] [Accepted: 08/20/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Qualitative features of aortic and mitral valvar pathology have traditionally been used to classify congenital cardiac anomalies for which the left heart structures are unable to sustain adequate systemic cardiac output. We aimed to determine if novel groups of patients with greater clinical relevance could be defined within this population of patients with critical left heart obstruction (CLHO) using a data-driven approach based on both qualitative and quantitative echocardiographic measures. METHODS An independent standardized review of recordings from pre-intervention transthoracic echocardiograms for 651 neonates with CLHO was performed. An unsupervised cluster analysis, incorporating 136 echocardiographic measures, was used to group patients with similar characteristics. Key measures differentiating the groups were then identified. RESULTS Based on all measures, cluster analysis linked the 651 neonates into groups of 215 (Group 1), 338 (Group 2), and 98 (Group 3) patients. Aortic valve atresia and left ventricular (LV) end diastolic volume were identified as significant variables differentiating the groups. The median LV end diastolic area was 1.35, 0.69, and 2.47 cm2 in Groups 1, 2, and 3, respectively (p < 0.0001). Aortic atresia was present in 11% (24/215), 87% (294/338), and 8% (8/98), in Groups 1, 2, and 3, respectively (p < 0.0001). Balloon aortic valvotomy was the first intervention for 9% (19/215), 2% (6/338), and 61% (60/98), respectively (p < 0.0001). For those with an initial operation, single ventricle palliation was performed in 90% (176/215), 98% (326/338), and 58% (22/38) (p < 0.0001). Overall mortality in each group was 27% (59/215), 41% (138/338), and 12% (12/98) (p < 0.0001). CONCLUSIONS Using a data-driven approach, we conceptualized three distinct patient groups, primarily based quantitatively on baseline LV size and qualitatively by the presence of aortic valve atresia. Management strategy and overall mortality differed significantly by group. These groups roughly correspond anatomically and are analogous to multi-level LV hypoplasia, hypoplastic left heart syndrome, and critical aortic stenosis, respectively. Our analysis suggests that quantitative and qualitative assessment of left heart structures, particularly LV size and type of aortic valve pathology, may yield conceptually more internally consistent groups than a simplistic scheme limited to valvar pathology alone.
Collapse
Affiliation(s)
- James M Meza
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, CA .
| | - Martijn Slieker
- Division of Pediatric Cardiology, Radboud University Medical Center, Nijmegan, the Netherlands
| | - Eugene H Blackstone
- Division of Cardiovascular and Thoracic Surgery and Department of Quantitative Health Sciences, The Cleveland Clinic, Cleveland, OH
| | - Luc Mertens
- Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, CA
| | - William M DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Children's Hospital, Orlando, FL
| | - James K Kirklin
- Division of Cardiothoracic Surgery, University of Alabama-Birmingham, Birmingham, AL
| | - Mohsen Karimi
- Division of Pediatric Cardiac Surgery, Yale-New Haven Children's Hospital, New Haven, CT
| | - Pirooz Eghtesady
- Division of Cardiothoracic Surgery, St. Louis Children's Hospital, St. Louis. MO
| | - Kamal Pourmoghadam
- Division of Pediatric Cardiac Surgery, Arnold Palmer Children's Hospital, Orlando, FL
| | - Richard W Kim
- Division of Cardiothoracic Surgery, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Phillip T Burch
- Division of Cardiothoracic Surgery, Primary Children's Medical Center, Salt Lake City, UT
| | - Marshall L Jacobs
- Division of Cardiac Surgery, Johns Hopkins Heart and Vascular Institute, Baltimore, MD
| | - Tara Karamlou
- Division of Thoracic and Cardiovascular Surgery, Phoenix Children's Hospital, Phoenix, AZ
| | - Brian W McCrindle
- Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, CA ; Division of Pediatric Cardiac Surgery, Arnold Palmer Children's Hospital, Orlando, FL ; Department of Pediatrics, University of Toronto, Toronto, CA .
| |
Collapse
|
42
|
|
43
|
Cohen MS, Dagincourt N, Zak V, Baffa JM, Bartz P, Dragulescu A, Dudlani G, Henderson H, Krawczeski CD, Lai WW, Levine JC, Lewis AB, McCandless RT, Ohye RG, Owens ST, Schwartz SM, Slesnick TC, Taylor CL, Frommelt PC. The Impact of the Left Ventricle on Right Ventricular Function and Clinical Outcomes in Infants with Single-Right Ventricle Anomalies up to 14 Months of Age. J Am Soc Echocardiogr 2018; 31:1151-1157. [PMID: 29980396 DOI: 10.1016/j.echo.2018.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Children with single-right ventricle anomalies such as hypoplastic left heart syndrome (HLHS) have left ventricles of variable size and function. The impact of the left ventricle on the performance of the right ventricle and on survival remains unclear. The aim of this study was to identify whether left ventricular (LV) size and function influence right ventricular (RV) function and clinical outcome after staged palliation for single-right ventricle anomalies. METHODS In the Single Ventricle Reconstruction trial, echocardiography-derived measures of LV size and function were compared with measures of RV systolic and diastolic function, tricuspid regurgitation, and outcomes (death and/or heart transplantation) at baseline (preoperatively), early after Norwood palliation, before stage 2 palliation, and at 14 months of age. RESULTS Of the 522 subjects who met the study inclusion criteria, 381 (73%) had measurable left ventricles. The HLHS subtype of aortic atresia/mitral atresia was significantly less likely to have a measurable left ventricle (41%) compared with the other HLHS subtypes: aortic stenosis/mitral stenosis (100%), aortic atresia/mitral stenosis (96%), and those without HLHS (83%). RV end-diastolic and end-systolic volumes were significantly larger, while diastolic indices suggested better diastolic properties in those subjects with no left ventricles compared with those with measurable left ventricles. However, RV ejection fraction was not different on the basis of LV size and function after staged palliation. Moreover, there was no difference in transplantation-free survival to Norwood discharge, through the interstage period, or at 14 months of age between those subjects who had measurable left ventricles compared with those who did not. CONCLUSIONS LV size varies by anatomic subtype in infants with single-right ventricle anomalies. Although indices of RV size and diastolic function were influenced by the presence of a left ventricle, there was no difference in RV systolic function or transplantation-free survival on the basis of LV measures.
Collapse
Affiliation(s)
- Meryl S Cohen
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | | | - Victor Zak
- New England Research Institutes, Boston, Massachusetts
| | - Jeanne Marie Baffa
- Division of Cardiology, A.I. DuPont Hospital for Children, Wilmington, Delaware
| | - Peter Bartz
- Division of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Andreea Dragulescu
- Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gul Dudlani
- Division of Cardiology, Johns Hopkins All Children's Heart Institute, St. Petersburg, Florida
| | - Heather Henderson
- Division of Pediatric Cardiology, Duke University Medical Center, Raleigh, North Carolina
| | | | - Wyman W Lai
- Division of Cardiology, Morgan Stanley Children's Hospital, New York, New York
| | - Jami C Levine
- Department of Cardiology, Children's Hospital, Boston, Boston, Massachusetts
| | - Alan B Lewis
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, California
| | | | - Richard G Ohye
- Division of Cardiac Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Sonal T Owens
- Division of Pediatric Cardiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Steven M Schwartz
- Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Carolyn L Taylor
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Peter C Frommelt
- Division of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | |
Collapse
|
44
|
Son JS, James A, Fan CPS, Mertens L, McCrindle BW, Manlhiot C, Friedberg MK. Prognostic Value of Serial Echocardiography in Hypoplastic Left Heart Syndrome. Circ Cardiovasc Imaging 2018; 11:e006983. [DOI: 10.1161/circimaging.117.006983] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 05/17/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Jae Sung Son
- Division of Pediatric Cardiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea (J.S.S.)
| | - Adam James
- Division of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children and University of Toronto, ON, Canada (A.J., C.-P.S.F., L.M., B.W.M., C.M., M.K.F.)
| | - Chun-Po Steve Fan
- Division of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children and University of Toronto, ON, Canada (A.J., C.-P.S.F., L.M., B.W.M., C.M., M.K.F.)
| | - Luc Mertens
- Division of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children and University of Toronto, ON, Canada (A.J., C.-P.S.F., L.M., B.W.M., C.M., M.K.F.)
| | - Brian W. McCrindle
- Division of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children and University of Toronto, ON, Canada (A.J., C.-P.S.F., L.M., B.W.M., C.M., M.K.F.)
| | - Cedric Manlhiot
- Division of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children and University of Toronto, ON, Canada (A.J., C.-P.S.F., L.M., B.W.M., C.M., M.K.F.)
| | - Mark K. Friedberg
- Division of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children and University of Toronto, ON, Canada (A.J., C.-P.S.F., L.M., B.W.M., C.M., M.K.F.)
| |
Collapse
|
45
|
Jean-St-Michel E, Meza JM, Maguire J, Coles J, McCrindle BW. Survival to Stage II with Ventricular Dysfunction: Secondary Analysis of the Single Ventricle Reconstruction Trial. Pediatr Cardiol 2018. [PMID: 29520465 DOI: 10.1007/s00246-018-1845-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Ventricular dysfunction affects survival in patients with single right ventricle (RV), and remains one of the primary indications for heart transplantation. Since it is challenging to predict the capacity of patients with ventricular dysfunction to proceed to the stage II procedure, we sought to identify factors that would be associated with death or heart transplantation without achieving stage II for single RV patients with ventricular dysfunction after Norwood procedure. The Single Ventricle Reconstruction (SVR) trial public-use database was used. Patients with a RV ejection fraction less than 44% or a RV fractional area of change less than 35% on the post-Norwood echocardiogram were included. Parametric risk hazard analysis was used to identify risk factors for death or transplantation without achieving stage II. Of 365 patients with ventricular function measurements on the post-Norwood echocardiogram, 123 (34%) patients had RV dysfunction. The transplantation-free survival was significantly lower for those with ventricular dysfunction compared to those with normal function (log rank Chi-square = 4.23, p = 0.04). Furthermore, having a Blalock-Taussig (BT) shunt, a large RV, a post-Norwood infectious complication, and a surgeon who performs five or less Norwood per year were independent risk factors for death or transplantation without achieving stage II. The predicted 6-month transplantation-free survival for patients with all four identified risk factors was 1% (70% CI 0-13%). Early heart transplantation referral might be considered for post-Norwood patients with BT shunt and RV dysfunction, especially if other high-risk features are present.
Collapse
Affiliation(s)
- Emilie Jean-St-Michel
- Division of Cardiology, The Labatt Family Heart Centre, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - James M Meza
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, Department of Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Jonathon Maguire
- Li Ka Shing Knowledge Institute of St. Michael's hospital, Department of Pediatrics, St. Michael's Hospital, University of Toronto, 30 Bond St, Toronto, ON, M5B1W8, Canada
| | - John Coles
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, Department of Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Brian W McCrindle
- Division of Cardiology, The Labatt Family Heart Centre, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| |
Collapse
|
46
|
Abdulla RI. A Shift in Focus. Pediatr Cardiol 2018; 39:857-858. [PMID: 29637253 DOI: 10.1007/s00246-018-1856-1] [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: 02/25/2018] [Accepted: 03/02/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Ra-Id Abdulla
- Rush University, 1630 W Harrison Street, Chicago, IL, 60607, USA.
| |
Collapse
|
47
|
Colen T, Kutty S, Thompson RB, Tham E, Mackie AS, Li L, Truong DT, Maruyama M, Smallhorn JF, Khoo NS. Tricuspid Valve Adaptation during the First Interstage Period in Hypoplastic Left Heart Syndrome. J Am Soc Echocardiogr 2018; 31:624-633. [DOI: 10.1016/j.echo.2017.11.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Indexed: 11/15/2022]
|
48
|
Beke DM. Norwood Procedure for Palliation of Hypoplastic Left Heart Syndrome: Right Ventricle to Pulmonary Artery Conduit vs Modified Blalock-Taussig Shunt. Crit Care Nurse 2018; 36:42-51. [PMID: 27908945 DOI: 10.4037/ccn2016861] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Patients with hypoplastic left heart syndrome undergo a series of operations to separate the pulmonary and systemic circulations. The first of at least 3 operations occurs in the newborn period, with a stage I palliation. The goal of stage I palliation is to provide pulmonary blood flow and create an unobstructed systemic outflow tract. Advances in surgical techniques and intraoperative and postoperative care have helped decrease morbidity and mortality for patients with hypoplastic left heart syndrome who have the stage I Norwood operation, but the patients continue to be at increased risk for hemodynamic collapse and adverse outcomes. This article discusses risk factors, surgical approach, postoperative nursing and medical management strategies, differences between and outcomes for the Norwood operation with the right ventricle to pulmonary artery conduit and the Norwood operation with a modified Blalock-Taussig shunt.
Collapse
Affiliation(s)
- Dorothy M Beke
- Dorothy M. Beke is a clinical nurse specialist in the cardiac intensive care unit at Boston Children's Hospital, Boston, Massachusetts. She is the unit's mechanical circulatory support clinical resource, the cardiovascular program bereavement coordinator, and a nurse practitioner in the cardiology preoperative clinic.
| |
Collapse
|
49
|
Bucholz EM, Sleeper LA, Newburger JW. Neighborhood Socioeconomic Status and Outcomes Following the Norwood Procedure: An Analysis of the Pediatric Heart Network Single Ventricle Reconstruction Trial Public Data Set. J Am Heart Assoc 2018; 7:e007065. [PMID: 29420218 PMCID: PMC5850235 DOI: 10.1161/jaha.117.007065] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 12/13/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Children with single ventricle heart disease require frequent interventions and follow-up. Low socioeconomic status (SES) may limit access to high-quality care and place these children at risk for poor long-term outcomes. METHODS AND RESULTS Data from the SVR (Pediatric Heart Network Single Ventricle Reconstruction Trial Public Use) data set were used to examine the relationship of US neighborhood SES with 30-day and 1-year mortality or cardiac transplantation and length of stay among neonates undergoing the Norwood procedure (n=525). Crude rates of death or transplantation at 1 year after Norwood were highest for patients living in neighborhoods with low SES (lowest tertile 37.0% versus middle tertile 31.0% versus highest tertile 23.6%, P=0.024). After adjustment for patient demographics, birth characteristics, and anatomy, patients in the highest SES tertile had significantly lower risk of death or transplant than patients in the lowest SES tertile (hazard ratio 0.62, 95% confidence interval, 0.40, 0.96). When SES was examined continuously, the hazard of 1-year death or transplant decreased steadily with increasing neighborhood SES. Hazard ratios for 30-day transplant-free survival and 1-year transplant-free survival were similar in magnitude. There were no significant differences in length of stay following the Norwood procedure by SES. CONCLUSIONS Low neighborhood SES is associated with worse 1-year transplant-free survival after the Norwood procedure, suggesting that socioeconomic and environmental factors may be important determinants of outcome in critical congenital heart disease. Future studies should investigate aspects of SES and environment amenable to intervention. CLINICAL TRIAL REGISTRATION URL:http://www.clinicaltrials.gov> http://www.clinicaltrials.gov. Unique identifier: NCT00115934.
Collapse
Affiliation(s)
- Emily M Bucholz
- Department of Medicine, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Lynn A Sleeper
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Jane W Newburger
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| |
Collapse
|
50
|
Newburger JW, Sleeper LA, Gaynor JW, Hollenbeck-Pringle D, Frommelt PC, Li JS, Mahle WT, Williams IA, Atz AM, Burns KM, Chen S, Cnota J, Dunbar-Masterson C, Ghanayem NS, Goldberg CS, Jacobs JP, Lewis AB, Mital S, Pizarro C, Eckhauser A, Stark P, Ohye RG. Transplant-Free Survival and Interventions at 6 Years in the SVR Trial. Circulation 2018; 137:2246-2253. [PMID: 29437119 DOI: 10.1161/circulationaha.117.029375] [Citation(s) in RCA: 154] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 01/16/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the SVR trial (Single Ventricle Reconstruction), 1-year transplant-free survival was better for the Norwood procedure with right ventricle-to-pulmonary artery shunt (RVPAS) compared with a modified Blalock-Taussig shunt in patients with hypoplastic left heart and related syndromes. At 6 years, we compared transplant-free survival and other outcomes between the groups. METHODS Medical history was collected annually using medical record review, telephone interviews, and the death index. The cohort included 549 patients randomized and treated in the SVR trial. RESULTS Transplant-free survival for the RVPAS versus modified Blalock-Taussig shunt groups did not differ at 6 years (64% versus 59%, P=0.25) or with all available follow-up of 7.1±1.6 years (log-rank P=0.13). The RVPAS versus modified Blalock-Taussig shunt treatment effect had nonproportional hazards (P=0.009); the hazard ratio (HR) for death or transplant favored the RVPAS before stage II surgery (HR, 0.66; 95% confidence interval, 0.48-0.92). The effect of shunt type on death or transplant was not statistically significant between stage II to Fontan surgery (HR, 1.36; 95% confidence interval, 0.86-2.17; P=0.17) or after the Fontan procedure (HR, 0.76; 95% confidence interval, 0.33-1.74; P=0.52). By 6 years, patients with RVPAS had a higher incidence of catheter interventions (0.38 versus 0.23/patient-year, P<0.001), primarily because of more interventions between the stage II and Fontan procedures (HR, 1.72; 95% confidence interval, 1.00-3.03). Complications did not differ by shunt type; by 6 years, 1 in 5 patients had had a thrombotic event, and 1 in 6 had had seizures. CONCLUSIONS By 6 years, the hazards of death or transplant and catheter interventions were not different between the RVPAS versus modified Blalock-Taussig shunt groups. Children assigned to the RVPAS group had 5% higher transplant-free survival, but the difference did not reach statistical significance, and they required more catheter interventions. Both treatment groups have accrued important complications. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT00115934.
Collapse
Affiliation(s)
- Jane W Newburger
- Boston Children's Hospital and Harvard Medical School, MA (J.W.N., L.A.S., C.D.-M.).
| | - Lynn A Sleeper
- Boston Children's Hospital and Harvard Medical School, MA (J.W.N., L.A.S., C.D.-M.)
| | - J William Gaynor
- Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | | | - Peter C Frommelt
- Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F., N.S.G.)
| | - Jennifer S Li
- North Carolina Consortium, Duke University, Durham (J.S.L.).,East Carolina University, Greenville, NC (J.S.L.).,Wake Forest University, Winston-Salem, NC (J.S.L.)
| | - William T Mahle
- Children's Healthcare of Atlanta and Emory University, GA (W.T.M.)
| | - Ismee A Williams
- Morgan Stanley Children's Hospital of New York-Presbyterian, Columbia College of Physicians and Surgeons, NY (I.A.W.)
| | - Andrew M Atz
- Medical University of South Carolina, Charleston (A.M.A.)
| | - Kristin M Burns
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (KM.B.)
| | - Shan Chen
- New England Research Institutes, Watertown, MA (D.H.-P., S.C., P.S.)
| | - James Cnota
- Cincinnati Children's Medical Center, OH (J.C.)
| | | | - Nancy S Ghanayem
- Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F., N.S.G.)
| | - Caren S Goldberg
- University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.)
| | | | | | - Seema Mital
- Hospital for Sick Children, Toronto, Ontario, Canada (S.M.)
| | | | - Aaron Eckhauser
- Primary Children's Hospital and the University of Utah, Salt Lake City (A.E.)
| | - Paul Stark
- New England Research Institutes, Watertown, MA (D.H.-P., S.C., P.S.)
| | - Richard G Ohye
- University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.)
| | | |
Collapse
|