Quality of life in young patients after cone reconstruction for Ebstein anomaly

Contemporary Early Postoperative Cone Repair Outcomes for Patients With Ebstein Anomaly

OBJECTIVE

To describe the early postoperative outcomes after cone repair (CR) for Ebstein anomaly (EA) across the age spectrum.

PATIENTS AND METHODS

For this study, 284 patients from 1 to 73 years of age who underwent CR at Mayo Clinic from June 1, 2007, to December 21, 2018, were separated by age group (1-<4, 4-<19, 19-<40, and 40+ years) and by disease severity for analysis. Outcomes of interest included death, reoperation, readmission, early postoperative complications, cardiac intensive care unit and hospital length of stay, and need for superior cavopulmonary anastomosis.

RESULTS

Mortality within 30 days was 0%. The reoperation rate was 4.9% (n=14) and the median hospital length of stay was 5 days, with no statistical difference between ages at time of CR or severity groups. The readmission rate was 2% (n=6). Postoperative complications were seen in 8.8% (n=25) of cases overall, with higher rates in the youngest age group (21%, P<.001). Superior cavopulmonary anastomosis was most common in the youngest age group (37% vs 17% overall, P<.001) and in those with severe disease (35%, P<.001).

CONCLUSION

Children and adults with Ebstein anomaly have very good early postoperative outcomes with a less than 10% complication and reoperation rate and very low mortality following cone reconstruction. In the setting of good and stable right ventricle function and no symptoms of heart failure or cyanosis, waiting for CR until 4 years of age may minimize early postoperative complications and need for superior cavopulmonary anastomosis.

The Association of Age and Repair Modification with Outcome after Cone Repair for Ebstein's Malformation

Cone repair (CR) uses native tissue for tricuspid valve (TV) repair and provides potential for growth. Results after CR were investigated in different age groups including several surgical modifications. Single institution retrospective analysis of all CR excluding neonatal procedures. Endpoints included TV reoperation, late tricuspid regurgitation (TR) and death. Between April 2006 and August 2019, 157 patients underwent CR at a median age of 11.7 years (range, 0.3-57.2). 20% (n=32) of patients had previous surgery. Repair modifications included atrial reduction (n=111,71%), right ventricular plication (n=85,55%), leaflet augmentation (n=36,23%), papillary muscle repositioning (n=50,32%), ring annuloplasty (n=70,45%). Early re-operation for recurrent TR occurred in 11 patients. Median follow-up time was 4.3 years (range, 9d-12.3y). There was no significant association between age at repair and time to TV reoperation (p=0.25). However, age <4 years at CR was identified as the most discriminating binary age threshold for the patients with TV reoperation (25.0% in <4y group vs 9.3% in the ≥4y group). Placement of an annuloplasty ring was protective against ≥moderate TR (OR=0.39, 95% CI 0.16-0.95, p=0.039). Freedom from late TV re-operation was 94.1% at 7 years. Survival was 97.9% at 6 years. Repair after age 18 years was associated with mortality in early follow-up (p=0.037). Mid-term results for CR are favorable in children and adults. Time to TV reoperation may be shorter when CR is performed before age four years, but this result requires confirmation in a larger sample. An annuloplasty ring should be considered when appropriate.

PedsQL for prediction of postoperative patient-reported outcomes following Chiari decompression surgery

OBJECTIVE

The purpose of this study is to determine if the preoperative Pediatric Quality of Life Inventory (PedsQL) score is predictive of short- and intermediate-term PedsQL outcomes following Chiari decompression surgery. The utility of preoperative patient-reported outcomes (PROs) in predicting pain, opioid consumption, and long-term PROs has been demonstrated in adult spine surgery. To the best of the authors' knowledge, however, there is currently no widely accepted tool to predict short-, intermediate-, or long-term outcomes after pediatric Chiari decompression surgery.

METHODS

A prospectively maintained database was retrospectively reviewed. Patients who had undergone first-time decompression for symptomatic Chiari malformation were identified and grouped according to their preoperative PedsQL scores: mild disability (score 80-100), moderate disability (score 60-79), and severe disability (score < 60). PedsQL scores at the 6-week, 3-month, and/or 6-month follow-ups were collected. Preoperative PedsQL subgroups were tested for an association with demographic and perioperative characteristics using one-way ANOVA or chi-square analysis. Preoperative PedsQL subgroups were tested for an association with improvements in short- and intermediate-term PedsQL scores using one-way ANOVA and a paired Wilcoxon signed-rank test controlling for statistically different demographic characteristics when appropriate.

RESULTS

A total of 87 patients were included in this analysis. According to their preoperative PedsQL scores, 28% of patients had mild disability, 40% had moderate disability, and 32% had severe disability. There was a significant difference in the prevalence of comorbidities (p = 0.009) and the presenting symptoms of headaches (p = 0.032) and myelopathy (p = 0.047) among the subgroups; however, in terms of other demographic or operative factors, there was no significant difference. Patients with greater preoperative disability demonstrated statistically significantly lower PedsQL scores at all postoperative time points, except in terms of the parent-reported PedsQL at 6 months after surgery (p = 0.195). Patients with severe disability demonstrated statistically significantly greater improvements (compared to preoperative scores) in PedsQL scores at all time points after surgery, except in terms of the 6-week and 6-month PROs and the 6-month parent-reported outcomes (p = 0.068, 0.483, and 0.076, respectively).

CONCLUSIONS

Patients with severe disability, as assessed by the PedsQL, had lower absolute PedsQL scores at all time points after surgery but greater improvement in short- and intermediate-term PROs. The authors conclude that the PedsQL is an efficient and accurate tool that can quickly assess patient disability in the preoperative period and predict both short- and intermediate-term surgical outcomes.