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Thangappan K, Fatuzzo S, Zafar F, Winlaw D, Lehenbauer D, Batlivala S, Cnota JF, Redington A, Tweddell JS, Morales DLS. Management of Neonates Admitted with Tetralogy of Fallot: Changing Patterns Across the United States. Ann Thorac Surg 2021; 114:1419-1426. [PMID: 34600902 DOI: 10.1016/j.athoracsur.2021.08.064] [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: 03/21/2021] [Revised: 08/20/2021] [Accepted: 08/30/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND This study describes the evolving in-hospital management strategies for neonates who are diagnosed with Tetralogy of Fallot (ToF). METHODS The Pediatric Health Information System (PHIS) database was used to identify admitted patients 0-1 month old with ToF from 2010-2019. Era 1: 2010-2014; Era 2: 2015-2019. ICD codes were used to identify related interventions, which occurred during this admission but not necessarily as a neonate: full repair, systemic-to-pulmonary shunt, and percutaneous stent in the RVOT &/or PDA. RESULTS 6,021 neonates were diagnosed with ToF. 2,030(34%) of them underwent an intervention:60% had total repair, 31% systemic-to-pulmonary shunt, 9% percutaneous stent. In the no-intervention cohort, in-hospital mortality was 9%. In-hospital mortality between repair(6%), shunt(6%), and stent(3%) patients(p=0.446) did not differ. Regarding regional practices, no-intervention was most frequently employed in the Midwest (69%vs.65% average for all other regions(avg),p=0.075) while interventions overall were performed most frequently in the West (36%vs.33.5% avg, p=0.075). Amongst the interventions, full repair was most frequent in the Northeast (76%vs.57% avg,p<0.001), shunt was most frequent in the Midwest (39%vs28% avg, p<0.001), and stent was most frequent in the South (11%vs.7%avg,p=0.083). Between Eras 1 & 2, the type of intervention changed: full repair (52%vs69%,p<0.001) and stent (1%vs16%,p<0.001) increased, while shunt decreased (47%vs15%,p<0.001). CONCLUSIONS Although the majority of neonates admitted with ToF are discharged with no intervention, over 1/3 undergo some intervention with a 3-6% mortality. Though the proportion of these patients intervened upon is unchanged over the past decade, the types of intervention have changed and significant regional differences exist.
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Affiliation(s)
- Karthik Thangappan
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Stephen Fatuzzo
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Farhan Zafar
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David Winlaw
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David Lehenbauer
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Sarosh Batlivala
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - James F Cnota
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Andrew Redington
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - James S Tweddell
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David L S Morales
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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Zurakowski D, Jonas RA. The many factors leading to resurgence of the Blalock shunt for tetralogy. J Thorac Cardiovasc Surg 2021; 161:396-399. [DOI: 10.1016/j.jtcvs.2020.03.172] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/02/2020] [Accepted: 03/05/2020] [Indexed: 02/07/2023]
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Xu J, Guthrey C, Dalby S, Tang X, Daily J, Collins RT. The Limited Benefit of Follow-Up Echocardiograms After Repair of Tetralogy of Fallot. Pediatr Cardiol 2019; 40:1722-1727. [PMID: 31535184 DOI: 10.1007/s00246-019-02210-3] [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: 04/25/2019] [Accepted: 08/10/2019] [Indexed: 11/26/2022]
Abstract
Tetralogy of Fallot (ToF) is the most common cyanotic congenital heart disease, making up 10% of all congenital heart defects. Annual follow-up echocardiograms are recommended in patients with repaired ToF, but evidence-based guidelines do not exist. We hypothesized that most echocardiograms performed in asymptomatic patients with repaired ToF and no physical exam change do not result in an actionable change (AC) in management. We retrospectively reviewed records of all patients with ToF and prior complete repair at our institution between January 2000 and September 2015. Changes in echocardiograms resulting in hospital admission, medication addition/change, cardiac catheterization, or surgical procedure were identified via chart review. These changes were referred to as an AC. A total of 1135 echocardiograms were reviewed from 233 patients (160 with initial complete repair, 70 with prior shunt, and 3 with other initial surgery). The median number of echocardiograms per patient was 5. Of the 1135 echocardiograms, 15 (1.3%) were associated with AC. Of the 15 patients with AC echocardiograms, 9 underwent a shunt prior to complete repair (9/70, 12.9%) and 6 had undergone an initial complete repair (6/160, 3.8%). The median age at AC was 6.3 years (IQR 4.4, 6.8) in the shunt group and 0.90 years (IQR 0.87, 1.1) in the initial complete repair group. In asymptomatic patients with repaired ToF and no physical exam change, echocardiograms rarely lead to a change in clinical management. In conclusion, the likelihood and timing of AC echocardiograms and reinterventions vary based on the type of initial surgery.
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Affiliation(s)
- Jack Xu
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Caleb Guthrey
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Stephen Dalby
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Xinyu Tang
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Joshua Daily
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - R Thomas Collins
- Stanford University School of Medicine, 750 Welch Road, Suite 321, Palo Alto, CA, 94304, USA.
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA.
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Peer SM, Jonas RA. Controlling the Cost of Management of Congenital Heart Disease. Ann Thorac Surg 2019; 109:988-989. [PMID: 31521596 DOI: 10.1016/j.athoracsur.2019.07.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 07/11/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Syed Murfad Peer
- Department of Cardiac Surgery, Children's National Health System, 111 Michigan Ave NW, Washington, DC 20010.
| | - Richard A Jonas
- Department of Cardiac Surgery, Children's National Health System, 111 Michigan Ave NW, Washington, DC 20010
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Jonas RA. WJPCHS Presidential Address: Threats to the Continuing Globalization of Early Primary Repair. World J Pediatr Congenit Heart Surg 2019; 10:58-65. [PMID: 30799711 DOI: 10.1177/2150135118815028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The outgoing presidential address presented by the author at the July 2018 meeting of the World Society for Pediatric and Congenital Heart Surgery focuses on forces threatening the movement toward single-stage repair of congenital heart anomalies in the young. Issues that are of particular importance in the United States are challenges in training the next generation of surgeons, an increasing percentage of premature neonates, and the use of data analytics by hospital administration which incentivizes inflation of procedural numbers. However, the most important factor is the ranking of hospitals by the lay press with heavy emphasis on early procedural mortality rather than patient survival. In contrast to current databases used for such rankings, the new World Society database is planning to collect patient admissions rather than procedural number as the key denominator to allow accurate calculation of patient survival. The current heavy weighting of procedural success (ie, early hospital mortality) in establishing rankings of hospitals is encouraging centers to undertake palliative procedures in high-risk patients or avoiding a surgical procedure altogether.
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Affiliation(s)
- Richard A Jonas
- 1 Department of Cardiovascular Surgery, Children's National Health System, Washington, DC, USA
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Cunningham MEA, Donofrio MT, Peer SM, Zurakowski D, Jonas R, Sinha P. Influence of Age and Weight on Technical Repair of Tetralogy of Fallot. Ann Thorac Surg 2016; 102:864-869. [PMID: 27154147 DOI: 10.1016/j.athoracsur.2016.02.087] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 02/21/2016] [Accepted: 02/25/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND We have previously shown that early primary repair of tetralogy of Fallot can be performed without increased morbidity or resource utilization. The technical performance score (TPS) is a self-assessment tool used to identify patients at risk of poor postoperative outcomes. We hypothesized that adequate technical repair can be obtained regardless of the patient's preoperative age or size. METHODS A retrospective review of all tetralogy of Fallot patients repaired between September 2004 and December 2013 was performed. The postoperative predischarge echocardiogram was reviewed to assign a TPS rating of optimal, adequate, or inadequate. The TPS groups were compared by univariate analysis using the Kruskal-Wallis test for continuous variables and χ(2) analysis for categoric variables. Multivariable logistic regression analysis was performed to identify independent predictors of inadequate TPS. RESULTS Among 167 patients (1 operative mortality), TPS was optimal in 88, adequate in 62, and inadequate in 17. Patients with worse TPS had longer ventilation time (p = 0.031), hospital length of stay (p = 0.036), and higher hospital charges (p = 0.005). Multivariable regression analysis revealed discontinuous branch pulmonary arteries (odds ratio 18.24, 95% confidence interval: 1.42 to 234, p = 0.015) as the only independent predictor of inadequate TPS. Younger age at repair (p = 0.245) and smaller weight (p = 0.260) were not associated with inadequate TPS. CONCLUSIONS Technical adequacy of tetralogy of Fallot repair is affected by anatomic subsets (discontinuous branch pulmonary arteries) and not by the patient's age or size. Worse TPS is associated with higher postoperative morbidity and hospital charges. Younger age and size should not be a deterrent for early primary repair.
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Affiliation(s)
| | - Mary T Donofrio
- Department of Cardiology, Children's National Health System, Washington, DC
| | - Syed Murfad Peer
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC
| | - David Zurakowski
- Departments of Anesthesia and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Richard Jonas
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC
| | - Pranava Sinha
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC.
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Alternative repair strategies for ductal-dependent tetralogy of fallot and short-term postoperative outcomes, a multicenter analysis. Pediatr Cardiol 2015; 36:177-89. [PMID: 25164237 DOI: 10.1007/s00246-014-0983-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 07/22/2014] [Indexed: 10/24/2022]
Abstract
Our aim was to evaluate postoperative morbidity and mortality following initial intervention, comparing primary repair versus palliative shunt in the setting of ductal-dependent tetralogy of Fallot. When neonatal surgical intervention is required, controversy and cross-center variability exists with regard to surgical strategy. The multicenter Pediatric Health Information System database was queried to identify patients with TOF and ductal-dependent physiology, excluding pulmonary atresia. Eight hundred forty-five patients were included-349 (41.3%) underwent primary complete repair, while 496 (58.7%) underwent initial palliation. Palliated patients had significantly higher comorbid diagnoses of genetic syndrome and coronary artery anomalies. Primary complete repair patients had significantly increased morbidity across a number of variables compared to shunt palliation, but mortality rate was equal (6%). Second-stage complete repair was analyzed for 285 of palliated patients, with median inter-stage duration of 231 days (175-322 days). In comparison to primary complete repairs, second-stage repairs had significantly decreased morbidity and mortality. However, cumulative morbidity was higher for the staged patients. Median adjusted billed charges were lower for primary complete repair ($363,554) compared to staged repair ($428,109). For ductal-dependent TOF, there is no difference in postoperative mortality following the initial surgery (6%) whether management involves primary repair or palliative shunt. Although delaying complete repair by performing a palliative shunt is associated with a shift of much of the morbidity burden to outside of the newborn period, there is greater total postoperative morbidity and resource utilization associated with the staged approach.
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Brennan A, Gauvreau K, Connor J, O’Connell C, David S, Almodovar M, DiNardo J, Banka P, Mayer JE, Marshall AC, Bergersen L. Development of a charge adjustment model for cardiac catheterization. Pediatr Cardiol 2015; 36:264-73. [PMID: 25113520 PMCID: PMC4303716 DOI: 10.1007/s00246-014-0994-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 07/23/2014] [Indexed: 11/15/2022]
Abstract
A methodology that would allow for comparison of charges across institutions has not been developed for catheterization in congenital heart disease. A single institution catheterization database with prospectively collected case characteristics was linked to hospital charges related and limited to an episode of care in the catheterization laboratory for fiscal years 2008-2010. Catheterization charge categories (CCC) were developed to group types of catheterization procedures using a combination of empiric data and expert consensus. A multivariable model with outcome charges was created using CCC and additional patient and procedural characteristics. In 3 fiscal years, 3,839 cases were available for analysis. Forty catheterization procedure types were categorized into 7 CCC yielding a grouper variable with an R (2) explanatory value of 72.6%. In the final CCC, the largest proportion of cases was in CCC 2 (34%), which included diagnostic cases without intervention. Biopsy cases were isolated in CCC 1 (12%), and percutaneous pulmonary valve placement alone made up CCC 7 (2%). The final model included CCC, number of interventions, and cardiac diagnosis (R (2) = 74.2%). Additionally, current financial metrics such as APR-DRG severity of illness and case mix index demonstrated a lack of correlation with CCC. We have developed a catheterization procedure type financial grouper that accounts for the diverse case population encountered in catheterization for congenital heart disease. CCC and our multivariable model could be used to understand financial characteristics of a population at a single point in time, longitudinally, and to compare populations.
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Affiliation(s)
- Andrew Brennan
- Department of Cardiology, Children’s Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Kimberlee Gauvreau
- Department of Cardiology, Children’s Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Jean Connor
- Department of Cardiology, Children’s Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Cheryl O’Connell
- Department of Cardiology, Children’s Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Sthuthi David
- Department of Cardiology, Children’s Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Melvin Almodovar
- Department of Cardiology, Children’s Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
| | - James DiNardo
- Department of Cardiology, Children’s Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Puja Banka
- Department of Cardiology, Children’s Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
| | - John E. Mayer
- Department of Cardiology, Children’s Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Audrey C. Marshall
- Department of Cardiology, Children’s Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Lisa Bergersen
- Department of Cardiology, Children’s Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115 USA
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Abstract
Uncertainty surrounds both the timing and ideal form of early management of tetralogy of Fallot. Some centers perform early complete repair in all patients regardless of age, symptoms and morphology. Others recommend a two-stage approach involving initial palliation in symptomatic neonates and young infants and those with unfavorable anatomy (anomalous coronary anatomy or hypoplastic pulmonary arteries). Advantages of early anatomic correction include alleviation of cyanosis, normal growth and organ development, removal of stimulus for right ventricular hypertrophy and avoidance of risks associated with initial palliation. With recent advances in anesthetic, operative and postoperative management, routine primary repair of tetralogy of Fallot in the neonate and young infant can be accomplished with excellent early and mid-term results. However, long-term follow-up is necessary to assess the impact of early repair on late right ventricular function, arrhythmias and need for reintervention.
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Affiliation(s)
- Christopher D Derby
- Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Wilmington, DE 19899, USA.
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Hunter RM, Isaac M, Frigiola A, Blundell D, Brown K, Bull K. Lifetime costs and outcomes of repair of Tetralogy of Fallot compared to natural progression of the disease: Great Ormond Street Hospital cohort. PLoS One 2013; 8:e59734. [PMID: 23533645 PMCID: PMC3606116 DOI: 10.1371/journal.pone.0059734] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 02/17/2013] [Indexed: 11/19/2022] Open
Abstract
Background Tetralogy of Fallot is a congenital heart disease that requires surgical repair without which survival through childhood is extremely rare. The aim of this paper is to use data from the mandatory follow-up of patients with Tetralogy of Fallot to model the health-related costs and outcomes over the first 55-years of life. Method A decision analytical model was developed to establish costs and outcomes for patients up to 55 years after diagnosis and first repair of Tetralogy of Fallot compared to natural progression. Data from Adult Congenital Heart Disease (ACHD) centres that follow up Tetralogy of Fallot patients and Great Ormond Street Hospital (GOSH), London, United Kingdom (UK) medical records was used to establish the cost and effectiveness of current interventions. Data from a Czech cohort was used for the natural, no intervention condition. Results The average cost per patient of a repair for Tetralogy of Fallot was £26,938 (SE = £4,140). The full life time cost per patient, with no discount rate, was £65,310 (95% CI £64,981–£65,729); £56,559 discounted (95% CI £56,159–£56,960). Patients with a repair had an average of 35 Quality Adjusted Life Years (QALYs) per patient over 55 years undiscounted and 20.16 QALYs discounted. If the disorder was left to take its natural course, patients on average had a total of 3 QALYs per patient with no discount rate and 2.30 QALYs discounted. Conclusion A model has been developed that provides an estimate of the value for money of an expensive repair of a congenital heart disease. The model could be used to test the cost-effectiveness of making amendments to the care pathway.
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Mercer-Rosa L, Pinto N, Yang W, Tanel R, Goldmuntz E. 22q11.2 Deletion syndrome is associated with perioperative outcome in tetralogy of Fallot. J Thorac Cardiovasc Surg 2013; 146:868-73. [PMID: 23312975 DOI: 10.1016/j.jtcvs.2012.12.028] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 11/01/2012] [Accepted: 12/10/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We sought to investigate the impact of 22q11.2 deletion on perioperative outcome in tetralogy of Fallot. METHODS We conducted a retrospective review of patients with tetralogy of Fallot who underwent complete surgical reconstruction at The Children's Hospital of Philadelphia between 1995 and 2006. Inclusion criteria included diagnosis of tetralogy of Fallot and known genotype. Fisher exact and Mann-Whitney tests were used for categoric and continuous variables, respectively. Regression analysis was used to determine whether deletion status predicts outcome. RESULTS We studied 208 subjects with tetralogy of Fallot, 164 (79%) without and 44 (20%) with 22q11.2 deletion syndrome. There were no differences in sex, race, gestational age, age at diagnosis, admission weight, and duration of mechanical ventilation. Presenting anatomy, survival, complications and reoperations were also comparable between patients with and without 22q11.2 deletion syndrome. Those with 22q11.2 deletion syndrome had more aortopulmonary shunts preceding complete surgical repair (21% vs 7%, P = .02). This association was present after adjustment for presenting anatomy (stenosis, atresia, or absence of pulmonary valve and common atrioventricular canal) and surgical era. In addition, those with 22q11.2 deletion syndrome had longer cardiopulmonary bypass time (84 vs 72 minutes, P = .02) and duration of intensive care (6 vs 4 days, P = .007). CONCLUSIONS Genotype affects early operative outcomes in tetralogy of Fallot resulting, in particular, in longer duration of intensive care. Future studies are required to determine factors contributing to such differences in this susceptible population.
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Affiliation(s)
- Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa.
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Reddy VM. Low birth weight and very low birth weight neonates with congenital heart disease: timing of surgery, reasons for delaying or not delaying surgery. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2013; 16:13-20. [PMID: 23561813 DOI: 10.1053/j.pcsu.2013.01.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Conventional management of low birth weight and very low birth weight neonates was composed of deferring corrective surgery by aggressive medical management or palliative surgery which does not require cardiopulmonary bypass. However, while waiting for weight gain, these neonates are at risk for various comorbidities. In the current era, this "wait and let the baby grow" approach has not been shown to result in better clinical outcomes. Early primary repair hence has become the standard strategy for congenital heart disease requiring surgery in these neonates. However, there still exist some circumstances, which are considered to be unfavorable for corrective surgery due to medical, physiologic, surgeon's technical and institutional-systemic factors. We reviewed the recent literature and examined the reasons for delaying or not delaying surgery.
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Affiliation(s)
- V Mohan Reddy
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94305-5407, USA.
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Oster ME, Dawson AL, Batenhorst CM, Strickland MJ, Kleinbaum DG, Mahle WT. Relationship between resource utilization and length of stay following tetralogy of Fallot repair. CONGENIT HEART DIS 2012; 8:535-40. [PMID: 23241434 DOI: 10.1111/chd.12023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND The relationship between resource utilization and postoperative length of stay (PLOS) following congenital heart disease surgery is unknown. METHODS We performed a retrospective cohort study using data from the Pediatric Health Information Systems database. We included subjects 1 month to 1 year of age with a PLOS of ≤ 1 month following elective, complete repair of tetralogy of Fallot (TOF) during 2004-2008 at children's hospitals that performed ≥ 10 such surgeries during the study period. We constructed three generalized linear models to assess the relationships of total costs, laboratory costs, and imaging costs during the first three postoperative days with overall PLOS. Race/ethnicity, insurance type, sex, and presence of a genetic syndrome (by ICD-9 codes) were included in the models as fixed effects; hospital of surgery was included as a random effect. RESULTS For 1161 eligible surgical encounters at 36 children's hospitals, mean PLOS was 7.1 days (median = 6 days). Mean total, laboratory, and imaging costs for the first three postoperative days were $26,455, $2941, and $813, respectively. Most subjects were male (58.9%), did not have a genetic syndrome (88.3%), were non-Hispanic white (58.3%), and had either public or private insurance (41.0% and 39.1%, respectively). An estimated increase in total costs of $4600 or laboratory costs of $700 in the first three postoperative days was associated with a 1-day increase in PLOS. Imaging costs were not associated with PLOS. CONCLUSIONS Increased resource utilization is not associated with a shorter PLOS following elective TOF repair, and it may be associated with longer PLOS.
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Affiliation(s)
- Matthew E Oster
- Emory University Rollins School of Public Health, Atlanta, Ga, USA; Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga, USA
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Ishibashi N, Scafidi J, Murata A, Korotcova L, Zurakowski D, Gallo V, Jonas RA. White matter protection in congenital heart surgery. Circulation 2012; 125:859-71. [PMID: 22247493 DOI: 10.1161/circulationaha.111.048215] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Neurodevelopmental delays in motor skills and white matter (WM) injury have been documented in congenital heart disease and after pediatric cardiac surgery. The lack of a suitable animal model has hampered our understanding of the cellular mechanisms underlying WM injury in these patients. Our aim is to identify an optimal surgical strategy for WM protection to reduce neurological injury in congenital heart disease patients. METHODS AND RESULTS We developed a porcine cardiopulmonary bypass model that displays area-dependent WM maturation. In this model, WM injury was identified after cardiopulmonary bypass-induced ischemia-reperfusion injury. The degree of injury was inversely correlated with the maturation stage, which indicates maturation-dependent vulnerability of WM. Within different oligodendrocyte developmental stages, we show selective vulnerability of O4+ preoligodendrocytes, whereas oligodendrocyte progenitor cells were resistant to insults. This indicates that immature WM is vulnerable to cardiopulmonary bypass-induced injury but has an intrinsic potential for recovery mediated by endogenous oligodendrocyte progenitor cells. Oligodendrocyte progenitor cell number decreased with age, which suggests that earlier repair allows successful WM development. Oligodendrocyte progenitor cell proliferation was observed within a few days after cardiopulmonary bypass-induced ischemia-reperfusion injury; however, by 4 weeks, arrested oligodendrocyte maturation and delayed myelination were detected. Logistic model confirmed that maintenance of higher oxygenation and reduction of inflammation were effective in minimizing the risk of injury at immature stages of WM development. CONCLUSIONS Primary repair in neonates and young infants potentially provides successful WM development in congenital heart disease patients. Cardiac surgery during this susceptible period should avoid ischemia-reperfusion injury and minimize inflammation to prevent long-term WM-related neurological impairment.
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Affiliation(s)
- Nobuyuki Ishibashi
- Children's National Medical Center, 111 Michigan Ave NW, Washington, DC 20010-2970, USA
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Pasquali SK, Sun JL, d'Almada P, Jaquiss RDB, Lodge AJ, Miller N, Kemper AR, Lannon CM, Li JS. Center variation in hospital costs for patients undergoing congenital heart surgery. Circ Cardiovasc Qual Outcomes 2011; 4:306-12. [PMID: 21505154 DOI: 10.1161/circoutcomes.110.958959] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Congenital heart disease consumes significant health care resources; however, there are limited data regarding factors affecting resource utilization. The purpose of this study was to evaluate variation between centers in total hospital costs for 4 congenital heart operations of varying complexity and associated factors. METHODS AND RESULTS The Premier Database was used to evaluate total cost in children undergoing isolated atrial septal defect (ASD) repair, ventricular septal defect (VSD) repair, tetralogy of Fallot (TOF) repair, or arterial switch operation (ASO) from 2001 to 2007. Mixed models were used to evaluate the impact of center on total hospital costs adjusting for patient and center characteristics and length of stay. A total of 2124 patients were included: 719 ASD (19 centers), 792 VSD (20 centers), 420 TOF (17 centers), and 193 ASO (13 centers). Total cost increased with complexity of operation from median $12 761 (ASD repair) to $55 430 (ASO). In multivariable analysis, models that accounted for center effects versus those that did not performed significantly better for all 4 surgeries (all P≤0.01). The proportion of total cost variation explained by center was 19% (ASD repair), 11% (VSD repair), 6% (TOF repair), and 3% (ASO). Higher-volume centers had significantly lower hospital costs for ASD and VSD repair but not for TOF repair and ASO. CONCLUSIONS Total hospital costs varied significantly by center for all congenital heart surgeries evaluated, even after adjustment for patient and center characteristics and length of stay. Differences among centers were most prominent for lower complexity procedures.
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Affiliation(s)
- Sara K Pasquali
- Divisions of Pediatric Cardiology and Cardiothoracic Surgery and the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27715, USA.
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16
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Jonas R. Advantages of early primary repair of congenital heart disease. World J Pediatr Congenit Heart Surg 2010; 1:407-10. [PMID: 23804898 DOI: 10.1177/2150135110376081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Richard Jonas
- Childrens National Medical Center, Washington DC, USA
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17
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Kanter KR, Kogon BE, Kirshbom PM, Carlock PR. Symptomatic Neonatal Tetralogy of Fallot: Repair or Shunt? Ann Thorac Surg 2010; 89:858-63. [DOI: 10.1016/j.athoracsur.2009.12.060] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Revised: 12/23/2009] [Accepted: 12/24/2009] [Indexed: 10/19/2022]
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18
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Long-term results of right ventricular outflow tract reconstruction in neonatal cardiac surgery: Options and outcomes. J Thorac Cardiovasc Surg 2009; 138:911-6. [DOI: 10.1016/j.jtcvs.2008.10.058] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2008] [Revised: 09/16/2008] [Accepted: 10/13/2008] [Indexed: 11/17/2022]
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19
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Karamlou T, McCrindle BW, Williams WG. Surgery Insight: late complications following repair of tetralogy of Fallot and related surgical strategies for management. ACTA ACUST UNITED AC 2006; 3:611-22. [PMID: 17063166 DOI: 10.1038/ncpcardio0682] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2005] [Accepted: 06/19/2006] [Indexed: 11/09/2022]
Abstract
Biventricular correction of tetralogy of Fallot was devised more than 50 years ago. Current short-term outcomes are excellent. The potential for late complications is, however, an important concern for the growing number of postrepair survivors. Progressive pulmonary valve regurgitation leading to right heart failure and arrhythmia are centrally important problems faced by these patients. New techniques are, however, likely to change the future outcomes for postrepair survivors. These techniques include percutaneous valve replacement, arrhythmia ablation surgery, and strategies that emphasize preservation of the pulmonary valve even at the cost of leaving some residual valvular stenosis. The objectives of this Review are to outline the major complications that arise late after repair of tetralogy of Fallot, to describe the surgical approaches that have been developed to avoid and manage arising complications, and to briefly explore how novel treatment paradigms could change the future long-term outlook for patients following tetralogy repair.
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Affiliation(s)
- Tara Karamlou
- Division of Cardiovascular Surgery, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada
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20
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Reddy P, Song J. Cost comparisons of pharmacological strategies in open-heart surgery. PHARMACOECONOMICS 2003; 21:249-262. [PMID: 12600220 DOI: 10.2165/00019053-200321040-00003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Open-heart surgery (OHS) is performed to bypass occluded arteries, replace malfunctioning cardiac valves or correct congenital abnormalities. The average cost of OHS varies from $US25 057-$US79 795 (1997 values). The objective of this paper was to review economic studies of pharmacological strategies in open-heart surgery. Pharmacological strategies studied include the prevention of postoperative complications such as atrial fibrillation (AF), bleeding and infection. Modifications in anaesthetic technique have been attempted by using agents that promote early extubation. In addition, strategies for postoperative management of sedation, analgesia and AF and use of neuromuscular blockers have also been compared. The majority of studies in this area have been cost analyses with few cost-effectiveness studies performed. Prophylaxis against AF with amiodarone is associated with a reduction in AF and was cost-neutral compared with placebo. Compared with placebo, prevention of bleeding with antifibrinolytics reduces transfusion costs. In direct comparative studies, lysine analogues, due to lower drug acquisition costs, offset transfusion costs to a greater extent than aprotinin. However, safety concerns with the lysine analogues remain. Erythropoietin decreases transfusion requirements and is cost effective compared with no intervention when the cost of postoperative bacterial complications is included. First- and second-generation cephalosporins prevent postoperative infections. Based on drug acquisition cost, the first-generation agents are less expensive although when administration costs are included, both classes have similar costs. Modifications in anaesthetic technique with short-acting anaesthetic agents, results in higher drug costs although nursing and total hospital costs are typically reduced. For neuromuscular blockers, drug acquisition costs are lowest with pancuronium but administration costs and the cost of adverse events have not been included in existing analyses. Midazolam provides an equivalent level of postoperative sedation to propofol but the acquisition cost is lower. The combined use of propofol and midazolam warrants further investigation, as its use is associated with lower sedative agent costs compared with either agent alone. There is limited data on the economics of postoperative analgesia and the management of AF. As the majority of studies to date are partial cost analyses, additional studies that include length of stay and other hospitalisation data are warranted. In future, cost-effectiveness and cost-utility studies, which incorporate quality of life and the cost of adverse effects and other longer term costs, should be undertaken.
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21
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Abstract
The optimal surgical approach and timing for patients with tetralogy of Fallot remain controversial. There are two options in current practice: a two-stage repair (an initial palliative aortopulmonary shunt at an early age followed by complete repair at an older age) or primary complete repair. There has been a trend towards primary repair at a young age, which can be attributed to advances in anesthetic and cardiac surgical techniques. Primary repair has several advantages. The correction can be done in one operation and shunt complications are avoided. Progressive right ventricular fibrosis, ventricular hypertrophy, and chronic hypoxia are avoided, which may reduce the incidence of late ventricular arrhythmias. However, surgical correction at a young age is associated with an increased incidence of transannular patching and consequent pulmonary regurgitation. Progressive pulmonary regurgitation is associated with late ventricular arrhythmias and sudden death. These consequences may be prevented by timely pulmonary valve replacement. Palliative procedures include an aortopulmonary shunt, balloon dilation of the right ventricular tract, and stent placement. Of these measures, the aortopulmonary shunt is preferred, as it results in a more predictable outcome. Complications associated with shunt placement include shunt occlusion, pulmonary artery distortion, and occasionally, volume overloading of the left ventricle and pulmonary circulation. Institutional and surgeon preferences exist for either surgical strategy, and ultimately are justifiable when they produce the best outcomes for the individual patient. The optimal surgical strategy has to be determined by large prospective randomized studies that compare the functional status of the pulmonary valve and the need for reoperation at long-term follow-up.
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Affiliation(s)
- Samantha C. Gouw
- Department of Cardiology, Wilhelmina Children's Hospital, Postbox 85090, 3508 AB Utrecht, The Netherlands.
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22
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Van Arsdell GS, Maharaj GS, Tom J, Rao VK, Coles JG, Freedom RM, Williams WG, McCrindle BW. What is the Optimal Age for Repair of Tetralogy of Fallot? Circulation 2000. [DOI: 10.1161/circ.102.suppl_3.iii-123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
—Controversy regarding the timing for the repair of tetralogy of Fallot centers around initial palliation versus primary repair for the symptomatic neonate/young infant and the optimal age for repair of the asymptomatic child. We changed our approach from one of initial palliation in the infant to one of primary repair around the age of 6 months, or earlier if clinically indicated. We examined the effects of this change in protocol and age on outcomes.
Methods and Results
—The records of 227 consecutive children who had repair of isolated tetralogy of Fallot from January 1993 to June 1998 were reviewed. The median age of repair by year fell from 17 to 8 months (
P
<0.01). The presence of a palliative shunt at the time of repair decreased from 38% to 0% (
P
<0.01). Mortality (6 deaths, 2.6%) improved with time (
P
=0.02), with no mortality since the change in protocol (late 1995/early 1996). Multivariate analysis for physiological outcomes of time to lactate clearance, ventilation hours, and length of stay, but not death, demonstrated that an age <3 months was independently associated with prolongation of times (
P
<0.03). Each of the deaths occurred with primary repair at an age >12 months. The best survival and physiological outcomes were achieved with primary repair in children aged 3 to 11 months.
Conclusions
—On the basis of mortality and physiological outcomes, the optimal age for elective repair of tetralogy of Fallot is 3 to 11 months of age.
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Affiliation(s)
- Glen S. Van Arsdell
- From the Divisions of Cardiac Surgery and Cardiology (R.M.F., B.W.M.), The Hospital for Sick Children, Toronto, and the Departments of Surgery and Pediatrics (R.M.F., B.W.M.), the University of Toronto, Toronto, Canada
| | - Gyaandeo S. Maharaj
- From the Divisions of Cardiac Surgery and Cardiology (R.M.F., B.W.M.), The Hospital for Sick Children, Toronto, and the Departments of Surgery and Pediatrics (R.M.F., B.W.M.), the University of Toronto, Toronto, Canada
| | - Julie Tom
- From the Divisions of Cardiac Surgery and Cardiology (R.M.F., B.W.M.), The Hospital for Sick Children, Toronto, and the Departments of Surgery and Pediatrics (R.M.F., B.W.M.), the University of Toronto, Toronto, Canada
| | - Vivek K. Rao
- From the Divisions of Cardiac Surgery and Cardiology (R.M.F., B.W.M.), The Hospital for Sick Children, Toronto, and the Departments of Surgery and Pediatrics (R.M.F., B.W.M.), the University of Toronto, Toronto, Canada
| | - John G. Coles
- From the Divisions of Cardiac Surgery and Cardiology (R.M.F., B.W.M.), The Hospital for Sick Children, Toronto, and the Departments of Surgery and Pediatrics (R.M.F., B.W.M.), the University of Toronto, Toronto, Canada
| | - Robert M. Freedom
- From the Divisions of Cardiac Surgery and Cardiology (R.M.F., B.W.M.), The Hospital for Sick Children, Toronto, and the Departments of Surgery and Pediatrics (R.M.F., B.W.M.), the University of Toronto, Toronto, Canada
| | - William G. Williams
- From the Divisions of Cardiac Surgery and Cardiology (R.M.F., B.W.M.), The Hospital for Sick Children, Toronto, and the Departments of Surgery and Pediatrics (R.M.F., B.W.M.), the University of Toronto, Toronto, Canada
| | - Brian W. McCrindle
- From the Divisions of Cardiac Surgery and Cardiology (R.M.F., B.W.M.), The Hospital for Sick Children, Toronto, and the Departments of Surgery and Pediatrics (R.M.F., B.W.M.), the University of Toronto, Toronto, Canada
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23
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Hirsch JC, Mosca RS, Bove EL. Complete repair of tetralogy of Fallot in the neonate: results in the modern era. Ann Surg 2000; 232:508-14. [PMID: 10998649 PMCID: PMC1421183 DOI: 10.1097/00000658-200010000-00006] [Citation(s) in RCA: 126] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To review more than a decade of experience with complete repair of tetralogy of Fallot (TOF) in neonates at the University of Michigan; to assess early and late survival, perioperative complications, and the incidence of reoperation; and to analyze patient, procedural, and morphologic risk factors to determine their effects on outcome. SUMMARY BACKGROUND DATA Palliation of TOF with systemic-to-pulmonary artery shunts has been the accepted standard for symptomatic neonates and infants. Complete repair has traditionally been reserved for infants older than 6 months of age because of the perception that younger and smaller infants face an unacceptably high surgical risk. RESULTS A retrospective review from August 1988 to November 1999 consisted of 61 consecutive symptomatic neonates with TOF who underwent complete repair. Thirty-one patients had TOF with pulmonary stenosis, 24 had TOF with pulmonary atresia, and 6 had TOF with nonconfluent pulmonary arteries. The mean age at repair was 16 +/- 13 days, and the mean weight was 3.2 +/- 0.7 kg. Before surgery, 36 patients were receiving an infusion of prostaglandin, 26 were mechanically ventilated, and 11 required inotropic support. Right ventricular outflow tract obstruction was managed with a transannular patch in 49 patients and a right ventricle-to-pulmonary artery conduit in 12. Cardiopulmonary bypass time averaged 71 +/- 26 minutes. Hypothermic circulatory arrest was used in 52 patients (mean 38 +/- 12 minutes). After cardiopulmonary bypass, the average intraoperative right/left ventricular pressure ratio was 55% +/- 13%. There were no new clinically apparent neurologic sequelae after repair. The postoperative intensive care unit stay was 9.1 +/- 8 days, with 6.8 +/- 7 days of mechanical ventilation. There was one hospital death from postoperative necrotizing enterocolitis on postoperative day 71 and four late deaths, only one of which was cardiac-related. Actuarial survival was 93% at 5 years. Follow-up was available for all 60 hospital survivors and averaged 62 months (range 1-141 months). Twenty-two patients required a total of 24 reoperations at an average interval of 26 months after repair. Indications for reoperation included right ventricular outflow tract obstruction (19), branch pulmonary artery stenosis (11), severe pulmonary insufficiency (4), and residual ventricular septal defect (1). The 1-month, 1-year, and 5-year freedom from reoperation rates were 100%, 89%, and 58%, respectively. CONCLUSIONS Complete repair of TOF in the neonate is associated with excellent intermediate-term survival. Although the reoperation rate is significant, this is to be expected with the complex right ventricular outflow tract and pulmonary artery anatomy seen in symptomatic neonates and the need for conduit replacement in patients with TOF with pulmonary atresia.
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Affiliation(s)
- J C Hirsch
- Section of Cardiac Surgery, Department of Surgery, The University of Michigan School of Medicine, Ann Arbor, Michigan 48109-0223, USA
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24
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Knott-Craig CJ, Elkins RC, Lane MM, Holz J, McCue C, Ward KE. A 26-year experience with surgical management of tetralogy of Fallot: risk analysis for mortality or late reintervention. Ann Thorac Surg 1998; 66:506-11. [PMID: 9725393 DOI: 10.1016/s0003-4975(98)00493-7] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Over the past decade repair of tetralogy of Fallot (TOF) in infancy has gained favor. It is still uncertain what effect early complete repair will have on survival or late reoperation on the right ventricular outflow tract. METHODS To assess these outcomes, we reviewed our experience (1971-1997) with 294 patients undergoing operation at one institution. Median follow-up was 10.6 years (range, 0.1 to 26 years), and was complete for 90.2% patients. RESULTS Primary complete repair was done in 199 patients (68%), and a staged repair in 62 patients (21%). Thirty-three patients had only a palliative procedure. Sixty-eight patients (23.1%) had complex pathologic processes, including pulmonary atresia in 53. Hospital mortality for primary repair was 11.1% (22/199), for staged repair was 17.7% (11/62), and for palliative procedures was 15.5% (16/103 procedures). Since 1990 mortality has been 2.1%, 11.8%, and 0% respectively (p < 0.001), despite younger age at repair (0.6+/-0.1 versus 2.1+/-0.2 years; p < 0.001). Multivariate analysis identified longer period of hypothermic circulatory arrest, pulmonary artery patch angioplasty, earlier year of operation, and closure of the foramen ovale as risk factors for hospital death. For hospital survivors 20-year survival was 98%+/-3% for TOF with pulmonary stenosis and 88%+/-9% for TOF with pulmonary atresia (p=0.09). Reintervention on the right ventricular outflow tract was needed in 14.1% (37/261) patients. Freedom from reintervention on the right ventricular outflow tract at 20 years was 86%+/-4% for TOF with pulmonary stenosis and 43%+/-16% for TOF with pulmonary atresia (p=0.001). For the subgroup TOF with pulmonary stenosis, this was 85%+/-5% after primary repair and 91%+/-8% after staged repair (not significant). At 15-year follow-up, this was 78%+/-10% for patients not older than 1 year at operation compared with 88%+/-4% for older patients (not significant). CONCLUSIONS Early mortality after primary repair of TOF has significantly improved and late survival is excellent. Primary repair in infancy does not increase risk for reintervention on the right ventricular outflow tract.
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Affiliation(s)
- C J Knott-Craig
- Section of Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190, USA
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25
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Jaggers J, Harrison JK, Bashore TM, Davis RD, Glower DD, Ungerleider RM. The Ross procedure: shorter hospital stay, decreased morbidity, and cost effective. Ann Thorac Surg 1998; 65:1553-7; discussion 1557-8. [PMID: 9647057 DOI: 10.1016/s0003-4975(98)00288-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The Ross procedure has become an accepted and sometimes preferred alternative to mechanical aortic valve replacement. One criticism of the Ross procedure is that it may have a higher operative mortality, morbidity, and cost. Several groups have shown that this operation can be performed safely with less than 3% mortality. The issue of higher cost has not been resolved. In this retrospective study we compared a consecutive group of patients undergoing the Ross procedure with an age- and disease-matched group of patients who underwent mechanical aortic valve replacement. METHODS From 1993 to 1996, 22 consecutive adult patients (age range, 20 to 57 years; mean, 38 +/- 14 years) underwent the Ross procedure. Twenty-seven patients (age range, 17 to 57 years; mean, 41 +/- 10 years) underwent mechanical aortic valve replacement between 1991 and 1996. The hospital cost (in 1996 dollars) and postoperative length of stay were calculated for each patient using Transition I, a hospital-wide cost accounting system. RESULTS There was no hospital mortality in either group. The incidence of significant valve-related complication was 5% (1/22 patients) in the Ross procedure group and 22% (6/27 patients) in the mechanical valve group. There were two late deaths in the group with mechanical aortic valve replacement. The length of stay for the Ross procedure group was 5.9 +/- 2.1 days, versus 8 +/- 1.85 days for the mechanical valve group (p < 0.01). The mean hospital costs were not significantly different, $23,140 +/- $7,825 for the mechanical valve group and $23,226 +/- $6,960 for the group having the Ross procedure. CONCLUSIONS The data from this review demonstrate that the Ross procedure can be done safely, with short hospital stays, decreased morbidity, and costs comparable with those of standard mechanical aortic valve replacement in patients with isolated aortic valve disease.
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Affiliation(s)
- J Jaggers
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.
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Ungerleider RM, Bengur AR, Kessenich AL, Liekweg RJ, Hart EM, Rice BA, Miller CE, Lockwood NW, Knauss SA, Jaggers J, Sanders SP, Greeley WJ. Risk factors for higher cost in congenital heart operations. Ann Thorac Surg 1997; 64:44-8; discussion 49. [PMID: 9236333 DOI: 10.1016/s0003-4975(97)00503-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND For many congenital heart defects, hospital mortality is no longer a sensitive parameter by which to measure outcome. Although hospital survival rates are now excellent for a wide variety of lesions, many patients require expensive and extensive hospital-based services during the perioperative period to enable their convalescence. These services can substantially increase the cost of care delivery. In today's managed care environment, it would be useful if risk factors for higher cost could be identified preoperatively so that appropriate resources could be made available for the care of these patients. The focus of this retrospective investigation is to determine if risk factors for high cost for repair of congenital heart defects can be identified. METHODS We assessed financial risk by tracking actual hospital costs (not charges) for 144 patients undergoing repair of atrial septal defect (58 patients), ventricular septal defect (48 patients), atrioventricular canals (14 patients), or tetralogy of Fallot (24 patients) at Duke University Medical Center between July 1, 1992, and September 15, 1995. Furthermore, we were able to identify where the costs occurred within the hospital. Financial risk was defined as a large (> 60% of mean costs) standard deviation, which indicated unpredictability and variability in the treatment for a group of patients. RESULTS Cost for atrial septal defect repair was predictably consistent (low standard deviation) and was related to hospital length of stay. There were factors, however, for ventricular septal defect, atrioventricular canal, and tetralogy of Fallot repair that are identifiable preoperatively that predict low- and high-risk groups using cost as an outcome parameter. Patients undergoing ventricular septal defect repair who were younger than 6 months of age at the time of repair, who required preoperative hospital stays of longer than 7 days before surgical repair, or who had Down's syndrome had a less predictable cost picture than patients undergoing ventricular septal defect repair who were older than 2 years, who had short (< 4 days) preoperative hospitalization, or who did not have Down's syndrome ($48,252 +/- $42,539 versus $15,819 +/- $7,219; p = 0.008). Patients with atrioventricular canals who had long preoperative hospitalization (> 7 days), usually due to pneumonia (respiratory syncytial virus) with preoperative mechanical ventilation had significantly higher cost than patients with atrioventricular canals who underwent elective repair with short preoperative hospitalization ($83,324 +/- $60,138 versus $26,904 +/- $5,384; p = 0.05). Patients with tetralogy of Fallot had higher costs if they had multiple congenital anomalies, previous palliation (combining costs of both surgical procedures and hospital stays), or severe "tet" spells at the time of presentation for operation compared with patients without these risk factors ($114,202 +/- $88,524 versus $22,241 +/- $7,071; p = 0.0005). One patient (with tetralogy of Fallot) with multiple congenital anomalies died 42 days after tetralogy of Fallot repair of sepsis after a gastrointestinal operation. Otherwise, hospital mortality was 0% for all groups. CONCLUSIONS Low mortality and good long-term outcome for surgical correction of congenital heart defects is now commonplace, but can be expensive as some patients with complex problems receive the care necessary to survive. This study demonstrates that it is possible to identify factors preoperatively that predict financial risk. This knowledge may facilitate implementation of risk adjustments for managed care contracting and for strategic resource allocation.
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Affiliation(s)
- R M Ungerleider
- Department of Nursing Services, Duke University Medical Center, Durham, NC 27712, USA.
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