The influence of congenital heart disease on survival of infants with oesophageal atresia

Survival Trends and Syndromic Esophageal Atresia

BACKGROUND AND OBJECTIVES

Presence of a syndrome (or association) is predictive of poor survival in esophageal atresia (EA). However, most reports rely on historical patient outcomes, limiting their usefulness when estimating risk for neonates born today. We hypothesized improved syndromic EA survival due to advances in neonatal care.

METHODS

A retrospective single-center review of survival in 626 consecutive patients with EA from 1980 to 2017 was performed. Data were collected for recognized risk factors: preterm delivery; birth weight <1500 g; major cardiac disease; vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula, renal anomalies, and limb abnormalities (VACTERL); and non-VACTERL syndromes. Cox proportional hazards regression models were used to evaluate temporal trends in survival with respect to year of birth and syndromic EA.

RESULTS

Overall, 87% of 626 patients with EA survived, ranging from 82% in the 1980s to 91% in the 2010s. After adjusting for confounders, syndromic EA survival did not improve during the study, with no association found between year of birth and survival (hazard ratio [HR] 0.98, 95% confidence interval [CI]: 0.95-1.01). Aside from lethal non-VACTERL syndromes, patients with nonlethal non-VACTERL syndromes (HR 6.85, 95% CI: 3.50-13.41) and VACTERL syndrome (HR 3.02, 95% CI: 1.66-5.49) had a higher risk of death than those with nonsyndromic EA.

CONCLUSIONS

Survival of patients with syndromic EA has not improved, and patients with non-VACTERL syndromes have the highest risk of death. Importantly, this is independent of syndrome lethality, birth weight, and cardiac disease. This contemporary survival assessment will enable more accurate perinatal counseling of parents of patients with syndromic EA.

Type C Esophageal Atresia and d-Transposition of the Great Arteries in a Newborn

A newborn was diagnosed with type C esophageal atresia and d-transposition of the great arteries (d-TGA). In this report, we discuss the management implications of the co-occurrence of two rare congenital abnormalities, including extracorporeal membrane oxygenation support prior to surgical intervention for d-TGA.

Esophageal atresia and tracheoesophageal fistula associated with tetralogy of Fallot: a review of mortality

INTRODUCTION

Oesophageal atresia ± tracheoesophageal fistula (EA/TEF) associated with congenital heart disease (CHD) carries a worse prognosis than EA/TEF alone. Though the Spitz classification takes major CHD into account, there are no data regarding survival with the specific combination of EA/TEF and Tetralogy of Fallot (TOF). With advances in postnatal care, we hypothesised that, survival is improving in these complex patients. This study reports morbidity and mortality outcomes of newborns with oesophageal atresia and TOF cardiac malformations METHODS: All patients with EA/TEF and TOF treated at Alder Hey Children's Hospital between the years 2000-2020, were identified. Data sets regarding gestation, birth weight, associated anomalies, operative intervention, morbidity, and mortality were analysed.

RESULTS

Of a total of 350, EA/TEF patients 9 (2.6%) cases had EA/TEF associated with TOF (M:F 4:5). The median gestational age was 35/40 (range 28-41 weeks) with a median birth weight of 1790 g (range 1060-3350 g). Overall survival was 56% (5/9 cases) and all survivors remain under follow up (range 37-4458 days). Surgical strategies for managing EA/TEF with Fallot's tetralogy included 6/9 primary repairs and 3/9 cases with TEF ligation only (+ gastrostomy ± oesophagostomy).

CONCLUSIONS

This study reports outcome data from one of the largest series of EA TEF patients with Fallot's tetralogy. Whilst outcomes may be challenging for this unique patient cohort, survival metrics provide important prognostic information that can be widely shared with health care teams and parents.

Characteristics and outcomes of children with ductal-dependent congenital heart disease and esophageal atresia/tracheoesophageal fistula: A multi-institutional analysis

BACKGROUND

Extracardiac birth defects are associated with worse outcomes in congenital heart disease (CHD). The impact of esophageal atresia/trachea-esophageal fistula (EA/TEF) on outcomes after surgery for ductal-dependent CHD is unknown.

METHODS

Retrospective matched cohort study using the Pediatric Health Information System database from 07/2004 to 06/2015. Hospitalizations with ductal-dependent CHD and EA/TEF, undergoing CHD surgery were included as cases. Admissions with ductal-dependent CHD without EA/TEF were matched 3:1 for age at admission and Risk Adjustment for Congenital Heart Surgery-1 classification. Comparisons were performed using generalized estimating equations.

RESULTS

There were 124 cases and 372 controls. Cases included 32 (25.8%) low-risk, 86 (69.3%) intermediate-risk, and 6 (4.8%) high-risk patients. Cases had more females compared to controls (53.2% vs 41.1%, P = .022). Cases were more likely to be premature (28.2% vs 13.7%, P = .001) and low birth weight (29.8% vs 11.8%, P < .001). Cases had a similar frequency of Down syndrome, and DiGeorge/Velocardiofacial syndrome, but a higher frequency of anorectal malformations (4.3% vs 2.4%, P < .001) and renal anomalies (27.4% vs 9.9%, P < .001) than controls. Cases had a higher mortality on univariate (22.0% vs 8.4%, P < .001) and multivariable analysis (odds ratio 2.45, 95%, confidence interval 1.34 - 4.49). Prematurity also was significantly associated with mortality on multivariable analysis. Cases had a longer duration of mechanical ventilation, longer hospital duration of stay, and higher total cost than controls (all P < .001).

CONCLUSION

In children with ductal-dependent CHD, EA/TEF is associated with increased morbidity, mortality and resource utilization. A majority of patients undergo EA/TEF repair prior to congenital heart disease surgery. (Surgery 2017;160:XXX-XXX.).

Isolated tracheoesophageal fistula versus esophageal atresia - Early morbidity and short-term outcome. A single institution series

PURPOSE

We compared the postnatal course, morbidity and early results after repair for cases of isolated or "pure" TEF with those for cases of esophageal atresia (EA) with distal tracheoesophageal fistula (TEF).

METHODS

Twenty-four consecutive infants were divided into two groups: isolated TEF [TEF group] (n = 5) and EA with distal TEF [EA group] (n = 19).

RESULTS

A high rate of prematurity (29%) and major cardiac and other surgically-relevant malformations (0.8 vs. 0.7 per infant) was found in both groups. The median age at surgery was 8 days for the TEF group vs. 1 day for the EA group (p < 0.01). Most infants of both cohorts had stable acid-base and respiratory parameters at admission. Generally, tracheoscopy provided valuable information regarding the position of the TEF. Surgery for isolated TEF was performed via right cervicotomy in 4 cases and via thoracotomy in one. Postoperative thoracostomy tubes were inserted in 3 cases and one emergency gastrostomy was created for acute gastric overextension (exclusively in patients with EA). The duration of postoperative mechanical ventilation (49 vs. 113 h, p = 0.045) and the median length of stay in the pediatric surgery unit (10 vs. 20.5 days, p = 0.003) were shorter for the isolated TEF group. Four EA patients experienced severe events. Total mortality was 8% (0 out of 5 with TEF vs. 2 out of 19 with EA).

CONCLUSION

Developmental delay and a high rate of morbidity were found in both groups. More complex surgery increased perioperative morbidity in cases of EA. With early recognition of isolated TEF, a less complicated course can be expected in comparison with esophageal atresia.

Statistical modelling of survival for babies with oesophageal atresia

AIM OF STUDY

We examined variables associated with survival for oesophageal atresia between 1996 and 2014.

METHODS

Possible explanatory variables: birth weight, gestation, cardiac anomalies (any or major), renal anomalies (any or severe), primary anastomosis, leak, secondary oesophageal surgery, tracheomalacia, aortopexy, tracheostomy, gastrostomy, fundoplication, karyotype, neurological status. Variables were assessed with logistic regression and a new model assessed with Kaplan-Meier graphs.

RESULTS

104/120 (87%) babies survived. Median gestation 37weeks, 4 (3%) born before 28weeks. Mean birth weight 2.3 (SD 0.7) kg, 17 (14%) less than 1500g. Frequency (%) of explanatory variables: Major cardiac anomaly 21 (18%), any cardiac anomaly 48 (40%), severe renal anomaly 10 (8%), any renal anomaly 25 (21%), primary anastomosis 105 (88%), anastomotic leak 16 (13%), symptomatic tracheomalacia 28 (23%), aortopexy 17 (14%), tracheostomy 12 (10%), neurological anomaly 7 (6%), fundoplication 15 (13%), gastrostomy 30 (25%), secondary oesophageal surgery 8 (7%), abnormal karyotype 6 (5%). Multivariate analysis showed only renal (OR 0.04, 0.007 0.2) p=0.001, cardiac (OR 0.1, 0.002 0.6) p=0.01 and a primary anastomosis (OR 12.2, 1.8 81.6) p=0.01 (R2=0.48), or major cardiac (OR 0.04, 0.007 0.29) p=0.001 and severe renal anomalies (OR 0.009, 0.001 0.12) p<0.001 alone were significant (R2=0.57).

CONCLUSIONS

Survival is dependent on cardiac and renal anomalies. Birth weight is not significant. We propose a new classification system: 1: neither severe renal nor major cardiac anomaly, 2: either severe renal or major cardiac anomaly, 3: severe renal and major cardiac anomaly.

The impact of the National Institute for Health Research Health Technology Assessment programme, 2003-13: a multimethod evaluation

BACKGROUND

The National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme supports research tailored to the needs of NHS decision-makers, patients and clinicians. This study reviewed the impact of the programme, from 2003 to 2013, on health, clinical practice, health policy, the economy and academia. It also considered how HTA could maintain and increase its impact.

METHODS

Interviews (n = 20): senior stakeholders from academia, policy-making organisations and the HTA programme. Bibliometric analysis: citation analysis of publications arising from HTA programme-funded research. Researchfish survey: electronic survey of all HTA grant holders. Payback case studies (n = 12): in-depth case studies of HTA programme-funded research.

RESULTS

We make the following observations about the impact, and routes to impact, of the HTA programme: it has had an impact on patients, primarily through changes in guidelines, but also directly (e.g. changing clinical practice); it has had an impact on UK health policy, through providing high-quality scientific evidence - its close relationships with the National Institute for Health and Care Excellence (NICE) and the National Screening Committee (NSC) contributed to the observed impact on health policy, although in some instances other organisations may better facilitate impact; HTA research is used outside the UK by other HTA organisations and systematic reviewers - the programme has an impact on HTA practice internationally as a leader in HTA research methods and the funding of HTA research; the work of the programme is of high academic quality - the Health Technology Assessment journal ensures that the vast majority of HTA programme-funded research is published in full, while the HTA programme still encourages publication in other peer-reviewed journals; academics agree that the programme has played an important role in building and retaining HTA research capacity in the UK; the HTA programme has played a role in increasing the focus on effectiveness and cost-effectiveness in medicine - it has also contributed to increasingly positive attitudes towards HTA research both within the research community and the NHS; and the HTA focuses resources on research that is of value to patients and the UK NHS, which would not otherwise be funded (e.g. where there is no commercial incentive to undertake research). The programme should consider the following to maintain and increase its impact: providing targeted support for dissemination, focusing resources when important results are unlikely to be implemented by other stakeholders, particularly when findings challenge vested interests; maintaining close relationships with NICE and the NSC, but also considering other potential users of HTA research; maintaining flexibility and good relationships with researchers, giving particular consideration to the Technology Assessment Report (TAR) programme and the potential for learning between TAR centres; maintaining the academic quality of the work and the focus on NHS need; considering funding research on the short-term costs of the implementation of new health technologies; improving the monitoring and evaluation of whether or not patient and public involvement influences research; improve the transparency of the priority-setting process; and continuing to monitor the impact and value of the programme to inform its future scientific and administrative development.

Temporary Retrograde Occlusion of High-Flow Tracheo-Esophageal Fistula

This report describes a temporary retrograde occlusion technique for control of a high-flow tracheo-esophageal fistula in a critically ill, premature infant born at 29 weeks' gestational age, with a diagnosis of type C (Gross) esophageal atresia and tetralogy of Fallot (TOF). This procedure is a useful bridging maneuver before definitive surgical correction for extremely low birth weight, unstable neonates with tracheo-esophageal fistula who are suffering from associated malformations.

A contemporary prediction rule for esophageal atresia (EA) and tracheo-esophageal fistula (TEF)

BACKGROUND/PURPOSE

Existing prediction models for tracheo-esophageal fistula (TEF) and esophageal atresia (EA) are derived from small single-institution populations treated over long periods. A prediction rule developed in a contemporary, multicenter cohort is important for counseling, tailoring therapy, and benchmarking outcomes.

METHODS

Data were obtained from the 2003, 2006, and 2009 editions of the HCUP Kids' Inpatient Database. Subjects included patients with admission age<three days and ICD-9 diagnostic classification of EA or TEF or procedural coding for TEF repair. An internally validated prediction rule for survival to discharge was developed using a stepwise logistic regression selection algorithm. Predictors included were sex, birth weight, gestational age, cardiac anomalies (major and minor), and chromosomal, other gastrointestinal, central nervous system, and renal anomalies. The model was evaluated for discrimination and calibration and compared with that of Spitz.

RESULTS

An integer-based prediction model was created, identifying patients at high, intermediate, and low risk of death with very good discrimination (c=0.723) and calibration. It is particularly effective at identifying the small population at highest risk of death. The model can be summarized as follows with patients first assigned a score for associated abnormalities: chromosomal abnormality=6 points, major cardiac anomaly=3 points, renal anomaly=2 points, and weight less than 1500g=9 points. Point score cut-offs were 0-6 points low risk, 7-14 intermediate risk, and 15-20 high risk.

CONCLUSIONS

This model compares well with existing prediction models and more effectively discriminates the highest risk patients who may require tailored therapy. The Spitz model is also validated.

Strategy for ventricular septal defect closure after prior gastric pull-through

A 9-year-old boy was referred with a perimembranous ventricular septal defect. At birth, he had undergone a right thoracotomy with ligation of a tracheoesophageal fistula, cervical esophagostomy, and feeding gastrostomy. At 2 years of age, he had gastric tube reconstruction with a pull-through retrosternally, anterior to the heart, and an end-to-end esophagogastric anastomosis. Via a right anterolateral thoracotomy through the previous scar, the entire gastric tube was mobilized away from the sternum to facilitate a median sternotomy. With the patient supine, a median sternotomy was performed without difficulty, and the ventricular septal defect was closed under cardiopulmonary bypass.

20-year survival of children born with congenital anomalies: a population-based study

BACKGROUND

Congenital anomalies are a leading cause of perinatal and infant mortality. Advances in care have improved the prognosis for some congenital anomaly groups and subtypes, but there remains a paucity of knowledge about survival for many others, especially beyond the first year of life. We estimated survival up to 20 years of age for a range of congenital anomaly groups and subtypes.

METHODS

Information about children with at least one congenital anomaly, delivered between 1985 and 2003, was obtained from the UK Northern Congenital Abnormality Survey (NorCAS). Anomalies were categorised by group (the system affected), subtype (the individual disorder), and syndrome according to European Surveillance of Congenital Anomalies (EUROCAT) guidelines. Local hospital and national mortality records were used to identify the survival status of liveborn children. Survival up to 20 years of age was estimated by use of Kaplan-Meier methods. Cox proportional hazards regression was used to examine factors that affected survival.

FINDINGS

13,758 cases of congenital anomaly were notified to NorCAS between 1985 and 2003. Survival status was available for 10 850 (99.0%) of 10 964 livebirths. 20-year survival was 85.5% (95% CI 84.8-86.3) in individuals born with at least one congenital anomaly, 89.5% (88.4-90.6) for cardiovascular system anomalies, 79.1% (76.7-81.3) for chromosomal anomalies, 93.2% (91.6-94.5) for urinary system anomalies, 83.2% (79.8-86.0) for digestive system anomalies, 97.6% (95.9-98.6) for orofacial clefts, and 66.2% (61.5-70.5) for nervous system anomalies. Survival varied between subtypes within the same congenital anomaly group. The proportion of terminations for fetal anomaly increased throughout the study period (from 12.4%, 9.8-15.5, in 1985 to 18.3%, 15.6-21.2, in 2003; p<0.0001) and, together with year of birth, was an independent predictor of survival (adjusted hazard ratio [HR] for proportion of terminations 0.95, 95% CI 0.91-0.99, p=0.023; adjusted HR for year of birth 0.94, 0.92-0.96, p<0.0001).

INTERPRETATION

Estimates of survival for congenital anomaly groups and subtypes will be valuable for families and health professionals when a congenital anomaly is detected, and will assist in planning for the future care needs of affected individuals.

FUNDING

BDF Newlife.

Associated malformations in patients with esophageal atresia

Esophageal atresia is a common type of congenital malformation. The etiology of esophageal atresia is unclear and its pathogenesis is controversial. Because previous reports have inconsistently noted the type and frequency of malformations associated with esophageal atresia, we conducted this study in a geographically well-defined population, evaluating the birth prevalence of esophageal atresia and associated malformations ascertained between 1979 and 2003 in 334,262 consecutive births. Of the 99 patients with esophageal atresia, 46 (46.5%) had associated malformations. These included patients with chromosomal abnormalities (8 patients, 8%); non-chromosomal recognized syndromes (4 patients), including one each CHARGE syndrome, Fanconi anemia, Fryns syndrome, and Opitz G/BBB syndrome; associations including VACTERL (10 patients), and one schisis; one oculo-auriculo-vertebral spectrum; one malformation complex, a sirenomelia, and non-syndromic multiple congenital anomalies (MCA) (21 patients, 21%). Malformations of the cardiovascular system (24%), urogenital system (21%), digestive system (21%), musculoskeletal system (14%), and central nervous system (7%) were the most common other congenital malformations occurring in patients with esophageal atresia and non-syndromic MCA. We observed a high prevalence of total malformations and specific patterns of malformations associated with esophageal atresia which emphasizes the need to evaluate all patients with esophageal atresia for possible associated malformations. The malformations associated with esophageal atresia could be classified into a recognizable malformation syndrome or pattern in 25 out of 46 patients (54%).

Congenital cardiac malformations in neonates with apparently isolated gastrointestinal malformations

BACKGROUND

The association of congenital cardiac malformations (CCM) with malformations of the gastrointestinal tract/abdominal wall is known. Nevertheless, the data presently available are derived from patient populations that include some special conditions known to be associated with a high rate of CCM. The aim of the present study was therefore to determine the incidence of cardiac malformations among neonates with apparently isolated malformations of the gastrointestinal tract/abdominal wall.

METHODS

A total of 201 neonates with apparently isolated gastrointestinal malformations were screened on echocardiography.

RESULT

Thirty-six (17.9%) of the neonates were diagnosed as having a CCM. When the four most frequent gastrointestinal malformations were evaluated, a CCM was diagnosed in 11/69 (15.9%) with anal atresia, in 9/38 (23.7%) with tracheoesophageal fistula/esophageal atresia, in 2/25 (8%) with diaphragmatic hernia and in 5/17 (29.4%) with intestinal atresia. In 11 of 36 patients (30.6%) with CCM, the cardiac problems were hemodynamically significant, requiring anti-congestive and/or surgical treatment.

CONCLUSION

A significant number of neonates with apparently isolated gastrointestinal malformations had CCM. Because almost all patients with malformations of the gastrointestinal tract/abdominal wall require early surgical intervention, they should be evaluated on echocardiography to investigate CCM at the earliest opportunity.

Cardiovascular malformations among preterm infants

OBJECTIVE

Preterm birth and cardiovascular malformations are the 2 most common causes of neonatal and infant death, but there are no published population-based reports on the relationship between them. We undertook this study to determine the prevalence and spectrum of cardiovascular malformations in a preterm population, the prevalence of prematurity among infants with cardiovascular malformations, and the influence of prematurity and cardiovascular malformations on outcomes.

METHODS

We based the study on the population of the former Northern Health Region of England. We identified all live-born infants with cardiovascular malformations diagnosed in the first 1 year of life from the regional pediatric cardiology database, which includes the gestational age and details of the diagnosis. We limited ascertainment to malformations diagnosed by the age of 12 months. Infants with isolated patent ductus arteriosus or atrial septal defect were excluded, to avoid ascertainment bias. Infants with ventricular septal defect were classified according to whether they required surgery in the first 1 year. There are no population data on gestational ages for all births in our population for the era of this study; therefore, we used data published in the literature for populations similar to our own to predict that 0.4% of live births occur at <28 weeks of gestation, 0.9% at 28 to 31 weeks, and 6% at 32 to 36 weeks. Overall, 7.3% of live-born infants are preterm.

RESULTS

Of 521619 live-born infants in 1987-2001, 2964 had cardiovascular malformations (prevalence: 5.7 cases per 1000 live births). Cardiovascular malformations were present at 5.1 cases per 1000 term infants and 12.5 cases per 1000 preterm infants. The odds ratio (OR) for a cardiovascular malformation in prematurity was 2.4 (95% confidence interval [CI]: 2.2-2.7). We found that 474 infants (16%) with cardiovascular malformations were born at <37 weeks of gestation, giving an OR for prematurity among infants with a cardiovascular malformation of 2.4 (95% CI: 2.2-2.7). More infants were born preterm with diagnoses of pulmonary atresia with ventricular septal defect (23%), complete atrioventricular septal defect (22%), and coarctation of the aorta, tetralogy of Fallot, and pulmonary valve stenosis (each 20%). Fewer were born preterm with diagnoses of pulmonary atresia and intact ventricular septum (7%), transposition of the great arteries (8%), and single ventricle (9%). We found that 18% of infants with ventricular septal defect requiring surgery were preterm, compared with 13% in the nonsurgical group. Preterm infants with ventricular septal defect required surgery in 30% of cases, compared with 23% of term infants with ventricular septal defect. These figures show that the excess of cardiovascular malformations among preterm infants cannot be explained by greater ascertainment of minor ventricular septal defects. In our denominator population, 646 live-born infants were recognized as having trisomy 21, and gestational age data were available for 609. Of these, 149 (25%; 95% CI: 21-28%) were preterm. Approximately two thirds of infants with complete atrioventricular septal defect have trisomy 21. Complete atrioventricular septal defect was no more common among preterm infants with trisomy 21 (16%) than among term infants with trisomy 21. However, the increased incidence of prematurity among infants with trisomy 21 probably explains some of the excess of preterm births among infants with complete atrioventricular septal defect. Only 4 (11%) of 38 infants with 22q11 deletion were born preterm. None of those infants had pulmonary atresia with ventricular septal defect; therefore, 22q11 deletion does not explain the excess of preterm births in pulmonary atresia with ventricular septal defect. The OR for death in the first 1 year in the presence of a cardiovascular malformation was 4.4 (95% CI: 3.1-5.5) overall; ORs were 1.8 at <28 weeks of gestation, 3.7 at 28 to 31 weeks, 11.0 at 32 to 36 weeks, and 35.6 at term.

CONCLUSIONS

This study showed that preterm infants have more than twice as many cardiovascular malformations as do infants born at term and that 16% of all infants with cardiovascular malformations are preterm. It also showed, not surprisingly, that there is an increased mortality rate among infants born preterm with a cardiovascular malformation. The additional effect of cardiovascular malformations on mortality rates is most marked for term and near-term infants, for whom mortality rates are otherwise low. The excess of cardiovascular malformations among preterm infants is intriguing but not easy to explain. Previous studies of birth weight among infants with cardiovascular malformations reported a significant increase in the likelihood of being small for gestational age among infants with tetralogy of Fallot, complete atrioventricular septal defect, hypoplastic left heart, or large ventricular septal defect. There is an obvious relationship between birth weight and gestational age, and those studies also showed an increased prevalence of prematurity among infants with tetralogy of Fallot, pulmonary stenosis, aortic stenosis, coarctation of the aorta, complete atrioventricular septal defect, or ventricular septal defect. There is also a high prevalence of cardiovascular malformations among late stillbirths, with major differences in the number and spectrum of cardiovascular malformations, compared with those seen in postnatal life. In particular, there is a greater incidence of coarctation of the aorta, double-inlet left ventricle, hypoplastic left heart, truncus arteriosus, double-outlet right ventricle, and atrioventricular septal defect among stillbirths. This spectrum of malformations is similar to that in our study and to those in other reports. Whether the increased prevalence of cardiovascular malformations among preterm infants and the increase in stillbirths suggest clues to the cause is difficult to say. The influence of preterm birth should be taken into account in risk assessment and risk stratification for surgical repair.

Oesophageal atresia: what has changed in the last 3 decades?

The aim of the study was to analyse the outcomes of children born with oesophageal atresia over the last 3 decades. The records of 104 patients born between 1973 and 1999 were reviewed retrospectively. To evaluate changes over time, the analysis was done for three consecutive time periods: 1973-79, 1980-89, and 1990-99. Mean birth weight was 2553 g (SD 640), and mean gestational age was 39 weeks (SD 4). Forty-two newborns (40%) had one or more associated congenital malformations, and 30% had associated cardiac malformations. There was no change in incidence of associated anomalies over the three time periods studied. Mortality of patients decreased from 33% to 14% (p = 0.048). There was a significant association between the presence of a major cardiac malformation and survival (survival: 88% vs. 57%, p = 0.004). Analysing the three different time periods separately reveals that cardiac disease was not a significant risk factor in the first period but became significant in the period from 1980-99 (relative risk: 6.76, 95% CI 1.44-31.77). Birth weight was significantly higher in infants who survived (2626 g, SD 642) compared with those who died (2290, SD 570, p = 0.028). This effect, however, is mainly based on the difference during the first period and is lost later. Early and late postoperative complications occurred in 44/102 patients. Strictures developed in 33/91 patients who survived the first month of life (33%). The rate of symptomatic strictures decreased significantly over the three time periods, from 50% to 23% (p = 0.022). In summary, this study shows no significant change in patient characteristics over the last 3 decades, but mortality and postoperative complication rates decreased, and associated cardiac anomalies became the far most important risk factor for mortality.