Predictors of postoperative outcome after general surgical procedures in patients with congenital heart disease

doi:10.1016/0022-3468(94)90004-3

Journal of Pediatric Surgery

Volume 29, Issue 7, July 1994, Pages 866-870

https://doi.org/10.1016/0022-3468(94)90004-3 Get rights and content

Abstract

This study was undertaken to evaluate factors predictive of postoperative outcome after general surgical (GS) procedures in patients with congenital heart disease (CHD). All patients with a diagnosis of CHD who underwent a GS procedure under general anesthesia during a consecutive 10-year period were considered eligible for the study. The congenital heart defect was classified as either simple (ASD, VSD, PDA) or complex (endocardial cushion defects, transposition of the great vessels, tetralogy of Fallot), and the GS procedure as either major (intraperitoneal, intrathoracic, or vascular reconstructive) or minor (inguinal herniorrhaphy, vascular access). The overall mortality rate for the patient population was 12% (27 deaths among 226 procedures), minor procedures being associated with a 3% mortality rate (2 of 70 procedures), and major procedures with a 16% mortality rate (25 of 156 procedures). Incremental risk factors for mortality included a preoperative American Society of Anesthesiologists' (ASA) physical status class of IV or higher (P = .0003), a preoperative in-hospital stay of 10 or more days (P = .004), birth at a tertiary care center (P = .04), and emergency operations (P = .05). In the subgroup of patients less than 6 months old, weight of less than 2.4 kg at the time of surgery and a 1-minute Apgar score of less than 4 were additional independent risk factors (P = .04 and .01, respectively). By logistic analysis, previous corrective cardiac procedures, whether complete or palliative, did not significantly alter the postoperative outcome. The authors conclude that physiologically well-compensated patients with CHD can undergo elective operations at a low operative risk; however, poorly compensated patients undergoing urgent or emergent operations are at high risk. Previous corrective cardiac procedures may improve the overall outcome if the physiological state of the patient could be improved.

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Time from first symptoms to diagnosis, called time to diagnosis, is related to prognosis in several diseases. The aim of this study was to assess time to diagnosis in children with new-onset heart failure (HF) and assess its consequences and determinants.
A retrospective population-based observational study was conducted between 2007 and 2016 in a French tertiary care center. We included all children under 16 years old with no known heart disease, and HF confirmed by echocardiography. With logistic regression used for outcomes and a Cox proportional-hazards model for determinants, analyses were stratified by HF etiology: congenital heart diseases (CHD) and cardiomyopathies/myocarditis (CM).
A total of 117 children were included (median age [interquartile range (IQR)] 25 days (6–146), 50.4% were male, 60 had CHD and 57 had CM). Overall median (IQR) time to diagnosis was 3.3 days (1.0–21.2). The frequency of 1-year mortality was 17% and 1-year neuromotor sequel 18%. Death at 1 year was associated with low birth weight for all patients (adjusted odds ratio 0.24, 95% confidence interval [CI] 0.08–0.68) and time to diagnosis below the median with CM (0.09, 0.01–0.87) but not time to diagnosis above the median for all patients (0.59, 0.13-2.66). Short time to diagnosis was associated with clinical severity on the first day of symptoms for all patients (adjusted hazard ratio 3.39, 95% CI 2.01–5.72), and young age with CM (0.09, 0.02–0.41).
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2019, Seminars in Pediatric Surgery
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The perioperative physiologic status and the complexity of the heart defect are the most important factors in determining perioperative risk.8 The repair status of CHD (unrepaired, palliative, or complete) has not shown to impact operative mortality.9 There are many risk stratification tools for children with congenital heart disease (e.g. RACHS-1,10 STAT,11,12 PRISM13).
More children with congenital heart disease are surviving and require noncardiac surgery. A high-yield summary of congenital heart anatomy and pathophysiology is presented to contextualize these patients for surgeons. Preoperative planning including risk stratification, anesthetic management and timing of elective surgery are discussed. Specific intraoperative considerations for particular cases, such as the use of laparoscopy and thoracic surgery, are reviewed. Postoperative outcomes and recommended management required to mitigate complications are summarized.
Early Extubation After Repair of Tetralogy of Fallot and the Fontan Procedure: An Analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database
2016, Annals of Thoracic Surgery
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Such a relationship makes sense in the current era of complete repair of TOF primarily in infants. Several decades ago, the postoperative course after TOF repair was marked by low cardiac output and hospital LOS of 10 days or more [21]. Presently, the median LOS after TOF repair based on STS-CHSD is 7 days.
There is increasing interest in reducing the duration of mechanical ventilation after pediatric cardiac operations. However, the contemporary use of an early extubation strategy and its effect on clinical outcomes is poorly understood.
Data from The Society of Thoracic Surgeons Congenital Heart Surgery Database (2010 to 2013) were analyzed to determine the association of early extubation with postoperative length of stay (PLOS). Two operations were analyzed: complete repair of tetralogy of Fallot (TOF) in patients older than 45 days and the Fontan procedure. Centers were stratified into tertiles by frequency of early extubation, defined as less than 6 hours after leaving the operating room. Patients extubated after 48 hours were excluded.
Among 92 centers, early extubation was performed in 31.5% (478 of 1,519) of children undergoing TOF repair and in 69.8% (1,153 of 1,653) of those undergoing the Fontan procedure. Early extubation after TOF repair was associated with heavier weight at operation (p < 0.001) and fewer preoperative risk factors (p = 0.016). After adjustment for covariates, average PLOS after TOF repair was shorter for centers in the highest tertile of early extubation rate than for the lowest tertile centers, which have low early extubation rate (p = 0.04). No association was found between center early extubation rate and PLOS for Fontan procedures (p = 0.08).
Early extubation is common after repair of TOF and the Fontan procedure. A high institutional rate of early extubation after TOF repair is associated with shorter PLOS. Further analysis is needed to understand what effect early extubation might have on other meaningful measures such as resource use.
Outcome of noncardiac surgery in children with congenital heart disease performed outside a cardiac center
2016, Journal of Pediatric Surgery
Citation Excerpt :
There are no studies dealing specifically with the outcome of noncardiac surgery in children with CHD in the UK. A few studies have shown higher mortality rates in younger age groups (< 1 year) [6,7]. Our study has not shown any correlation between age when the procedure was performed and mortality rate.
The objective of this study was to review the outcome of children with congenital heart disease (CHD) undergoing noncardiac surgery requiring general anesthesia (GA) in a tertiary pediatric center between January 2010 and December 2012.
A retrospective case note review of children < 16 years of age with confirmed CHD undergoing a surgical or interventional procedure requiring GA was performed. Patients were categorized into three risk groups according to White and Peyton’s anesthetic risk classification of children with CHD undergoing noncardiac surgery [Critical Care and Pain 2012;12:17–22].
117 children with CHD were identified with a total of 240 procedures conducted. 36 procedures were conducted in the high-risk group, 135 in the intermediate-risk group, and 69 in the low-risk group. 40% of these were major operations such as small bowel and colonic procedures. Overall mortality rate at 7 days and 30 days was 0% and 0.4%, respectively, with a 1% mortality rate in minor procedures and 0% mortality rate in major procedures. There were no unexpected deaths. 17% of procedures resulted in complications. A higher rate of complications was recorded in emergency procedures. 17% of these procedures required admission to the intensive care unit, with the highest admissions rate in the high-risk group. The median duration of hospital stay for the whole cohort was 1 day (range of 0–71 days).
Our study shows that procedures requiring GA can be safely conducted on children from any of the three risk groups in a nonspecialist cardiac center provided that there is close liaison and careful planning between the different specialties.
Anaesthetic implications of congenital heart disease for children undergoing non-cardiac surgery
2015, Anaesthesia and Intensive Care Medicine
Children with congenital heart disease (CHD) are at increased risk of morbidity, perioperative cardiac arrest and 30-day mortality from major and minor surgical procedures compared to healthy children. Factors associated with greatest risk are the complexity of cardiac disease and the physiological status of the child. Therefore the anaesthetist must understand balanced and single ventricle circulations and be able to assess the effects of four major complications of CHD: cardiac failure, arrhythmias, pulmonary hypertension and cyanosis. Other risk factors include type of surgery, age, ASA physical status and length of preoperative hospital stay. Because of the diversity of CHD and the range of surgical procedures a generalized approach to anaesthesia is impossible. Preoperative assessment, induction and maintenance should all be individualized to the child and tailored to the type of surgery. Whether surgery occurs in the local hospital or tertiary cardiac centre depends on risk classification (high, intermediate and low). Some children require full cardiac anaesthesia, intensive care and cardiology support making care in the local hospital inappropriate, whereas for others, care in their local hospital is both safe and convenient.
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Anthropometric data are important indicators of child health. This study sought to determine whether anthropometric data of extreme weight were significant predictors of perioperative morbidity in pediatric surgery.
This was a cohort study of children 29 days up to 18 years of age undergoing surgical procedures at participating American College of Surgeons’ NSQIP Pediatric hospitals in 2011 and 2012. The primary outcomes were composite morbidity and surgical site infection. The primary predictor of interest was weight percentile, which was divided into the following categories: ≤5^th percentile, 6^th to 94^th, or ≥95^th percentile. A hierarchical multivariate logistic model, adjusting for procedure case mix, demographic, and clinical patient characteristic variables, was used to quantify the relationship between weight percentile category and outcomes.
Children in the ≤5th weight percentile had 1.19-fold higher odds of overall postoperative morbidity developing than children in the nonextreme range (95% CI, 1.10–1.30) when controlling for clinical variables. Yet these children did not have higher odds of surgical site infection developing. Children in the ≥95^th weight percentile did not have a significant increase in overall postoperative morbidity. However, they were at 1.35-fold increased odds of surgical site infection compared with those in the nonextreme range when controlling for clinical variables (95% CI, 1.16–1.57).
Both extremely high and extremely low weight percentile scores can be associated with increased postoperative complications after controlling for clinical variables.

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Predictors of postoperative outcome after general surgical procedures in patients with congenital heart disease

Abstract

J Thorac Cardiovasc Surg

Multifactorial index of cardiac risk in noncardiac surgical procedures

N Engl J Med

Longitudinal results after first-stage palliation for hypoplastic left heart syndrome

Circulation

Outcome after a “perfect” Fontan operation

Circulation