Congenital Heart Surgery

In-Hospital Outcomes in Fontan Completion Surgery According to Age. Ghimire LV, Chou FS, Pundi K, Moon-Grady AJ.Am J Cardiol. 2022 Mar 1;166:81-87. doi: 10.1016/j.amjcard.2021.11.019. Epub 2021 Dec 18.PMID: 34933746   Take Home Points: Age at Fontan completion does not adversely affect the in-hospital outcomes. Commentary from Dr. Shuhua Luo (Chengdu, Sichuan, China), section editor of Congenital Cardiac Surgery Journal Watch: Summary: A total of 6,647 children with median age 3 (interquartile range 2 to 4) years underwent the Fontan completion procedure were retrospectively included in this study. The patients were categorized into 1 of 5 groups according to their age at the time of Fontan completion: <2(n=956, 14.4% ), 2(n=2190, 32.9%), 3(n=1634, 24.6%), 4(n=829, 12.5%), and ≥5 years(n=1039, 15.6%). The in-hospital mortality rate for the whole cohort was 2.1% (n = 139), and 1.8% (n = 117) needed ECMO during the ICU stay. Independent risk factor for mortality in the multivariable logistic regression was a presence of atrioventricular septal defect (AVSD) [OR4.3 (2.4 to 7.9), p <0.001]. Age was not identified as a risk factor in this study.   Comment: Age older than 4 years at the time of Fontan is one of the original “Ten Commandments” for case selection. In more recent years, the Fontan operation has been performed in younger patients. However, the impact of patient age on outcome remains unclear. A recent large retrospective study(n=3319) showed a U-shaped relationship between age and in-hospital mortality, with the lowest risk when the procedure was performed at age 3(1). While other authors suggested that age is not significantly associated with postoperative outcomes (2,3). The current study supported the latter finding in a large multi-institutional population. However, one should interpret this result with caution, as the risk of needing ECMO was significantly higher in those that received the Fontan surgery before 2 years of age with an adjusted OR of 3.1 (95% CI 1.4 to 7.0). As expected, home health care resource utilization was the highest in patients who underwent surgery at <2 years of age (13.7%), compared with 5.6% in the 3-year-old group (p <0.001). These results suggested patients with younger ages (<2 years) may have a complicated postoperative recovery. Furthermore, the occurrence of early Fontan failure was not reported in this study. Unfortunately, other important demographic(e,g weight), physiologic (e.g pre-Fontan arterial oxygen saturation), and anatomic(e.g heterotaxy) risk factors were also not included in the multivariable analysis. With the modification of surgical technique and advancement of perioperative management, age might not be as important as we thought in the era of “Ten Commandments”. The clinical decision-making of timing of Fontan completion should be individualized and always balance the associated benefits and risks. A large multicenter prospective longitudinally follow-up study might help us to generate new evidence regarding Fontan patients' selection.   Reference 1. Marathe SP, d’Udekem Y, Winlaw DS. What Is the Ideal Age for the Fontan Operation? Ann Thorac Surg. 2020 Sep;110(3):1095–6. 2. Salvin JW, Scheurer MA, Laussen PC, Mayer JE, Del Nido PJ, Pigula FA, et al. Factors associated with prolonged recovery after the fontan operation. Circulation. 2008 Sep 30;118(14 Suppl):S171-176. 3. Hosein RBM, Clarke AJB, McGuirk SP, Griselli M, Stumper O, De Giovanni JV, et al. Factors influencing early and late outcome following the Fontan procedure in the current era. The “Two Commandments”? Eur J Cardio-Thorac Surg Off J Eur Assoc Cardio-Thorac Surg. 2007 Mar;31(3):344–52; discussion 353.    

Successful Reduction of Postoperative Chest Tube Duration and Length of Stay After Congenital Heart Surgery: A Multicenter Collaborative Improvement Project. Bates KE, Connelly C, Khadr L, Graupe M, Hlavacek AM, Morell E, Pasquali SK, Russell JL, Schachtner SK, Strohacker C, Tanel RE, Ware AL, Wooton S, Madsen NL, Kipps AK.J Am Heart Assoc. 2021 Nov 2;10(21):e020730. doi: 10.1161/JAHA.121.020730. Epub 2021 Oct 29. PMID: 34713712    Take Home Points: Using collaborative learning methodology across 9 centers, statistically significant decreases in the postoperative CT duration and reduction in LOS were successfully achieved without any increases in adverse events. Collaborative learning is an effective methodology to reduce variation across centers and ultimately improve patient outcomes. Commentary from Dr. Masamichi Ono (Munich, Germany), section editor of Congenital Heart Surgery Journal Watch: Summary: Nine pediatric heart centers collaborated through 2 learning networks. Patients undergoing one of 9 benchmark congenital heart operations were included (patients who underwent the Fontan operation were excluded). Baseline data were collected from June 2017 to June 2018, and intervention-phase data were collected from July 2018 to December 2019. Collaborative learning methods included review of best practices from a model center, regular data feedback, and quality improvement coaching. Center teams adapted CT removal practices (eg, timing, volume criteria) from the model center to their local resources, practices, and setting. Postoperative CT duration in hours and LOS in days were analyzed using statistical process control methodology. Overall, 2309 patients were included. Patient characteristics did not differ between the study and intervention phases. Statistical process control analysis showed an aggregate 15.6% decrease in geometric mean CT duration (72.6 hours at baseline to 61.3 hours during intervention) and a 9.8% reduction in geometric mean LOS (9.2 days at baseline to 8.3 days during intervention). Adverse events did not increase when comparing the baseline and intervention phases: CT replacement (1.8% versus 2.0%, P=0.56) and readmission for pleural effusion (0.4% versus 0.5%, P=0.29).   Significance: Introducing collaborative learning model, they could shorten the duration of chest tube, and ICU length of stay in patients after 9 benchmark CHD operations. Collaborative learning model included regular data feedback on practices and outcomes using a shared data-reporting platform, monthly webinars to share intervention ideas and results, and quality improvement coaching. These efforts enabled to improve the postoperative management.   Comment: Congenital heart disease practices and outcomes vary significantly across centers, including postoperative chest tube (CT) management, which may influence postoperative length of stay (LOS). In this study, they showed collaborative learning methods to determine whether centers could adapt and safely implement best practices for CT management, resulting in reduced postoperative CT duration and LOS. As results, the centerline CT duration was decreased from 72.6 to 61.3 hours, representing a 15.6% reduction. As for ICU LOS, the centerline LOS was decreased from 9.2 to 8.3 days, representing 9.8% reduction. There was no difference between baseline and intervention phases concerning frequency of CT replacement or hospital readmissions within 7 days because of pleural effusion. To shorten the postoperative ICU LOS, not only standardized management algorithm, but also collaborative learning across the center, play an important role.   They commented that the relationship between CT duration and LOS might vary depending on operation and patient age. For example, the LOS for a newborn following a Norwood operation is likely impacted more by the need to establish enteral feeding and preparation for inter-stage home monitoring than by CT duration, given the large gap between CT duration and LOS shown in our previous work. We agree with this comment in patients undergoing neonatal Norwood procedure.   Further expansion of the multicenter collaborative leaning structure might create more effective management protocol.   In this study, patients undergoing the Fontan procedure were excluded. As we all know, post-operative chest tube management is the most important issue in these patients. Further studies on this comfort are also expected.   

High-degree Norwood neoaortic tapering is associated with abnormal flow conduction and elevated flow-mediated energy loss. Schäfer M, Di Maria MV, Jaggers J, Stone ML, Ivy DD, Barker AJ, Mitchell MB.J Thorac Cardiovasc Surg. 2021 Dec;162(6):1791-1804. doi: 10.1016/j.jtcvs.2021.01.111. Epub 2021 Feb 4. PMID: 33653609   Take Home Points: Geometry, i.e., smooth narrowing of the reconstructed aorta from the ascending to the descending aorta is more important than hemodynamics parameters, such as pressure difference. Impact of arch growth on change in energy loss is not fully understood and further study to see a serial assessment in this entity is necessary. Commentary from Dr. Yasuhiro Kotani (Okayama, Japan), chief section editor of Congenital Heart Surgery Journal Watch: Summary: A total of 26 patients who underwent Norwood operation was included in this study. Patients were evaluated by 4-dimentional-flow magnetic resonance imaging and were then divided based on the degree of neoaortic tapering defined as the standard deviation of diameter values measured at the ascending aorta, transverse arch, aortic isthmus, and the descending aorta. The median tapering value of neoaortic was 0.52cm and patients were divided into 2 groups: high degree (>0.52cm)(Group H: n=13) and low degree (≦0.52cm)(Group L: n=13). Group H had a higher prevalence of abnormal recirculating flow in the neoaorta and elevated neoaortic flow-mediated viscous energy loss in the ascending aorta (Group H: 1.0±0.4 vs. Group L: 0.6±0.3 mW, p=0.004). The study concluded that oversizing neoaortic reconstruction should be avoided from the point of ventricular-aortic coupling in patients undergoing Norwood operation.   Comment: Previous studies showed the shape of reconstructed neoaortic arch is important in terms of the afterload of systemic ventricle in HLHS patients which impacts on RV dysfunction and subsequent long-term outcomes. This study showed that suboptimal neoaortic geometry, i.e., size discrepancy among the ascending, transverse, and descending aorta, was associated with an increased flow-mediated viscous energy loss and an increased wasted RV mechanical power. This is the first study to evaluate neoaortic flow hemodynamics in a sizable group of patients with HLHS having Norwood operation. Importantly, no patients in this study had a residual hemodynamic coarctation which makes us think of the importance of cardiac MRI assessment in this particular patient group.   This study raised a couple of questions. One is do we need to routinely use MRI assessment in all patients after Norwood operation. Because of increased evidence of MRI assessment for flow dynamics and its influence on cardiac function, it is ideal to perform MRI assessment. On the other hands there are still some problems, including the costs of the examination and availability (not all hospitals have facility and staffs for cardiac MRI). Another question is that how to implicate this result in the clinical practice. This study highlighted the importance of geometry rather than physiology as even patients without no evidence of residual hemodynamic recoarctation showed higher energy loss if size discrepancy between the ascending aorta and descending aorta existed. Taken together, the lessons learned from this study is that surgeons need to reconstruct the neoaortic arch in a good shape no matter other physiologic parameters give us a green light. But again, the problem is achieving this goal is challenging due to the complex patch shape in highly variable anatomy in HLHS.