Grown-up Congenital Heart Surgery in 1093 Consecutive Cases: A “Hidden” Burden of Early Outcome
Haapanen H, Tsang V, Kempny A, Neijenhuis R, Kennedy F, Cullen S, Walker F, Kostolny M, Hsia TY, Van Doorn C.
Ann Thorac Surg. 2020 Mar 5. pii: S0003-4975(20)30338-6. doi: 10.1016/j.athoracsur.2020.01.071.
PMID: 32147413
Select item 32131918
Take-Home Points:
- This retrospective study from Great Ormond Street Hospital retrospectively analyzes over 1,000 ACHD surgeries and possible risk factors for adverse outcomes over a 17-year period.
- The 30-day mortality outcome was overall low but increased by 6 months following CHD surgical procedures.
- The increasing complexity of CHD patients may be associated with longer ICU lengths of stay.
- Further consideration for updating standard outcomes metrics may be needed to accurately account for the extended window of postoperative risk beyond 30 days.
Commentary from Dr. Jeremy Herrmann (Indianapolis), section editor of Congenital Heart Surgery Journal Watch: Recognizing that surgical outcomes for adult congenital heart disease (ACHD) have progressively improved over the past two decades, the authors questioned whether the metric of 30-day postoperative mortality remains valid. Specifically, they aimed to determine whether prolonged ICU stay (>7 days) and 6-month mortality are more appropriate for assessing postoperative risk. The authors retrospectively reviewed over 1,000 consecutive ACHD surgeries performed over a 17-year period at Great Ormond Street Hospital in London. Surgical procedures spanned the full ACHD spectrum with the top three procedures being pulmonary procedure, aortic procedure, and ASD repair. Over half (55%) were reoperations and over one-third (36.8%) included concomitant procedures.
Overall, the mortality at 30 days was very low at 1.5% but increased to 2.4% at the 6-month mark. Forward stepwise regression analyses revealed several parameters associated with prolonged ICU stay (>7 days) OR 6-month mortality: sex, NHYA class III or greater, EF 50% or less, renal failure, multiple sternotomies, CHD complexity, urgent operation, preoperative ventilator support, CPB time, DHCA use, and concomitant procedures. Of these, higher NHYA class, complex CHD, preoperative ventilator support, CPB time, and concomitant procedures were significant associated with prolonged ICU stay (>7 days) OR 6-month mortality using multivariate logistic regression. Repeat sternotomy was not a risk factor, though the authors highlight discrepant information in the literature. The distribution of CHD complexity was similar across 4 eras of the study period, though the 6-month mortality decreased from 5.0% in the first era to 1.4% in the two most recent eras. The frequency of prolonged ICU stay increased during the study period possibly due to a greater degree of CHD complexity in the latter eras.
The authors conclude that 30-day mortality may be too short to fully account for the postoperative morbidity and mortality. This could also result from sicker patients receiving ICU-level care and surviving beyond 30 days but not for 6 months. This could be an important consideration for patient care given that patients will typically be home during most of the immediate 6-month postoperative window. This may also be an important consideration for outcomes data gathering and reporting. Regardless, it is gratifying to know that as a field, we have been able to elevate the standard of care for these potentially complex patients such that mere 30-day survival is an insufficient estimation of outcomes.
