Walsh B, Mueller B, Roche SL, Alonso-Gonzalez R, Somerset E, Sano M, Villagran Schmidt M, Hickey E, Barron D, Heggie J.JTCVS Open. 2023 May 2;14:188-204. doi: 10.1016/j.xjon.2023.04.016. eCollection 2023 Jun.PMID: 37425473
Commentary by:
David Preston DO, Sana Ullah MD
Children’s Medical Center, Dallas TX
Take-home points
- Implementation of a perioperative quality improvement initiative specific to adult congenital cardiac surgery within an adult quaternary referral center was associated with an observed reduction in in-hospital mortality as well as one-year mortality.
- Aside from slightly decreased ventilation times, secondary outcomes including blood product exposure, postoperative renal failure, and stroke were not impacted by the implementation of the quality improvement bundle.
- A cardiac anesthesia team specifically tailored to the perioperative care of adult congenital heart disease patients within an adult cardiac surgical setting may positively impact perioperative outcomes.
- Attendance at a dedicated adult congenital preoperative clinic for risk stratification prior to adult congenital cardiac surgery did not demonstrate a measurable impact on primary or secondary perioperative outcomes.
Adult congenital heart disease (ACHD) presents an ever-increasing patient population with unique challenges in the perioperative setting.1 As the need for surgical interventions in this population continues to increase, adult cardiac surgery departments have developed dedicated ACHD programs to provide targeted care for these patients.2 This study, from Toronto General Hospital, reflects on the impact of implementing a bundle of perioperative quality improvement measures with a specific focus on an ACHD program housed within an adult cardiothoracic surgery center.3
Summary of the Study
The authors conducted a single center retrospective analysis of perioperative outcomes of cardiac surgeries within a dedicated ACHD program at Toronto General Hospital after implementation of three quality improvement measures: (1) The anesthesia team was narrowed in scope from all forty cardiac anesthesiologists within the group down to three specific anesthesiologists who subsequently conducted all preoperative clinic evaluations and managed every anesthetic for ACHD patients undergoing cardiac surgery; (2) the ACHD anesthesia team staffed a dedicated ACHD preoperative clinic to identify risk factors that had previously been identified by this group as portending poorer post-operative outcomes in ACHD patients: the presence of cognitive impairment, Mayo End Stage Liver Disease modified score (MELD-xi), more than 3 prior chest wall incisions, and any anatomy other than a biventricular arrangement with a subaortic left ventricle;4 and (3) the use of factor concentrates was introduced to the group at this time as a blood conservation strategy, but their use was not protocolized in any formal way.
A total of 1032 patients were evaluated in this study, 784 of whom underwent surgery during the “before” era from 2004-2015. The “after” group was composed of 280 patients from 2016 to 2019 after the implementation of the quality improvement measures stated above. The primary outcome was in-hospital mortality, while the secondary outcomes included 1-year mortality, duration of mechanical ventilation, incidence of acute kidney injury (AKI) requiring renal replacement therapy, incidence of stroke, incidence of blood product exposure, and incidence of re-opening for bleeding. A sub-analysis was performed of the “after” group to compare matched preoperative clinic attenders with non-attenders in order to delineate the relative impact of clinic attendance on postoperative outcomes.
Overall, in-hospital mortality was reduced from 4.3% to 1.3% (P=0.012) in the “after” group after implementation of the quality improvement program. Likewise, one-year mortality showed a decrease from 5.8% to 1.3% (P=0.003). This improvement was in spite of a higher percentage of patients with more complex anatomy as well as a higher number of prior chest-wall incisions than in the “before” group. Post-operative ventilation times were slightly reduced, but there was no significant difference in the incidence of post-operative AKI requiring renal replacement therapy or post-operative stroke. Blood product use stayed statistically similar between the two groups and there was limited use of factor concentrates, which was attributed to the lack of protocolization of their use within any of the groups’ perioperative blood management algorithms. Finally, secondary analysis of preop clinic attendance showed no statistical significance in outcomes between attenders and non-attenders. The authors conclude by indicating that the observed improvements in in-hospital and 1-year mortality after the quality improvement program implementation should only be perceived as associations in the setting of a retrospective analysis. They highlight the likely positive, yet unmeasurable impact that the smaller team of anesthesiologists and preoperative clinic had on perioperative risk management and overall outcomes of ACHD patients undergoing cardiac surgery.
What Does This Mean for Our Practice?
The concept of forming subspecialized teams within anesthesia groups to maintain expertise in the perioperative care of specific pathologies has demonstrated associated benefits in a wide range of surgical arenas such as liver transplantation and craniofacial surgery.5,6 There is also evidence of benefit from dedicated teams of anesthesiologists and surgeons working frequently and closely together.7 So it comes as no surprise that a much smaller team that transitions to working within the context of a specific patient pathology (ACHD in this case) and a smaller subset of surgeons would demonstrate improved patient outcomes. But how small should these teams be? And who should compose them? In the unique world of ACHD, where the physiology, surgical operations, and perioperative needs can be quite different from non-congenital cardiac patients, it would make sense for these teams to be made up of those who have dedicated training in the field of congenital heart disease, especially in the context of an adult cardiac center.8
This study did not demonstrate any benefit from attendance at a preoperative clinic for risk assessment. This may be due to two separate issues. First, one area where preoperative clinics provide critical help is through the triage of patients to appropriate clinical teams. For example, in a pediatric setting, preoperative risk assessment will determine if a patient with congenital heart disease is best served by a core cardiac anesthesia team member rather than a general pediatric anesthesiology team member. Since the patients in this study were managed by the same group of anesthesiologists on the ACHD team regardless of risk factors, the benefit of the triage aspect of preoperative risk assessment could not be captured. Secondly, as the authors mentioned, some benefits of preoperative clinic attendance such as the need to delay or cancel cases due to previously unrecognized risk factors are difficult to measure. However, the importance of risk stratification for this population cannot be overlooked. The authors utilized a set of risk factors previously published from their institution to identify those at high risk of poor perioperative outcomes. We would also direct readers toward the STS ACHD mortality risk model for surgical risk as well as the PEACH (Perioperative ACHD) Score for in-hospital mortality after ACHD surgery as a means for further preoperative risk stratification in these patients.9,10
Finally, the institution of a quality improvement project involving an adjustment of perioperative team composition and deployment in the setting of an escalation in patient complexity and higher surgical volume raises the question: Does 2016 represent not just the beginning of a quality improvement initiative but also a new surgical era for this group? This is not delineated in this paper, but if so, it would be even more difficult to attribute the changes in outcomes solely to team composition and enhanced preoperative risk assessment. Indeed, the authors acknowledge that although this quality improvement initiative decreased mortality, they were not able to pinpoint the exact reasons why. Regardless, the authors appropriately recognize the importance of a focused team to address the specific complexities presented by ACHD patients and present a helpful model of care for other adult cardiac centers where the proportion of ACHD patients requiring intervention will inevitably increase in the coming years.
- Marelli AJ, Ionescu-Ittu R, Mackie AS, Guo L, Dendukuri N, Kaouache M. Lifetime prevalence of congenital heart disease in the general population from 2000 to 2010. Circulation. 2014;130(9):749-756. doi:10.1161/CIRCULATIONAHA.113.008396
- Tutarel O, Kempny A, Alonso-Gonzalez R, et al. Congenital heart disease beyond the age of 60: emergence of a new population with high resource utilization, high morbidity, and high mortality. Eur Heart J. 2014;35(11):725-732. doi:10.1093/eurheartj/eht257
- Walsh B, Mueller B, Roche SL, et al. Impact of a quality improvement initiative with a dedicated anesthesia team on outcomes after surgery for adult congenital heart disease. JTCVS Open. 2023;14:188-204. Published 2023 May 2. doi:10.1016/j.xjon.2023.04.016
- Lei Lei E, Ladha K, Mueller B, et al. Noncardiac determinants of death and intensive care morbidity in adult congenital heart disease surgery. J Thorac Cardiovasc Surg. 2020;159(6):2407-2415.e2. doi:10.1016/j.jtcvs.2019.07.106
- Hevesi ZG, Lopukhin SY, Mezrich JD, Andrei AC, Lee M. Designated liver transplant anesthesia team reduces blood transfusion, need for mechanical ventilation, and duration of intensive care. Liver Transpl. 2009;15(5):460-465. doi:10.1002/lt.21719
- Reddy SK, Patel RS, Rogers GF, Gordish-Dressman H, Keating RF, Pestieau SR. Intraoperative Management by a Craniofacial Team Anesthesiologist is Associated With Improved Outcomes for Children Undergoing Major Craniofacial Reconstructive Surgery. J Craniofac Surg. 2019;30(2):418-423. doi:10.1097/SCS.0000000000005086
- Hallet J, Sutradhar R, Jerath A, et al. Association Between Familiarity of the Surgeon-Anesthesiologist Dyad and Postoperative Patient Outcomes for Complex Gastrointestinal Cancer Surgery [published correction appears in JAMA Surg. 2023 Apr 5;:]. JAMA Surg. 2023;158(5):465-473. doi:10.1001/jamasurg.2022.8228
- Stout KK, Daniels CJ, Aboulhosn JA, et al. 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in J Am Coll Cardiol. 2019 May 14;73(18):2361]. J Am Coll Cardiol. 2019;73(12):1494-1563. doi:10.1016/j.jacc.2018.08.1028
- Nelson JS, Thibault D, O’Brien SM, et al. Development of a Novel Society of Thoracic Surgeons Adult Congenital Mortality Risk Model. Ann Thorac Surg. 2023;116(2):331-338. doi:10.1016/j.athoracsur.2023.01.015
- Constantine A, Costola G, Bianchi P, et al. Enhanced Assessment of Perioperative Mortality Risk in Adults With Congenital Heart Disease. J Am Coll Cardiol. 2021;78(3):234-242. doi:10.1016/j.jacc.2021.04.096
