Christopher E. Mascio

Perioperative mechanical circulatory support in children: An analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database

OBJECTIVES Analyses of mechanical circulatory support (MCS) in pediatric heart surgery have primarily focused on single-center outcomes or narrow applications. We describe the patterns of use, patient characteristics, and MCS-associated outcomes across a large multicenter cohort. METHODS Patients (aged <18 years) in the Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database (2000-2010) were included. The characteristics and outcomes of those receiving postoperative MCS were described, and bayesian hierarchical models were used to examine variations in the adjusted MCS rates across institutions. RESULTS Of 96,596 operations (80 centers), MCS was used in 2.4%. The MCS patients were younger (13 vs 195 days, P < .0001) and more often had STS-defined preoperative risk factors (57.2% vs 32.7%, P < .0001). The operations with the greatest MCS rates included the Norwood procedure (17%) and complex biventricular repairs (arterial switch, ventricular septal defect, and arch repair [14%]). More than one half of the MCS patients did not survive to hospital discharge (53.2% vs 2.9% of non-MCS patients; P < .0001). MCS-associated mortality was greatest for truncus arteriosus and Ross-Konno operations (both 71%). The hospital-level MCS rates adjusted for patient characteristics and case mix varied by 15-fold across institutions, with both high- and low-volume hospitals having substantial variation in MCS rates. CONCLUSIONS Perioperative MCS use varied widely across centers. The MCS rates were greatest overall for the Norwood procedure and complex biventricular repairs. Although MCS can be a life-saving therapy, more than one half of MCS patients will not survive to hospital discharge, with mortality >70% for some operations. Future studies aimed at better understanding the appropriate indications, optimal timing, and management of MCS could help to reduce the variation in MCS use across hospitals and improve outcomes.

The Use of Ventricular Assist Device Support in Children: The State of the Art

Improved survival, recognition, and management of patients with congenital heart disease have increased the number of pediatric patients with ventricular dysfunction. Many of these patients require mechanical support to bridge to transplant or recovery. Development of pediatric ventricular assist devices has lagged behind adult devices. Until recently, adult devices were used in pediatric patients, with suboptimal results in the smaller patient population. Extracorporeal membrane oxygenation can be life saving, but is a poor choice for long-term support. The Berlin Heart EXCOR (Berlin Heart AG, Berlin, Germany) is a paracorporeal device with a variety of pumps for patients of all sizes. The PumpKIN Trial will compare this device to the Infant Jarvik 2000 (Jarvik Heart, New York, NY, USA) in a prospective, randomized study. The single ventricle population presents unique challenges to placement and proper functioning of assist devices. Data are anecdotal and mortality is high. A registry has been developed to assist in caring for this challenging population.

Early and Midterm Outcomes Following Surgery for Acute Type A Aortic Dissection

Surgical repair of acute Type A aortic dissection (AADA) is still associated with high in‐hospital mortality. We evaluated the impact of perioperative risk factors on early and midterm survival.

Outcomes of Single-Ventricle Patients Supported With Extracorporeal Membrane Oxygenation.

Objectives: Extracorporeal membrane oxygenation is often used in children with single-ventricle anomalies. We aimed to describe extracorporeal membrane oxygenation use in single-ventricle patients to test the hypothesis that despite increasing prevalence, mortality has not improved and overall burden measure by hospital charges and length of stay have increased. Design: Retrospective analysis of the Healthcare Cost and Utilization Project Kids’ Inpatient Database was performed with sample weighting to generate national estimates. Patients: Pediatric patients (age ⩽ 20) with a diagnosis of single ventricle heart disease requiring extracorporeal membrane oxygenation support from 2000 to 2009. Interventions None. Measurements and Main Results: Seven hundred one children (95% CI, 559–943) with single ventricle were supported with extracorporeal membrane oxygenation in the reporting period. Mortality was 57% and did not improve over time (2000 = 52%, 2003 = 63%, 2006 = 57%, and 2009 = 55%; p = 0.66). Single-ventricle patients who required extracorporeal membrane oxygenation were more likely to have had a cardiac procedure (90% vs 46%; p < 0.001), a diagnosis of arrhythmia (22% vs 13%; p < 0.001), cerebrovascular or neurologic insult (9% vs 1%; p < 0.001), heart failure (24% vs 12%; p < 0.001), acute renal failure (28% vs 3%; p < 0.001), or sepsis (28% vs 8%; p < 0.001). By multivariable analysis, acute renal failure was a risk factor for mortality (adjusted odds ratio, 3.12; 95% CI, 1.95–4.98; p < 0.001). The length of stay for single-ventricle patients with extracorporeal membrane oxygenation increased from 25.2 days in 2000 to 55.6 days in 2009 (p < 0.001). Total inflation-adjusted charges increased from

Intramural Ventricular Septal Defect is a Distinct Clinical Entity Associated with Postoperative Morbidity in Children after Repair of Conotruncal Anomalies

358,021 (95% CI,

Clinical Outcome After Triple-Valve Operations in the Modern Era: Are Elderly Patients at Increased Surgical Risk?

278,658–439,765) in 2000 to

Near-infrared spectroscopy as a guide for an intermittent cerebral perfusion strategy during neonatal circulatory arrest.

732,349 (95% CI,

Proximal Thoracic Aortic Replacement for Aneurysmal Disease Using the Freestyle Stentless Bioprosthesis: A 10-Year Experience

671,781–792,917) in 2009 (p < 0.001). Conclusions: Extracorporeal membrane oxygenation support is uncommon with single-ventricle admissions occurring in 2.3% of all hospitalizations. Among those patients, the mortality rate was 57% with no change over time. Acute renal failure was an independent risk factor for mortality during hospitalization. In addition, length of stay for these patients increased and hospital charges doubled. Further studies are needed to determine suitability and cost-effectiveness of extracorporeal membrane oxygenation in single-ventricle patients.

Pleural effusions following the Fontan procedure.

Background— Intramural ventricular septal defects (VSDs) are interventricular communications through right ventricular free wall trabeculations that can occur after repair of conotruncal anomalies. We assessed the prevalence of residual intramural VSDs and their effect on postoperative course. Methods and Results— Children who underwent biventricular repair of a conotruncal anomaly from January 1, 2006, to June 30, 2013, and had a postoperative transthoracic echocardiogram were included. Images were reviewed for residual intramural or nonintramural VSDs. The primary outcome was a composite of mortality, extracorporeal membrane oxygenation use, and need for subsequent catheter or surgical VSD closure. The secondary outcome was postoperative hospital length of stay. A residual VSD was present in 256 of the 442 subjects (58%), of which 231 (90%) were <2 mm in size. Forty‐nine patients (11%) had intramural VSDs, and 207 (47%) had nonintramural VSDs. Patients with intramural VSDs were more likely to reach the primary composite outcome compared with those with nonintramural VSDs or no residual VSD (14 of 49 [29%] versus 15 of 207 [7%] versus 6 of 186 [3%]; P<0.0001). In addition, those with intramural VSDs had longer postoperative hospital length of stay compared with those with nonintramural VSDs or no residual VSD (20 days [interquartile range, 11‐42 days] versus 7 days [interquartile range, 5‐14 days] versus 6 days [interquartile range, 4‐11 days]; P=0.0001). These associations remained significant after adjustment for known risk factors for poor outcomes, including residual VSD size and operative complexity. Conclusions— Among residual VSDs after repair of conotruncal anomalies, intramural VSDs are uniquely associated with postoperative morbidity, mortality, and longer postoperative hospital length of stay. It is important to recognize intramural VSDs in the postoperative period.

Changes in the methodology of pre‐heart transplant human leukocyte antibody assessment: an analysis of the United Network for Organ Sharing database

BACKGROUND Despite modern advances in surgical care, triple-valve surgery (TVS) remains a challenge and carries a mortality of 10% to 20%. No validated risk score is available for TVS, and the effect of advanced age is unknown. This study examined our results in the modern era with the aim of identifying perioperative predictors of adverse outcomes. METHODS Between 1997 and 2013, 131 patients (mean age, 67.2±13.4 years) underwent TVS at our institution. Sixty-eight patients (51.9%) were aged 70 years and older. The most common etiology for aortic and mitral disease was degenerative (77.1%), rheumatic (10%), and endocarditis or prosthetic-related, or both, in the rest. Tricuspid valve disease was functional in 96%. New York Heart Association functional class III/IV was present in 69.4%, and 24% had had previous cardiac operations. One or more concomitant cardiac procedures were performed in 77 patients (58.8%), including coronary revascularization in 54. All aortic procedures were replacements, 14 patients required a prosthetic root conduit and 7 thoracic aorta replacement. Mitral replacements were used in 55%, repairs in 45%, and 96.2% of tricuspid procedures were repairs. Univariate and multivariate analyses were used to determine predictors of adverse outcomes. RESULTS The 30-day and hospital mortality was 10.6% (n=14). Major complications occurred in 70 (53.4%). Univariate analysis identified New York Heart Association functional class III/IV (p=0.04), preoperative renal failure requiring dialysis (p=0.04), urgent operation (p=0.04), intraaortic balloon pump placement (p=0.02), and postoperative low cardiac output (p<0.0001) as predictors for early death. Proximal aortic operations, urgent operation, and New York Heart Association class IV correlated with increased early mortality (p<0.04) in patients aged 70 and older in addition to their decreased overall survival and decreased likelihood of discharge to home. Overall actuarial survival at 1, 5, and 10 years was 84.5%, 75%, and 45%, respectively. CONCLUSIONS TVS remains a surgical challenge in the modern era. Despite a trend of increasing age and surgical risk, the early mortality rate and long-term survival remain respectable. Advanced age is associated with increased perioperative risk, but age per se should not be a contraindication for TVS.