David M. Overman

The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2016 Update on Outcomes and Quality.

The Society of Thoracic Surgeons Congenital Heart Surgery Database is the largest congenital and pediatric cardiac surgical clinical data registry in the world. It is the platform for all activities of The Society of Thoracic Surgeons related to the analysis of outcomes and the improvement of quality in this subspecialty. This article summarizes current aggregate national outcomes in congenital and pediatric cardiac surgery and reviews related activities in the areas of quality measurement, performance improvement, and transparency. The reported data about aggregate national outcomes are exemplified by an analysis of 10 benchmark operations performed from January 2011 to December 2014 and documenting overall discharge mortality (interquartile range among programs with more than 9 cases): off-bypass coarctation, 1.0% (0.0% to 0.9%); ventricular septal defect repair, 0.7% (0.0% to 1.1%); tetralogy of Fallot repair, 1.0% (0.0% to 1.7%); complete atrioventricular canal repair, 3.2% (0.0% to 6.5%); arterial switch operation, 2.7% (0.0% to 5.6%); arterial switch operation plus ventricular septal defect, 5.3% (0.0% to 6.7%); Glenn/hemiFontan, 2.1% (0.0% to 3.8%); Fontan operation, 1.4% (0.0% to 2.4%); truncus arteriosus repair, 9.6% (0.0 % to 11.8%); and Norwood procedure, 15.6% (10.0% to 21.4%).

Report from the Society of Thoracic Surgeons National Database Workforce: clarifying the definition of operative mortality.

Several distinct definitions of postoperative death have been used in various quality reporting programs. Some have defined postoperative mortality as the occurrence of death after a surgical procedure when the patient dies while still in the hospital, while others have considered all deaths occurring within a predetermined, standardized time interval after surgery to be postoperative mortality. While mortality data are still collected and reported using both these individual definitions, the Society of Thoracic Surgeons (STS) believes that either approach alone may be inadequate. Accordingly, the STS prefers a more encompassing metric, Operative Mortality. Operative Mortality is defined in all STS databases as (1) all deaths, regardless of cause, occurring during the hospitalization in which the operation was performed, even if after 30 days (including patients transferred to other acute care facilities); and (2) all deaths, regardless of cause, occurring after discharge from the hospital, but before the end of the 30th postoperative day. This article provides clarification for some uncommon but important scenarios in which the correct application of this definition may be challenging.Several distinct definitions of postoperative death have been used in various quality reporting programs. Some have defined a postoperative mortality as a patient who expires while still in the hospital, while others have considered all deaths occurring within a predetermined, standardized time interval after surgery. While if continues to collect mortality data using both these individual definitions, the Society of Thoracic Surgeons (STS) believes that either alone may be inadequate. Accordingly, the STS prefers a more encompassing metric, Operative Mortality, which is defined as (1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days; and (2) all deaths occurring after discharge from the hospital, but before the end of the thirtieth postoperative day. This manuscript provides clarification for some uncommon but important scenarios where the correct application of this definition may be problematic.

Safety and accuracy of dual-source coronary computed tomography angiography in the pediatric population.

BACKGROUND High heart rates and radiation sensitivity have limited the use of coronary computed tomography angiography (CTA) in pediatric patients. OBJECTIVE A contemporary evaluation of image quality and reduction in radiation exposure with dual-source CT technology has not been reported in a large cohort of pediatric patients undergoing coronary angiography. METHODS Consecutive coronary CTA scans (n = 71) in 70 pediatric patients were retrospectively reviewed. Metoprolol was administered for heart rate control. Scans were divided by acquisition mode into 3 groups: retrospective electrocardiogram (ECG)-triggered spiral, prospective ECG-triggered, and prospective ECG-triggered high-pitch spiral scans. Heart rate, radiation dose, image quality, and diagnostic confidence were compared between groups. RESULTS Median decrease in heart rate with metoprolol was 24% ± 14%. Median effective age-adjusted radiation dose for the entire group was 0.97 ± 1.20 mSv. Retrospective ECG-triggered scans had a median dose of 1.71 ± 1.4 mSv, prospectively ECG-triggered scans had a median dose of 0.9 ± 1.1 mSv, and prospectively ECG-triggered high-pitch spiral scans had a median effective dose of 0.27 ± 0.4 mSv. The difference between groups was statistically significant (P < 0.05). The contrast-to-noise ratio and the image quality score were similar between groups. CONCLUSION Dual-source coronary CTA with a β-blocker protocol uniformly achieves diagnostic coronary scans at a low radiation dose in pediatric patients. Image quality and diagnostic confidence are excellent for all scan modes in a wide spectrum of patients.

Non-sedated, free breathing cardiac CT for evaluation of complex congenital heart disease in neonates

BACKGROUND Neonates with complex congenital heart disease (CHD) are at risk of adverse events from anesthesia. CT angiography (CTA) performed free breathing and without sedation has not been reported for evaluation of complex CHD in neonates. OBJECTIVES The aim was to evaluate the image quality and risk of free breathing, non-sedated cardiac CTA for definition of CHD in the neonatal period and to determine accuracy compared with interventional findings. METHODS This is a combined retrospective-prospective single institution review of all non-sedated, free breathing cardiac CT angiograms performed in patients <1 month of age with complex CHD. Diagnosis, scan acquisition parameters, image quality (1- to 4-point scale), adverse events, radiation dose estimates, and accuracy compared with operative and interventional catheterization findings were recorded. Results are reported as median and interquartile range. RESULTS Nineteen non-sedated, free breathing, neonatal cardiac CT angiograms were performed during the time of review. All studies were diagnostic with a mean image quality score of 1.1 ± 0.3. Median total procedural dose-length product was 11 (range, 10-14), CT dose index volume was 0.47 (range, 0.31-0.5). Median unadjusted radiation dose was 0.15 mSv (range, 0.14-0.2 mSv), age- and size-adjusted radiation dose was 0.86 mSv (range, 0.78-1.1 mSv). No adverse events and no discrepancies compared with surgical or catheterization findings were found in the 17 of 19 patients that had subsequent intervention. CONCLUSIONS Cardiac CTA can be performed in the neonatal period free breathing and without sedation. Image quality is excellent, and there is high accuracy compared with surgical and catheterization findings at the time of intervention.

Echocardiographic features defining right dominant unbalanced atrioventricular septal defect: a multi-institutional Congenital Heart Surgeons' Society study.

Background— Definition and management of right dominant unbalanced atrioventricular septal defect (AVSD) remains challenging because unbalance entails a spectrum of left heart hypoplasia. Previous work has highlighted atrioventricular valve (AVV) index as a reasonable defining echocardiographic measure. We sought to assess which additional echocardiographic features might provide further characterization. Methods and Results— From a multi-institutional cohort of complete AVSD, 52 preoperative echocardiograms of patients with presumed right dominant unbalanced AVSD (based on AVV index) and 60 randomly selected preoperative echocardiograms from patients with presumed balanced AVSD were reviewed. Cluster analysis of echocardiographic variables was used to group patients with similar features. Discriminant function analysis was used to explore which variables differentiated these groups. Three groups were identified from the cluster analysis. Echocardiographic variables that differentiated these groups were right ventricle:left ventricle inflow angle, LV width/LV length, left AVV color diameter at smallest inflow, left AVV color diameter at annulus, right AVV overriding left atrium, and LV width. Based on procedures and outcomes, 1 group likely represented balanced patients, whereas 2 groups with similar outcomes likely represented unbalanced patients. The dominant differentiating echocardiographic variable between the 3 cluster groups was the right ventricle:LV inflow angle (partial R 2=0.86), defined as the angle between the base of the right ventricle and LV free wall, using the crest of the ventricular septum as apex of the angle. Conclusions— The angle of right ventricle/LV inflow and other surrogates of inflow may be important defining echocardiographic measures of right dominant unbalanced AVSD, although confirmation is needed.Background—Definition and management of right dominant unbalanced atrioventricular septal defect (AVSD) remains challenging because unbalance entails a spectrum of left heart hypoplasia. Previous work has highlighted atrioventricular valve (AVV) index as a reasonable defining echocardiographic measure. We sought to assess which additional echocardiographic features might provide further characterization. Methods and Results—From a multi-institutional cohort of complete AVSD, 52 preoperative echocardiograms of patients with presumed right dominant unbalanced AVSD (based on AVV index) and 60 randomly selected preoperative echocardiograms from patients with presumed balanced AVSD were reviewed. Cluster analysis of echocardiographic variables was used to group patients with similar features. Discriminant function analysis was used to explore which variables differentiated these groups. Three groups were identified from the cluster analysis. Echocardiographic variables that differentiated these groups were right ventricle:left ventricle inflow angle, LV width/LV length, left AVV color diameter at smallest inflow, left AVV color diameter at annulus, right AVV overriding left atrium, and LV width. Based on procedures and outcomes, 1 group likely represented balanced patients, whereas 2 groups with similar outcomes likely represented unbalanced patients. The dominant differentiating echocardiographic variable between the 3 cluster groups was the right ventricle:LV inflow angle (partial R2=0.86), defined as the angle between the base of the right ventricle and LV free wall, using the crest of the ventricular septum as apex of the angle. Conclusions—The angle of right ventricle/LV inflow and other surrogates of inflow may be important defining echocardiographic measures of right dominant unbalanced AVSD, although confirmation is needed.

Unbalanced atrioventricular septal defect: definition and decision making.

Unbalanced atrioventricular septal defect is an uncommon lesion with widely varying anatomic manifestations. When unbalance is severe, diagnosis and treatment is straightforward, directed toward single-ventricle palliation. Milder forms, however, pose a challenge to current diagnostic and therapeutic approaches. The transition from anatomies that are capable of sustaining biventricular physiology to those that cannot is obscure, resulting in uneven application of surgical strategy and excess mortality. Imprecise assessments of ventricular competence have dominated clinical decision making in this regard. Malalignment of the atrioventricular junction and its attendant derangement of inflow physiology is a critical factor in determining the feasibility of biventricular repair in the setting of unbalanced atrioventricular septal defect. The atrioventricular valve index accurately identifies unbalanced atrioventricular septal defect and also brings into focus a zone of transition from anatomies that can support a biventricular end state and those that cannot.

Selective use of cardiac computed tomography angiography: An alternative diagnostic modality before second-stage single ventricle palliation

OBJECTIVES To assess the accuracy and risk of substituting cardiac computed tomography for cardiac catheterization in select patients for evaluation of anatomy before second-stage single ventricle palliation. METHODS This is a retrospective review of consecutive diagnostic cardiac catheterization (n=16) and computed tomography studies (n=16) performed before second-stage single ventricle palliation from March 2010 to July 2012 at a single institution. Risk (anesthesia, vascular access, contrast, and radiation exposure), accuracy, and postoperative course were compared. Nonparametric analysis was used to compare differences in group medians. RESULTS General anesthesia was used for 16 of 16 cardiac catheterization studies and 1 of 16 computed tomography studies. Vascular access was central venous and/or arterial for all cardiac catheterization studies and a peripheral intravenous line for all computed tomography studies. Median age- and size-adjusted radiation dose was 14.0 mSv for cardiac catheterization and 1.1 mSv for computed tomography. Contrast dose was 4.8 mL/kg for the cardiac catheterization group and 2 mL/kg for the computed tomography group. There were no computed tomography discrepancies and 1 discrepancy between cardiac catheterization and surgical findings. There were 8 adverse events in 6 patients in the cardiac catheterization group and 1 adverse event in the computed tomography group. There was no difference between groups in postoperative course or need for repeat intervention. CONCLUSIONS Cardiac computed tomography and cardiac catheterization are equally accurate for evaluation of anatomy before second-stage single ventricle palliation when compared with surgical findings. Computed tomography may be the preferred test in select patients because of decreased vascular access and anesthesia risk, lower radiation and contrast exposure, and fewer adverse events.

Long-Term Use of Ventricular Assist Device as a Bridge to Recovery in Acute Fulminant Myocarditis

We report the successful long-term use of a left ventricular assist device (Berlin EXCOR) as a bridge to recovery in a patient with fulminant parvovirus B19 myocarditis. The use of this device allowed time for myocardial recovery, avoiding the need for cardiac transplantation.

Reoperation for Left Ventricular Outflow Tract Obstruction After Repair of Atrioventricular Septal

Left ventricular outflow tract obstruction (LVOTO) is an important source of morbidity and mortality after repair of atrioventricular septal defect (AVSD). The intrinsic anatomy of the left ventricular outflow tract in AVSD is complex and predisposes to the development of LVOTO. LVOTO after repair of AVSD usually involves multiple levels and sources of obstruction, and surgical intervention must address each component of the obstruction. This includes fibromuscular obstruction, septal hypertrophy, and valve related sources of obstruction. Special attention is also directed to the anterolateral muscle bundle of the left ventricle, a well defined but under recognized feature of the left ventricular outflow tract in AVSD. It is present in all patients with AVSD, and resection of a hypertrophic anterolateral muscle bundle of the left ventricle should be incorporated in all operations for LVOTO after repair of AVSD. LVOTO after repair of AVSD has several unique features that must be taken into consideration to maximize outcome after surgical intervention. These include anatomic factors, technical aspects of surgical intervention, and proper selection of the operation used for relief of LVOTO.

Unbalanced Atrioventricular Septal Defect: Defining the Limits of Biventricular Repair

Unbalanced atrioventricular septal defect (uAVSD) is a challenging lesion with suboptimal outcomes in the current era. Severe forms of uAVSD mandate univentricular repair with well-documented outcomes. Determining the feasibility of biventricular repair (BVR) in patients with moderate forms of uAVSD is difficult. Ventricular hypoplasia has traditionally formed the cornerstone of defining uAVSD. However, malalignment of the atrioventricular junction and related derangements of the anatomy and physiology of the atrioventricular inflow play a central role in establishing and sustaining a biventricular end state. Atrioventricular valve index, left ventricular inflow index, and right ventricle/left ventricle inflow angle are important recently described measures of inflow physiology. Additional patient anatomic and physiologic factors that impact BVR feasibility undoubtedly exist. A recently launched Congenital Heart Surgeons Society prospective inception cohort study will address these and other issues that impair our ability to predict BVR feasibility in uAVSD.