Adult CHD: Risk factors for death in pediatric hospitals

Risk Factors for Death After Adult Congenital Heart Surgery in Pediatric Hospitals

1. Yuli Y. Kim, MD,
2. Kimberlee Gauvreau, ScD,
3. Emile A. Bacha, MD,
4. Michael J. Landzberg, MD and
5. Oscar J. Benavidez, MD, MPP

CIRCOUTCOMES.110.958256Published online before print June 21, 2011

1. From the Divisions of Cardiology (Y.Y.K.), Hospital of the University of Pennsylvania and Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA; the Department of Cardiology (K.G., M.J.L., O.J.B.), Children's Hospital Boston, Harvard Medical School, Boston, MA; Boston Adult Congenital Heart (BACH) Program (M.J.L.), the Department of Cardiology, Children's Hospital Boston, Boston, MA; the Division of Cardiology (M.J.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and the Department of Surgery (E.A.B.), Morgan Stanley Children's Hospital of New York, Columbia University College of Physicians and Surgeons, New York, NY.

1. Correspondence to Oscar J. Benavidez, MD, Department of Cardiology, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115. E-mailOscar.Benavidez@cardio.chboston.org

Abstract

Background Despite the central role that pediatric hospitals play in the surgical treatment of congenital heart disease, little is known about outcomes of adult congenital cardiac surgical care in pediatric hospitals. Risk factors for inpatient death, including adult congenital heart (ACH) surgery volume, are poorly described.

Methods and Results We obtained inpatient data from 42 free-standing pediatric hospitals using the Pediatric Health Information System data base 2000 to 2008 and selected ACH surgery admissions (ages 18 to 49 years). We examined admission characteristics and hospital surgery volume. Of 97 563 total (pediatric and adult) congenital heart surgery admissions, 3061 (3.1%) were ACH surgery admissions. Median adult age was 22 years and 39% were between ages 25 to 49 years. Most frequent surgical procedures were pulmonary valve replacement, secundum atrial septal defect repair, and aortic valve replacement. Adult mortality rate was 2.2% at discharge. Multivariable analyses identified the following risk factors for death: age 25 to 34 years (adjusted odds ratio [AOR], 2.1; P=0.009), age 35 to 49 years (AOR, 3.2; P=0.001), male sex (AOR, 1.8; P=0.04), government-sponsored insurance (AOR, 1.8; P=0.03), and higher surgical risk categories 4+ (AOR, 21.5; P=0.001). After adjusting for case mix, pediatric hospitals with high ACH surgery volume had reduced odds for death (AOR, 0.4; P=0.003). There was no relationship between total congenital heart surgery volume and ACH inpatient mortality.

Conclusions Older adults, male sex, government-sponsored insurance, and greater surgical case complexity have the highest likelihood of in-hospital death when adult congenital surgery is performed in free-standing pediatric hospitals. After risk-adjustment, pediatric hospitals with high ACH surgery volume have the lowest inpatient mortality.

Cath: Hybrid Procedure - Aortic stent placement for recoarctation after Norwood Procedure

1. Hybrid aortic reconstruction for treatment of recurrent aortic obstruction after stage 1 single ventricle palliation. Medium-term outcomes and results of redilataion.

1. Shelby Kutty MD¹,
2. Redmond P. Burke MD²,
3. Robert L. Hannan MD²,
4. Evan M. Zahn MD, FSCAI^2,*

Catheterization and Cardiovascular Interventions

Volume 78, Issue 1, pages 93–100, 1 July 2011

Catheterization and Cardiovascular Interventions

Volume 78, Issue 1, pages 93–100, 1 July 2011

Abstract

Objective:

We describe a hybrid approach to the treatment of aortic obstruction after stage 1 palliation (S1P) of hypoplastic left heart syndrome.

Background:

Recurrent aortic obstruction is a common problem after S1P of hypoplastic left heart syndrome. Even mild aortic obstruction is poorly tolerated so early and definitive therapy is desirable. Although stent implantation is an effective treatment for aortic obstruction in older children and adults, technical issues due to small vessels and concerns regarding future potential for expansion have generally precluded the use of stents in this setting.

Methods:

Six patients underwent hybrid aortic reconstruction (HAR) in the operating room or catheterization laboratory, with the interventional cardiologist and cardiac surgeon working in cooperation.

Results:

Patients had a mean weight of 5.8 kg (2.9–7.7) and a mean age of 5.6 months (0.5–12.9) at the time of HAR. Five patients had undergone prior balloon angioplasty at a mean age of 2.8 months (2.1–3.5), and five had moderately depressed single ventricular function prior to HAR. The balloons used had a diameter of 7–10 mm and introducer sheath size ranged from 6 to 10 F. There were no immediate or late procedure related complications. Stent redilation was performed in 5 patients for relief of recurrent obstruction or to keep pace with somatic growth. At a median follow up of 4.8 years (0.2–7.9), there were 3 patients progressing well after Fontan palliation and 3 deaths.

Conclusions:

HAR allows for placement of stents that can ultimately reach adult size in small infants who have recurrent aortic obstruction after balloon angioplasty following S1P. Advantages include freedom from delivery sheath constraints when determining stent type/size, facilitation of precise stent position, and avoidance of vascular damage or hemodynamic compromise during the procedure. Longer follow-up and larger experience are required to determine if this therapy will provide a long-term solution to this difficult problem. © 2011 Wiley-Liss, Inc

Cath: Melody Valve in Contegra Graft - Animal Study

Circulation. 2010;122:A19333

Abstract 19333: Transcatheter Delivery of Melody Valves (MelV) Larger Than Contegra Conduit (CC)

Core 3. Genetics, Genomics and Congenital CV Disorders Session Title: Cardiac Catheterization and Electrophysiology in the Young

Prakul Chanthong; Luis Quinonez; Patty Boylen; Jon Timinsky; James Y Coe

UNIVERSITY ALBERTA HOSPITAL, Edmonton, Canada; Medtronic Canada, Missisauga, Canada; UNIVERSITY ALBERTA HOSPITAL, Edmonton, Canada

Transcatheter replacement of pulmonary valves is used in failed right ventricular to pulmonary artery (RV-PA) homografts (H) or prosthetic valves (PV). The former calcify and the latter have metal rings ± struts, both providing secure landing spots for MelV. The MelV expansion is limited by the H or PV size, and H may rupture if expanded beyond its original diameter. CCs often do not calcify, yet may become aneurysmal with increased intraluminal pressure. We tested the hypothesis that transcatheter MelV replacement is possible in a hypertensive, supported CC. Under general anesthesia, supported 18 mm CCs were placed as descending aortic jump grafts via a left thoracotomy in sheep (n=6). After a recovery period, 22 mm MelVs (n=4) were delivered via a carotid artery into the CCs. 56-82 (mean 72) days after aortic placement, the 18 mm CC dilated to 36-37 mm under systemic pressure, while the ring diameter remained at 18 mm. Deploying the MelV at 22 mm expanded the CC rings to 22 mm. without CC rupture. Transcatheter Melody valve replacement into the Contegra conduits is feasible. The Melody valve will expand the rings of the Contegra conduit to the largest valve diameter.

Author Disclosures: P. Chanthong, None; L. Quinonez, None; P. Boylen, Medtronic, Modest, Employment; J. Timinsky, None; J.Y. Coe, Medtronic, Modest, Consultant/Advisory Board; NuMed, Modest,Consultant/Advisory Board.

General Cardiology: Heart Failure, Hyponatremia, Mortality

CIRCHEARTFAILURE.111.961011Published online before print June 14, 2011,

Impact of Change in Serum Sodium Concentration on Mortality in Patients Hospitalized with Heart Failure and Hyponatremia

1. Vinay D. Madan,
2. Eric Novak and
3. Michael W. Rich*

Abstract

Background—Hyponatremia is a common electrolyte abnormality among patients hospitalized with heart failure and it is a marker for increased short-term and long-term mortality. However, little is known about the time-course of hyponatremia and whether changes in serum sodium levels impact clinical outcomes.

Methods and Results—322 patients hospitalized with decompensated heart failure and serum sodium <135 mmol/L were evaluated. Following hospital discharge, the first sodium value obtained within a 60-270 day period was recorded, and patients were classified into 3 groups based on whether the serum sodium value increased (≥2 mmol/L), decreased (≤2 mmol/L), or remained unchanged (±1 mmol/L) relative to the baseline value. Kaplan-Meier survival curves were constructed to illustrate mortality as a function of change in sodium concentration over time, and a Cox-proportional hazards model was constructed to determine if change in serum sodium concentration predicted mortality after adjusting for relevant covariates. The mean age of the population was 66 years, 45% were women, and 55% were Caucasian. The mean baseline sodium level was 131 mmol/L and the mean ejection fraction was 32.5%. 222 patients (68.9%) exhibited an increase in sodium during follow-up; in 57 patients (17.7%) the level was unchanged and in 43 patients (13.4%) there was a decrease in sodium level. During a median follow-up of 610 days, there was a strong positive association between change in sodium level and survival (p for trend <0.001); i.e., increased sodium was associated with decreased mortality. In multivariable analysis, change in sodium concentration and higher blood urea nitrogen were the strongest predictors of mortality (both p<0.0001).

Conclusions—Among patients hospitalized with heart failure and hyponatremia, change in serum sodium concentration over time is a strong predictor of long-term survival.