Late Causes of Death After Pediatric Cardiac Surgery

Alireza Raissadati et al. JACC 2016;68:487-98.
From Finland.

1953-2009
Divided into two surgical era: 1953-89 & 1990-2009.

Cardiac causes of mortality:
Heart failure
Pulmonary hypertension
Sudden death (Aortic rupture, Arrhythmia, MI - majority were unexplained)
Death after reoperation

Non-cardiac causes of mortality:
Respiratory disease (esp. pneumonia associated with mental disability)
Neurologic and infectious diseases
Neoplasm (more common compared to general population)
Accidents (alcohol-related)

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.

Changing Mortality in Congenital Heart Disease

J Am Coll Cardiol, 2010; 56:1149-1157
Changing Mortality in Congenital Heart DiseasePaul Khairy, MD, PhD*, Raluca Ionescu-Ittu, MSc,, Andrew S. Mackie, MD, SM, Michal Abrahamowicz, PhD, Louise Pilote, MD, MPH, PhD, and Ariane J. Marelli, MD,*

Objectives: This study sought to characterize temporal trends in all-cause mortality in patients with congenital heart disease (CHD).
Background: Historically, most deaths in patients with CHD occurred in early childhood. Notable advances have since been achieved that may impact on mortality trends.

Methods: We conducted a population-based cohort study of patients with CHD in Quebec, Canada, from July 1987 to June 2005. A total of 8,561 deaths occurred in 71,686 patients with CHD followed for 982,363 patient-years.

Results: The proportion of infant and childhood deaths markedly declined from 1987 to 2005, with a reduction in mortality that exceeded that of the general population. Distribution of age at death transitioned from a bimodal to unimodal, albeit skewed, pattern, more closely approximating the general population. Overall, mortality decreased by 31% (mortality rate ratio: 0.69, 95% confidence interval [CI]: 0.61 to 0.79) in the last (2002 to 2005) relative to the first (1987 to 1990) period of observation. Mortality rates decreased in all age groups below 65 years, with the largest reduction in infants (mortality rate ratio: 0.23, 95% CI: 0.12 to 0.47). In adults 18 to 64 years, the mortality reduction (mortality rate ratio: 0.84, 95% CI: 0.73 to 0.97) paralleled the general population. Gains in survival were mostly driven by reduced mortality in severe forms of CHD, particularly in children (mortality rate ratio: 0.33, 95% CI: 0.19 to 0.60), and were consistent across most subtypes.

Conclusions: Deaths in CHD have shifted away from infants and towards adults, with a steady increase in age at death and decreasing mortality.

Figure 1 Distribution of Age at Death in Patients With Congenital Heart Disease in 1987 to 1988 and 2004 to 2005
Histogram bars depict the proportion of all deaths (x-axis) according to age at death (y-axis) in our cohort of patients with congenital heart disease in the first (1987 to 1988; left) and final (2004 to 2005; right) years of observation. Bold black curves with diamonds represent the corresponding age at death distribution in the general Quebec population during the same periods of observation.

Also read this related article:

European Heart Journal 2010;31:1220-29

Mortality in adult congenital heart disease. Verheugt CL, et al.

Article from Netherlands. The Dutch CONCOR Regional Registry.

6933 pts, 197 (2.8%) died. F-up of 24,865 patient-years were analyzed for cause of death. Higher mortality compared to general population. Median age of death was 48.8 yrs. 77% of deaths were cardiovascular in origin (CHF or Sudden death - 45%). Predictors of mortality were age, gender, severity of defect, number of interventions and number of complications (i.e. endocarditis, SVT, VT, conduction disturbances, MI and PAH).

Overall, nothing unexpected. But, they have data to confirm this common sense thought.