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Ann Thorac Surg 2000;69:871
© 2000 The Society of Thoracic Surgeons
a Pediatric and Congenital Cardiac Surgery, California Pacific Medical Center, 2100 Webster St, #332, San Francisco, CA 94115, USA,
e-mail: kt1pedcv{at}aol.com
Invited commentary
The Loma Linda group are to be commended for their exceptional application of the pathway method described in "ultra fast track" in elective congenital cardiac surgery. Their manuscript describes the application of an accelerated recovery program in 198 patients who were admitted on the same day as their cardiac operation. Those excluded were 23 cardiac transplants, 27 premature infants, 26 general thoracic patients, and 59 inpatients previously admitted for medical or "family environmental related issues" (original manuscript and authors’ response to reviewer’s comments, communication with Leonard Bailey, MD, August 10, 1999). Among the 201 procedures, there were 6 deaths (2.9%); among the 195 patients in whom the pathway methodology was used, 165 (84.6%) had no complications. Six diagnostic groups were described. In three of those groups (groups 2 through 4), patients with simple left-to-right shunts, right-to-left shunts with pulmonary obstruction, and isolated nonvalvular obstructive lesions, decreases in both mean length of stay and its variation were noted. Decreased length of stay with increased variation was observed in the patients with isolated valvular anomaly (group 5). Among those in group 1 (young patients with complex left-to-right shunts), an increased mortality (14.3%) and morbidity (16.6%) were noted. In group 3, patients with left-to-right shunt and pulmonary obstruction, increased mortality was observed, prompting the authors to comment that pulmonary hypertension, severe tricuspid regurgitation, and unifocalization may be better served by a "more conservative approach with regards to extubation (original manuscript and authors’ response to reviewer’s comments, communication with Leonard Bailey, MD, August 10, 1999)." Decreased variance was impressively demonstrated in 21 non-cardiopulmonary bypass patients and in 119 non-circulatory arrest patients, as well as among the 21 patients in whom hypothermic circulatory arrest of more than 20 minutes was used, reflecting the effectiveness of their methodology in even these more complex patients. Finally, in their most complex subgroup (group 6), which included patients undergoing Fontan palliation procedures, there was increased variability, consistent with the complex nature of the group; however, decreased length of stay was achieved in a significant number, and, as we have previously observed, the greatest benefit from the accelerated pathway may accrue in such patients [1].
The conclusion that "limited sternotomy ... may be safely accomplished among the vast majority of patients" is unfortunately not corroborated by the study as only 17 of the 201 patients underwent limited sternotomy (original manuscript and authors’ response to reviewer’s comments, communication with Leonard Bailey, MD, August 10, 1999). Currently more than 80% of our pediatric patients undergo limited incisions using three-dimensional visualization. That such an approach may facilitate accelerated recovery is consistent with our prior work on pain prevention [2], and decreased incisional size and stimulus for pain are the perfect match to aggressive recovery. Further experience will undoubtedly confirm the efficacy of this approach. The authors’ innovative "ultra fast track" does provide excellent outcomes and their message is clear—"prolonged hospitalization" contributes little to results.
References
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