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Ann Thorac Surg 2000;69:1236-1242
© 2000 The Society of Thoracic Surgeons

ORIGINAL ARTICLES: CARDIOVASCULAR

Influence of perioperative factors on outcomes in children younger than 18 months after repair of tetralogy of Fallot

Umesh Dyamenahalli, MDa,b,c,d,e,f, Brian W. McCrindle, MDa,b,c,d,e,f, Geoffrey A. Barker, MBa,b,c,d,e,f, William G. Williams, MDc, Robert M. Freedom, MDa,b,c,d,e,f, Desmond J. Bohn, MBa

a Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
b Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
c Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
d Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
e Department of Surgery, University of Toronto, Toronto, Ontario, Canada
f Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada

Address reprint requests to Dr Bohn, Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada M5G 1X8
e-mail: dbohn{at}sickkids.on.ca


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. There has been a trend toward advocating earlier repair of tetralogy of Fallot and avoiding palliative procedures. The impact of this trend on perioperative outcomes has not been adequately documented.

Methods. Data from consecutive patients undergoing repair of tetralogy of Fallot at less than 18 months of age from May 1987 to September 1994 were reviewed. Independent factors associated with duration of stay in the intensive care unit were sought.

Results. Repair was performed in 89 infants at a median age of 13 months (range, 15 days to 18 months). A systemic–pulmonary artery shunt was present in 24% of patients. Mean duration of cardiopulmonary bypass was 119 ± 37 minutes; 63% of patients received a transannular patch. There were six deaths (7%), all occurring less than 48 hours after repair. The median duration of stay in the intensive care unit was 5 days (range, 1 day to 8 months). Significant independent factors associated with increasing length of intensive care unit stay included younger age at repair, previous shunt, malformation syndrome, increased total dose and number of inotropic agents used, and respiratory complications. Hemodynamic variables serially recorded in the first 48 hours after repair were independently associated with death or prolonged (>7 days) duration of stay.

Conclusions. Although outcomes after repair of tetralogy of Fallot in infants are good, both younger age at repair and previous palliative procedures were associated with longer duration of stay in the intensive care unit.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Tetralogy of Fallot (ToF) was first palliated with a systemic–pulmonary artery shunt in 1944 [1]. Since then, there have been many modifications in the management of this lesion. Previously, the approach in our institution (The Hospital for Sick Children, Toronto) has been to perform a systemic–pulmonary artery shunt early in life in cyanotic infants and then a surgical repair when they were older than 18 months [2]. More recently, there has been a growing trend toward primary surgical repair in early infancy and toward surgical repair of symptomatic newborns with or without prior palliation by systemic–pulmonary artery shunt [3–7]. The rationale for this approach is the assumption that early normalization of physiology is better for neurologic development [6, 8], prevents impairment in pulmonary alveolar and vascular growth [9], and avoids progressive infundibular obstruction [10]. Early correction also avoids distortion of branch pulmonary arteries by palliative shunts [11]. The potential benefit of this approach must be weighed against the possibility that surgical repair in a young infant can be associated with an increased risk of morbidity, which can prolong the stay in the intensive care unit (ICU), and mortality [12]. To our knowledge, there are no published reports that determine the associations between perioperative factors, early postoperative hemodynamics, and short-term outcomes as indicated by complications, length of stay in the ICU, and mortality in ToF. We sought to relate preoperative cardiac catheterization data and hemodynamic measurements made in the first 48 hours after operation with outcomes, the end points being mortality, morbidity, and length of stay in the ICU.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
Consecutive patients with a diagnosis of ToF who underwent surgical repair when they were less than 18 months old and who were seen from May 1987 to September 1994 were identified from the cardiac surgery database of The Hospital for Sick Children. We included patients with or without a prior systemic–pulmonary artery shunt and patients with ToF with pulmonary atresia. We excluded patients who also had absent pulmonary valve syndrome or atrioventricular septal defect. All other associated cardiac anomalies, noncardiac anomalies, and malformation syndromes were noted.

Measurements
Data were collected from review of hospital records, preoperative cardiac catheterizations, operative notes, and autopsy reports. The ICU computer database, which uniquely records and stores physiologic data on a minute-to-minute basis, was used to obtain detailed postoperative hemodynamic data.

Factors assessed from preoperative cardiac catheterizations included the measurements of the diameters of the distal branch pulmonary artery proximal to lobar branching and the descending aorta at the level of the diaphragm. From these measurements the Nakata [13] and McGoon [14] indices were calculated. Operative factors that were assessed were the age, weight, and body surface area of the patient, the duration of aortic cross-clamping and cardiopulmonary bypass, the use of a transannular patch, and the ratio of right ventricular to left ventricular systolic pressure at the end of the procedure. Postoperative hemodynamic measurements recorded at 1 hour, 2 hours, 4, 8, 12, 16, 20, 24, 36, and 48 hours after repair, including heart rate, central venous pressure, left atrial pressure, and systemic arterial pressure, were analyzed. The presence of metabolic acidosis in arterial blood gas with a pH of less than 7.3 without respiratory acidosis was documented. The postoperative use of intravenous inotropic and vasodilator infusions with doses, the occurrence of postoperative arrhythmias, and the presence of chest roentgenographic changes such as pulmonary atelectasis and effusions were recorded.

Renal dysfunction was defined as the requirement of peritoneal dialysis or continuous venovenous hemofiltration in association with poor urine output and high serum urea and creatinine levels. Hepatic dysfunction was defined as a clinically significant elevation to more than twice the normal values for serum hepatic transaminases. Neurologic abnormalities such as abnormal tone, seizures, or abnormal involuntary movements were noted. Infectious complications including sepsis with positive blood cultures and wound and respiratory infections requiring antibiotic therapy were noted. The duration of mechanical ventilation and the length of stay in the ICU were recorded. The cases of patients who died were reviewed for cause of death, and available autopsy findings were noted.

Data analysis
Analysis of all data was performed using SAS Version 6.12 software (SAS Institute Inc, Cary, NC) with default settings. Data are described as frequencies, medians with ranges, and means with standard deviations as appropriate. Where there are missing data, the number of available values is given. Kaplan-Meier estimates of time to discharge from the ICU were plotted, with patients who died in the unit censored at the time of death. Independent factors associated with length of stay in the ICU were sought in Cox’s proportional hazard regression modeling. Postoperative hemodynamic variables were related to a dichotomous outcome of death or prolonged stay in the critical care unit of more than 7 days versus survival with length of stay of 7 days or less. Associated factors were explored in multiple logistic regression analyses, while controlling for the age of the patient and the time in the first 48 hours when the hemodynamic measurement was made. A p value of 0.05 was set as the level of significance.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
Patient characteristics
From May 1987 to September 1994, 92 consecutive patients were identified from the cardiac surgery database, and data from 89 patients were available for analysis. Medical records were not available and hemodynamic data were not recorded for 3 patients. The study group comprised 65 male and 24 female patients. Age at diagnosis (n = 68) was less than 1 month in 46 patients (68%), 1 month to 3 months in 16 (24%), and more than 3 months in 6 patients (9%). Associated malformation syndromes were present in 12 patients (13%) and included Down’s syndrome in 5 patients, Pierre Robin syndrome in 2, and Noonan’s syndrome, Williams syndrome, VATER (vertebral defects, anal atresia, tracheoesophageal fistula with esophageal atresia, renal defects, and radial dysplasia), and pentalogy of Cantrell (abdominal wall defect, agenesis of the lower part of the sternum and anterior part of the diaphragm, absence of the diaphragmatic part of the pericardium, and a cardiac defect) in 1 patient each. Three additional patients had dysmorphic features with no definite diagnosis of chromosomal abnormality or specified syndrome. Twenty-one patients (24%) had prior systemic–pulmonary artery shunts. Propranolol hydrochloride had been used before repair (n = 88) in 42 patients (48%). The following associated cardiac anomalies were present:
Right aortic arch 16 patients
Left superior vena cava 9 patients
Pulmonary atresia 4 patients
Aortopulmonary collaterals 7 patients
Vascular ring 3 patients
Aberrant right subclavian artery 4 patients
Additional ventricular septal defects 2 patients

The following additional lesions were noted in 1 patient each: isolated left pulmonary artery, anomalous left coronary artery from main pulmonary artery, single coronary artery, aortopulmonary window, subaortic ridge, supraaortic stenosis, supramitral ring, pulmonary vein stenosis, small left ventricle, tricuspid stenosis, small right ventricle, dextrocardia, scimitar variant, and Wolff-Parkinson-White syndrome.

Preoperative cardiac catheterization
Hemodynamic and angiographic data were reviewed from preoperative cardiac catheterizations for assessment of branch pulmonary artery size and morphology and size of the descending aorta at the level of the diaphragm. The mean Nakata index was 282 ± 132 (n = 83), and the mean McGoon index was 2.18 ± 0.50 (n = 79). There was angiographic evidence of branch pulmonary artery stenosis in 19 infants (21%).

Surgical repair
The median age at repair was 13 months (range, 15 days to 17.9 months). The distribution by age was as follows: less than 6 months, 9 patients (10%); 6 to 8 months, 10 patients (11%); 9 to 11 months, 17 patients (19%); 12 to 14 months, 22 patients (25%); and 15 to 17 months, 31 patients (35%). The median weight was 8.5 kg (range, 2.6 to 17.6 kg), and the median body surface area was 0.45 m2 (range, 0.18 to 0.50 m2). The mean cardiopulmonary bypass time (n = 88) was 119 ± 37 minutes, with a mean aortic cross-clamp time of 47 ± 14 minutes. Repair was performed through a right ventriculotomy (n = 85) in 79 patients (93%). A transannular patch (n = 87) was placed in 55 patients (63%), with main or branch pulmonary arterioplasty or a combination of both (n = 85) performed in 51 patients (60%). Patients with a transannular patch had significantly lower mean Nakata and McGoon indices than those without a patch (Nakata: 253 ± 120, n = 51, versus 334 ± 141, n = 30; p = 0.007; McGoon: 2.10 ± 0.54, n = 47, versus 2.33 ± 0.42, n = 30; p = 0.05), but the two groups did not differ regarding age at repair. The mean ratio of right ventricular to left ventricular systolic pressure measured intraoperatively after repair (n = 67) was 0.50 ± 0.13, and it was not significantly related to age at repair, preoperative Nakata or McGoon index; or placement of a transannular patch.

Mortality
There were six early deaths (7%), all occurring less than 48 hours after repair. Death was associated with arrhythmia in 3 patients (1 each had ventricular fibrillation, severe bradycardia, or narrow-complex tachycardia) and low cardiac output related to poor right ventricular systolic function in 2. A residual anatomic defect (major aortopulmonary collateral vessel) with a left-to-right shunt producing very low diastolic pressure was thought to be the cause of death in 1 patient. Associated noncardiac and cardiac lesions were present in 4 of these patients. Given the small number of deaths, there were no significant associated factors identified other than lower median weight at operation.

Reoperation
Three patients underwent reoperation. One patient with low cardiac output resulting from right ventricular hypoplasia had reoperation within 24 hours after repair to create atrial and ventricular septal defects and died during the procedure. The other 2 patients had successful reoperations. In 1, right ventricular outflow tract obstruction caused by kinking was relieved by placement of a homograft conduit at 3 days, and in the other, reoperation was carried out at 8 days to close a residual ventricular septal defect.

Postoperative management
Inotropic agents were used in the postoperative period in 75 patients (84%); 9 patients required two agents and 7 patients, three. These inotropic drugs were dopamine hydrochloride in 71 patients, amrinone lactate in 12, epinephrine in 9, and dobutamine hydrochloride in 8. The median duration of their use in 70 hospital survivors was 65 hours (range, 2 hours to 19 days). Vasodilator agents were used in 59 patients (66%), 6 of whom required two agents. These vasodilators were nitroglycerin in 34 patients and sodium nitroprusside in 31 patients. The median duration of vasodilator use in 54 hospital survivors was 66 hours (range, 13 hours to 10 days).

Of the 83 hospital survivors, 1 patient with pentalogy of Cantrell and severe bronchomalacia required prolonged mechanical ventilation for 7.9 months with a length of stay in the ICU of 8 months. For the others, the median duration of postoperative mechanical ventilation (n = 77) was 74 hours (range, 11 hours to 30 days), with a median length of ICU stay of 5 days (range, 1 to 40 days). A Kaplan-Meier plot of length of stay is shown in Figure 1; patients who died were censored at the time of death. Length of stay for survivors was significantly related to age at repair (p = 0.03); the median length of stay was 9.5 days (range, 2 to 243 days) for patients less than 6 months old, 5 days (range, 2 to 32 days) for those 6 to 8 months old, 6.5 days (range, 2 to 26 days) for patients 9 to 11 months old, 4.5 days (range, 2 to 40 days) for those 12 to 14 months old, and 4 days (range, 1 to 12 days) for patients 15 to 17 months old.



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  		Fig 1. Kaplan-Meier plot of length of stay in intensive care unit (ICU) after repair of tetralogy of Fallot. Deaths before discharge from the ICU (n = 6) were censored at the time of their occurrence. Broken lines represent 95% confidence limits.

 
Complications
Postoperative complications included major renal dysfunction in 6 patients, all of whom had recovery of renal function, and clinically significant increases in hepatic transaminases in 7 patients, again with complete recovery in all 7. Reversible neurologic complications included abnormal muscle tone in 3 patients and dyskinetic movements, seizures, and intracranial hemorrhage in 1 patient each. The presence of pleural effusion, marked atelectasis, or both on postoperative chest radiographs was noted in 37 patients, 2 of whom had chylous pleural effusions. Acidosis (pH < 7.3) was noted in 32 patients. Bacterial infections were diagnosed in 11 patients, 4 of whom had sepsis with Staphylococcus epidermidis and 1 with Staphylococcus aureus. Bacterial endocarditis was diagnosed in 1 patient. Three patients had chest infections (Pseudomonas in 2 and Pseudomonas and S epidermidis in 1). Wound infections were noted in 3 patients (sternal abscess in 1 (Staphylococcus aureus in 2 and S epidermidis in 1). Four patients had postoperative diaphragmatic paralysis.

Arrhythmias
Early postoperative arrhythmias were noted in 24 patients (27%), 5 of whom had more than one type of arrhythmia. Arrhythmias included junctional ectopic tachycardia (JET) in 18 patients, atrial ectopic tachycardia in 5, temporary atrioventricular block in 2, and narrow complex supraventricular tachycardia, atrial flutter, and ventricular fibrillation in 1 patient each.

Factors associated with JET were sought. None of the patients with JET died. Patients with JET had significantly longer mean cardiopulmonary bypass times (134 ± 44 minutes) than patients without JET (115 ± 34 minutes); (p = 0.03). Patients with JET were more likely to have acidosis (systemic arterial pH < 7.3 with a base excess > -5) than those without this type of arrhythmia (38% versus 11%; p = 0.002), were receiving two or more inotropic agents (63% versus 11%; p = 0.001), and required at least one vasodilating agent (27% versus 7%; p = 0.03). The presence of JET was not significantly associated with age or weight at repair, technique of repair, or intraoperative postrepair hemodynamics. The presence of JET did not significantly prolong length of stay in the ICU.

Hemodynamic measurements
Hemodynamic measurements that were recorded in the ICU during the first 48 hours after repair (1 hour, 2 hours, 4, 8, 12, 16, 20, 24, 36, and 48 hours) were analyzed. Median measurements were as follows: heart rate, 148 beats per minute (n = 832) (range, 100 to 205 beats per minute); central venous pressure, 13 mm Hg (n = 781) (range, 4 to 28 mm Hg); left atrial pressure, 10 mm Hg (n = 680) (range, 4 to 26 mm Hg); and mean systemic arterial pressure, 66 mm Hg (n = 802) (range, 15 to 91 mm Hg).

Factors associated with postoperative length of ICU stay
Cox’s proportional hazard modeling was used to determine independent factors associated with time to discharge from the ICU. Deaths before discharge were censored. Patient demographics and anatomic, procedural, and postoperative variables were tested with stepwise variable selection. Data from the final model are shown in Table 1. Increased length of stay in the ICU was independently associated with the presence of a preoperative systemic–arterial shunt, the presence of a malformation or genetic syndrome, increased total dose and number of inotropic agents required after repair, postoperative respiratory complications, and younger age at repair. After we controlled for these variables, no other factor was significantly associated with length of stay.


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  		Table 1. Independent Factors Associated With Postoperative Length of Stay in Intensive Care Unita

 
Hemodynamic factors associated with increasing postoperative stay or death after repair
Multiple logistic regression analysis was used to determine the independent influence of hemodynamic factors on a composite suboptimal outcome of postoperative ICU stay of more than 7 days or death before discharge from the ICU. After we controlled for age at repair and time that the measurement was made, an increased risk of a suboptimal outcome was independently associated with higher heart rate, higher central venous pressure and left atrial pressure, and lower mean systemic arterial pressure (Table 2).


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  		Table 2. Independent Factors Associated With Suboptimal Outcomea

 
To determine more precisely the adjusted relationship between each of the hemodynamic variables and the risk of a suboptimal outcome, every hemodynamic variable was categorized as a dummy variable and reentered into the final model. For heart rate, a rate between 141 and 150 beats per minute appeared to be optimal, with a slightly increased risk of a suboptimal outcome at lower rates and a much greater risk at rates of 171 beats per minute and higher (Fig 2). For central venous pressure, pressures between 13 and 18 mm Hg were associated with increased risk, and pressures of 19 mm Hg or higher, with a greatly increased risk (Fig 3). For left atrial pressure, there was a relative plateau of risk, which increased only at 17 mm Hg or higher, with decreased risk associated with pressures of 6 mm Hg or lower (Fig 4). For mean systemic arterial pressure, risk decreased for pressures of 66 mm Hg or higher, with a greater relative decrease at pressures higher than 80 mm Hg (Fig 5).



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  		Fig 2. Adjusted risk of suboptimal outcome associated with heart rate in first 48 hours after repair. Data are from multiple logistic regression modeling after controlling for time of measurement, age at repair, central venous pressure, left atrial pressure, and mean systemic arterial pressure. Suboptimal outcome refers to death before discharge from the intensive care unit or stay in the intensive care unit of more than 7 days. (CI = confidence interval.)

 


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  		Fig 3. Adjusted risk of suboptimal outcome associated with central venous pressure in the first 48 hours after repair. Data are from multiple logistic regression modeling after controlling for time of measurement, age at repair, heart rate, left atrial pressure, and mean systemic arterial pressure. Suboptimal outcome refers to death before discharge from the intensive care unit or stay in the intensive care unit of more than 7 days. (CI = confidence interval.)

 


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  		Fig 4. Adjusted risk of suboptimal outcome associated with left atrial pressure in first 48 hours after repair. Data are from multiple logistic regression modeling after controlling for time of measurement, age at repair, heart rate, central venous pressure, and mean systemic arterial pressure. Suboptimal outcome refers to death before discharge from the intensive care unit or stay in the intensive care unit of more than 7 days. (CI = confidence interval.)

 


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  		Fig 5. Adjusted risk of suboptimal outcome associated with mean systemic arterial pressure in first 48 hours after repair. Data are from multiple logistic regression modeling after controlling for time of measurement, age at repair, heart rate, central venous pressure, and left atrial pressure. Suboptimal outcome refers to death before discharge from the intensive care unit or stay in the intensive care unit of more than 7 days. (CI = confidence interval.)

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
Factors associated with length of ICU stay
The requirement of ongoing cardiorespiratory support is reflected in the increased length of ICU stay for patients needing higher doses of inotropic drugs or multiple inotropic agents for cardiac dysfunction or ventilatory support to optimize pulmonary function in the presence of respiratory compromise with pleural effusion with or without respiratory infection and diaphragmatic paresis. The criteria for ICU discharge were freedom from mechanical ventilation and discontinuation of inotropic support.

Impact of postoperative hemodynamic measurements
Studies that have attempted to relate the postoperative hemodynamic profile with the outcome after repair of congenital heart disease have shown that the nadir of cardiac dysfunction occurs between 4 and 12 hours after cardiopulmonary bypass [15, 16]. In addition, diastolic function can be impaired after repair of ToF [17]. In this series, tachycardia and high right-sided filling pressures, both features of poor ventricular compliance, were associated with increased risk of a suboptimal outcome (death or increased length of ICU stay), whereas increased left atrial pressures were an indication of left ventricular dysfunction.

Impact of postoperative complications
The incidence of postoperative JET has been reported to be as high as 36% in infants undergoing repair at age 4 months or less versus 9% in patients having repair at an older age [18]. Although this is a particularly important arrhythmia in terms of its effect on hemodynamics, we were unable to demonstrate an association between JET and length of ICU stay in this series.

Like other severely cyanotic patients, patients with ToF can have a particular tendency toward increased pleural, interstitial, and peritoneal fluid early in the postoperative period [19]. Hemoconcentration after cardiopulmonary bypass and fluid management along with alterations in membrane stability and hemodynamics play an important role in accumulation of fluid in the pleuroperitoneal space.

Postoperative infections after surgical procedures for congenital heart defects are not well documented in the literature. We noted that 11% of our patients with culture-proven infections were treated effectively with no early deaths. The infection was not correlated to age at operation. Postoperative metabolic acidosis, a nonspecific indicator of adequacy of cardiac output, was present in 36% of patients, and its occurrence did not influence length of ICU stay. Acute renal failure can occur in 1% to 10% of infants undergoing open heart operations and is related to low cardiac output. This can be treated by either continuous venovenous hemofiltration or peritoneal dialysis, which further helps to manage postoperative fluid and electrolyte problems [20–22]. Neurologic symptoms and signs are often overlooked, and the etiology of the neurologic problems can be related to hypothermia [23], embolization, hypoperfusion, and perioperative metabolic changes [24, 25].

Sudden onset of dysrhythmia was the probable cause of half of the early deaths in our series. Low cardiac output was the cause in 33%, and a major aortopulmonary collateral vessel producing a left-to-right shunt and very low diastolic pressures was the cause of death in 1 additional infant.

Limitations of study
This is a retrospective analysis of outcomes during a time when the institution (The Hospital for Sick Children, Toronto) was in transition from a protocol of initial palliation followed by repair at age older than 18 months to a protocol of primary repair at any age when symptoms warranted intervention. This inevitably leads to primary repair at an early age. In this institution, the median length of ICU stay for infants undergoing repair of ToF has fallen from 5 days during the period of this study to 3 days in our more recent experience from 1995 to 1998. It remains to be seen whether this strategy will have an impact on morbidity.

Conclusions
Repair of ToF in patients less than 18 months old was associated with acceptable mortality, but there were high rates of minor respiratory complications and JET. Increasing length of ICU stay is associated with younger age at operation, presence of a malformation of genetic syndrome, previous systemic–pulmonary artery shunt, requirement of increased number of postoperative inotropic agents and their total doses, and respiratory complications. Postoperative hemodynamic measurements in the first 48 hours after operation are useful predictors of death or prolonged ICU stay.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

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Accepted for publication September 23, 1999.




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ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
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