Ann Thorac Surg 2007;83:606-612
© 2007 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Adults Undergoing Cardiac Surgery at a Children’s Hospital: An Analysis of Perioperative Morbidity
Joseph W. Rossano, MDa,*,
E.O.’Brian Smith, PhDa,
Charles D. Fraser, Jr, MDa,b,
E. Dean McKenzie, MDa,b,
Anthony C. Chang, MDa,
Amy Hemingway, RN, CPNPb,
Jack F. Price, MDa,
Heather A. Dickerson, MDa,
Antonio R. Mott, MDa
a Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
b Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
Accepted for publication August 30, 2006.
* Address correspondence to Dr Rossano, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children’s Hospital, 6621 Fannin MC 19345-C, Houston, TX 77030 (Email: jrossano{at}bcm.tmc.edu).
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Abstract
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BACKGROUND: Limited data exist regarding the perioperative morbidity profile of adults who have cardiac operations at pediatric facilities.
METHODS: A retrospective review (January 2000 to December 2004) of patients (aged 18 years or older) who underwent cardiac surgery at our pediatric institution was performed.
RESULTS: There were 149 cardiac operations performed in 135 patients. There were 2 early deaths. There were 70 preoperative noncardiac morbidities in 49 patients (36%) and 140 preoperative cardiac morbidities in 78 patients (58%). Preoperative arrhythmia (n = 76) and moderate or greater ventricular systolic dysfunction (n = 24) were most common. There were 51 postoperative adverse noncardiac events in 32 patients (24%). Renal insufficiency (> 0.5 mg/dL baseline change; n = 8) was most common. There were 53 postoperative adverse cardiac events in 44 patients (33%). Ventricular tachycardia (n = 13) was most common. Risk factors for postoperative adverse noncardiac events included preoperative histories of New York Heart Association (NYHA) class III or greater (p < 0.001), seizure (p = 0.04), and psychiatric disorder (p = 0.002). Risk factors for postoperative adverse cardiac events included older patient age (p = 0.001), preoperative functional single ventricle (p = 0.006), NHYA class III or greater (p = 0.003), atrial fibrillation/flutter (p < 0.001), and ventricular tachycardia or fibrillation (p = 0.04).
CONCLUSIONS: Postoperative adverse events occur frequently when adults undergo cardiac operations at children’s hospitals. Older patient age, preoperative arrhythmias, and preoperative NHYA class are predictors of postoperative adverse cardiac events.
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Introduction
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There have been many advances in the medical and surgical treatment of congenital heart disease (CHD). Long-term survival is no longer the exception, as 85% of children born with CHD will survive to adulthood [1], and the estimated number of adults with CHD (ACHD) is approximately equal to the number of children with CHD [2]. Providing care to this new population of ACHD patients is a challenge. Those who have specialized training in pediatrics and pediatric cardiology provide the expertise in treating CHD, but lack expertise in managing adults. Adult cardiologists provide expertise in treating adults, but lack expertise in managing CHD [3].
As patients with CHD are rarely "cured" of their cardiac diseases, long-term care, both outpatient and inpatient, is necessary. Not infrequently, surgical or other interventional procedures are needed in adulthood. These cardiac procedures are frequently performed at children’s hospitals, and pediatric subspecialists are intimately involved in the perioperative care. To assure quality care for these patients, an understanding of the range of postoperative morbidities (noncardiac and cardiac) and the occurrence risk for these morbidities is important. That has not been a focus of prior studies. As such, there are limited data that focus on the impact of perioperative morbidity when ACHD patients undergo cardiac operations, more specifically when those cardiac operations are performed at pediatric facilities.
The purpose of our study was to perform a comprehensive review of perioperative morbidity among adults who have cardiac operations at a freestanding tertiary children’s hospital. In so doing, we propose to identify risk factors that portend postoperative adverse events.
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Material and Methods
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We reviewed the medical records of adult patients (aged 18 years or older) who underwent cardiac operations at our free-standing children’s hospital from January 1, 2000, through December 31, 2004. Demographic data such as age, sex, and weight were collected. Cardiac history that included cardiac diagnosis, oxygen saturation profile, and anatomic descriptors was obtained. The complexity of the CHD was defined using the 32nd Bethesda Conference–Task Force 1 recommendations [4]. The study was approved by the Institutional Review Board of Texas Children’s Hospital and Baylor College of Medicine. Individual consent was waived.
Echocardiographic data included ventricular morphology and qualitative assessment of ventricular systolic function. The presence of abnormal ventricular geometry, right ventricular morphology, or nonsinus rhythm in a significant number of patients precluded our obtaining reliable quantitative echocardiographic assessment of function. Thus, a qualitative echocardiographic description of ventricular function was obtained. Electrocardiograms were reviewed on every patient. Pertinent cardiac surgical history included cardiac surgery, previous cardiac surgeries, and use of sternotomy or thoracotomy. Functional capacity status was defined using the New York Heart Association (NYHA) scale.
Early mortality was defined as death less than 30 days postoperative or death in-hospital. Other variables collected included hospital, postoperative, and cardiovascular intensive care unit (CvICU) lengths of stay. Resource utilization data included readmission to the CvICU, hospital readmission after discharge (less than 6 weeks), and transfer to an adult facility for further care.
A comprehensive review for preexisting and postoperative morbidities was performed. The review included identifying morbidities that were associated with the following systems: cardiac, respiratory, neurologic, infectious, endocrine, genetic, psychiatric, and dermatologic.
More specific definitions included cyanosis (saturation less than 90%), postoperative renal insufficiency (increase in serum creatinine more than 0.5 from baseline), pericardial effusion (moderate or greater in size), pneumothorax (presence of symptoms or moderate or greater in size), and complicated pleural effusions (chest tube duration more than 10 days, pleural effusion requiring invasive therapy, or pleural effusion requiring hospital readmission). Some patients had exacerbations of preexisting chronic conditions in the postoperative period. These were considered postoperative adverse events if the conditions had been well controlled at the time of surgery. Conversely, chronic conditions that were unchanged with surgery were not considered postoperative morbidities.
All cardiac operations were performed by one of three congenital heart surgeons. The intraoperative anesthesia was provided a team of pediatric cardiac anesthesiologists, with techniques as previously described [5]. Mechanical ventilation (pressure regulated volume control) was delivered with Servo 300 ventilators (Siemans, Iselin, New Jersey). A pediatric cardiac intensivist managed each patient in the ICU.
Statistical Analysis
Statistical analysis was performed on SPSS, version 12.0 (Chicago, Illinois). Data are presented as percentages or medians with interquartile range as appropriate. Two-by-two contingency tables analysis was used to assess the effect of binary risk factors with results being expressed as odds ratios (OR) with 95% confidence intervals (CI). For continuous variables, event and no-event groups were compared with respect to the median using the Mann-Whitney U test. Risk factors for postoperative adverse cardiac events that were identified on univariate analysis were then assessed using stepwise logistic regression analysis to determine independent risk factors. For multivariable analysis, age was evaluated as a continuous variable. Statistical significance was defined as p value less than 0.05.
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Results
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There were 135 patients (female = 69) who underwent 149 cardiac operations. There were 2 early deaths. The median age for the cohort was 24 years (range, 18 to 54). The most common age group of the cohort was 20 to 29 years, which comprised 47% of the cohort (Fig 1). Of the 135 patients, 51 (38%) were new patients who were referred to our institution for surgical intervention. The remaining 84 patients had previous care at our institution. Ninety (67%) had undergone prior cardiac surgery. The median (25th to 75th percentile) total hospital length of stay was 7 days (range, 5 to 10), postoperative length of stay was 6 days (range, 4 to 9), and CvICU length of stay was 2 days (range, 1 to 2).
Preoperative Profile
There were 69 (51%) patients with complex congenital heart disease, 48 (36%) with moderate complex, and 19 (14%) with simple congenital heart disease. A functional single ventricle was present in 25 patients (19%).
There were 70 noncardiac morbidities present in 49 of 135 patients (36%; Table 1). Common noncardiac morbidities included histories of neurologic disease (n = 18), psychiatric disorder (n = 10), and genetic syndrome (n = 9). There were 140 cardiac morbidities present in 78 of 135 patients (58%; Table 2). The most common cardiac morbidity was arrhythmia (n = 76). Others included moderate or greater systolic ventricular dysfunction (n = 24), history of pacemaker (n = 16), cyanosis (n = 15), and NHYA class III or IV (n = 9).
Operative Profile
There were 149 cardiac operations performed, and 2 early deaths. One was a 20-year-old heart transplant recipient who presented with acute ventricular dysfunction and presumed graft rejection. She underwent placement of a mechanical assist device, multisystem organ failure developed, and she died 71 days after her surgery. The other was a 40-year-old man with ventricular inversion and congenital complete atrioventricular block who underwent placement of an epicardial pacemaker. He sustained a stroke and was transferred to an adult center, where multisystem organ failure developed and he died.
The most common cardiac operation was placement of a right ventricle to pulmonary artery conduit (n = 34; Table 3). Other common cardiac operations included closure of an atrial septal defect or ventricular septal defect (n = 28) and Fontan operation (n = 16; 2 first-time and 14 conversions). Cardiopulmonary bypass was used in 113 of 135 (84%) of the primary operations. Six patients underwent 14 additional surgeries, including reoperation for bleeding (n = 6), debridement of surgical incision (n = 4), placement or removal of a mechanical assist device (n = 3), and delayed sternal closure (n = 1).
Postoperative Adverse Event Profile
A postoperative adverse noncardiac event of any type occurred 51 times in 32 patients (Table 4). Common events included renal insufficiency (n = 8), stage 3 or 4 decubitus ulcers (n = 6), pneumothorax (n = 5), pleural effusion (n = 4), and stroke (n = 3). A postoperative serum glucose level of greater than 200 mg/dL was noted in 31 patients in the first 24 hours after surgery.
There were 53 postoperative adverse cardiac events in 44 patients (Table 4). The most common event was arrhythmia. There were 41 arrhythmias in 36 patients. Ventricular tachycardia (VT), which occurred in 13 patients, was the most common postoperative arrhythmia. The arrhythmias were new onset in 21 patients. The most common new-onset arrhythmia was also VT (n = 9). No patient required placement of a pacemaker or implantable cardioverter-defibrillator as a consequence of perioperative arrhythmias.
There were other postoperative adverse cardiac events. Two patients had significant pericardial effusions that required therapy—noninvasive therapy in 1 patient and placement of a pericardial drain in the other. Two patients required cardiopulmonary resuscitation.
Review of Resource Utilization
Nine (7%) patients required readmission to the CvICU after initial transfer to the general cardiology unit for the following reasons: treatment of arrhythmia (n = 3), chest tube bleeding (n = 2), and new-onset ventricular systolic dysfunction (n = 1). Thirteen patients (10%) were discharged and readmitted to the hospital (after 6 weeks or less) for treatment of arrhythmia (n = 5), surgical site infection (n = 2), and treatment of pericardial/pleural effusion (n = 2).
Analysis of Risk Factors for Postoperative Adverse Events
Univariate analysis identified preoperative factors associated with the occurrence of a postoperative adverse noncardiac event (Table 5). These included the presence of complex CHD (p = 0.02), preoperative cyanosis (p = 0.004), preoperative seizure (p = 0.04), and preoperative psychiatric disease (p = 0.002).
Univariate analysis also identified preoperative factors associated with the occurrence of a postoperative adverse cardiac event (Table 5). These included a history of atrial fibrillation/flutter (AF-F [p < 0.001]), ventricular tachycardia or ventricular fibrillation (VT or VF; p = 0.04), and NYHA class III or IV heart failure (p = 0.003). Older patient age was also associated with postoperative adverse cardiac events (p = 0.001; Table 6). Additionally, a postoperative glucose level greater than 200 mg/dL was associated with postoperative adverse cardiac events (p = 0.01).
By stepwise logistic analysis, older patient age and preoperative histories of AF-F, VT, or VF remained as independent risk factors for a postoperative adverse cardiac event (Table 7).
A number of preoperative factors were associated with increased postoperative length of stay, including the presence of complex CHD (p < 0.001), and the presence of the following preoperative arrhythmias: VT or VF (p = 0.03) and AF-F (p = 0.003). Additional perioperative factors included a postoperative glucose level of greater than 200 mg/dL (p < 0.001; Table 8). Factors associated with increased CvICU length of stay included preoperative NHYA class III or IV, complex CHD, preoperative cyanosis, and a history of a prior cardiac operations (Table 9).
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Comment
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Transitioning the ACHD patient from care provided by pediatric cardiologists to specialized adult cardiology practitioners has been inconsistent at best. Advocacy groups in Europe and North America have called for the establishment of regional centers where the ACHD patient can have care provided by those with specialized training [6–8]. The most recent Bethesda guidelines refer to the transitioning of ACHD patients as "crucial" to delivering optimal care [6]. However, there remains limited access to such centers in the United States. In Canada, 47% of young adults with CHD had transitioned care to specialized ACHD centers, but more than 25% had not been seen by any cardiologist since becoming an adult [9].
Many of these adult patients will have cardiac surgical care at pediatric facilities, and they are often managed by those with specialization in CHD but without specialized training in the care of adults. At our pediatric facility, approximately 5% of cardiac operations are performed on adult patients. The postoperative care is provided by cardiac surgeons, pediatric cardiac intensivists, and other pediatric subspecialists.
In the current era, the overall mortality rate after neonatal and infant cardiac surgeries to palliate or correct congenital heart defects has declined [10, 11]. There are similar trends when centers, most commonly those dedicated to the care of ACHD patients, have reported the postoperative mortality for ACHD patients [12–14]. Postoperative morbidities remain high in adult facilities operating on ACHD, with adverse events occurring in as many as 40% of patients [12, 15]. The frequency of postoperative adverse cardiac and noncardiac events when the ACHD patient has cardiac surgery at pediatric facilities has not been a focus of prior reports.
While the debate regarding where and how to optimally care for the ACHD patient continues, these adults are presenting for cardiac surgery at our facility. Our pediatric facility has been committed to providing cardiac surgery to this group by designing a model of care delivery that addresses issues that are unique to this patient population and by addressing issues that we as pediatric subspecialists have. An essential element in delivering optimal healthcare is an ongoing evaluation of one’s care delivery strategy. A goal of our evaluation was to define the patient population by characterizing the unique preoperative morbidity profile and the postoperative adverse cardiac and noncardiac event profile of this population of patients.
In our cohort, 36% of patients had preoperative noncardiac comorbidities, most commonly psychiatric, renal, and neurologic disorders. Unlike in most reports of pediatric patients, more than half of the patients in this cohort had preoperative cardiac morbidities. There were 76 total preoperative arrhythmias, of which AF-F was the most common.
Our surgical mortality rate, which compares favorably to other centers, is low, but the occurrence of postoperative adverse noncardiac and cardiac events is common. Noncardiac events occurred in 32 patients and included most frequently renal insufficiency and advanced decubitus ulcers. Renal insufficiency has been associated with decreased survival in adults with acquired heart disease undergoing surgery [16, 17]. Additionally, decubitus ulcers have been associated with increasing the infectious risk and are a significant source of postoperative morbidity and mortality [18, 19].
There is a renewed emphasis regarding the impact of postoperative gylcemic control in critically ill patients. "Tight glycemic control" (80 to 110 mg/dL) has been shown to improve mortality rates among critically ill adult patients with acquired heart disease [20, 21], but has not been previously been reported as an important perioperative factor in the ACHD patient. In our cohort, patients with a perioperative glucose of greater than 200 mg/dL within 24 hours after cardiac surgery had a median CvICU length of stay 3 days longer than patients with serum glucose levels less than 200 mg/dL. In our study, however, there was not a concerted effort to control the glycemic profile as in the aforementioned reports.
Postoperative adverse cardiac events occurred in approximately 30% of patients. As in the preoperative profile, there was a preponderance of postoperative arrhythmias, of which VT was the most common form. Postoperative arrhythmias occurred with greater frequency than has been reported in children undergoing cardiac surgery at our institution [22–24]. Importantly, on multivariable analysis, older patient age, preoperative history of AF-F, and preoperative history of VT or VF remained as independent risk factors for an adverse cardiac event occurring. It is important to note that older patients were more likely to have adverse events, especially in a pediatric center where patients are managed by pediatricians. These data may assist centers similar to ours in risk stratifying these surgical patients. Given the frequency of postoperative arrhythmias, it is now our practice to obtain consultation with electrophysiologists before the operation.
An assessment of resource utilization provides an indication of the true impact (financially and emotionally) of postoperative morbidities. In our cohort, 7% of patients required readmission to the CvICU after being discharged to the general cardiology floor. Additionally, 10% of our patients required hospital readmission after hospital discharge. This high rate of readmission highlights the complexity of this population.
When an ACHD patient has a cardiac operation, who should perform the surgery, who should provide the anesthetic care, and who should provide the postoperative care? In the ideal model of care, these patients should have the cardiac operation performed by cardiac surgeons with expertise in performing palliative or definitive surgeries for patients with CHD, the anesthesia performed by anesthesiologists who have expertise in delivering anesthesia to adults, and the postoperative care should be delivered by intensivists with expertise in the care of the adult patient and the understanding of CHD. Our model of care is quite different; notwithstanding, the complexity of the cardiac surgeries, the preoperative morbidity profile, the occurrence of postoperative morbidity, and postoperative mortality in our report compare favorably with previously published results, including results published from centers with a dedicated ACHD model. While the debate continues, the ACHD patient continues to present for surgical intervention, frequently at pediatric centers. To adequately define a more comprehensive documentation of outcomes when the ACHD patient undergoes cardiac surgery at a pediatric hospital, future studies from centers with other models of care are needed.
In conclusion, when adult patients undergo cardiac operations at a children’s hospital, an acceptable mortality rate can be achieved. However, postoperative adverse events, cardiac and noncardiac, occur frequently. Patient age and preoperative morbidity predict postoperative morbidity. Older patient age, preoperative AF-F, and preoperative VT or VF are independent predictors of postoperative adverse cardiac events. Further investigation is warranted to define the impact of postoperative morbidity when ACHD patients undergo cardiac operations at children’s hospitals.
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Abstract
Introduction
