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a Great Ormond Street Hospital, Great Ormond St, London WC1N 3JH, United Kingdom; The Heart Hospital, University College London, 16–18 Westmoreland St, London W1G 8PH, United Kingdom
b Clinical Operational Research Unit, University College London, Gower St, London WC1E 6BT, United Kingdom
(Email: tsangv{at}gosh.nhs.uk).
The work of Giamberti and colleagues [1] has several interesting features. Reoperations in adult congenital heart disease (ACHD) patients due to the right ventricular outflow tract, the left ventricular outflow track, residual septal defects, and in Fontan patients were associated with a low rate of mortality (3.6%). With just 6 deaths, it is not surprising that statistical analysis of the data did not identify any clinical features associated with in-hospital death, although the fact that 4 deaths occurred among the subset of 13 patients with a failing Fontan circulation supports the view that such patients require very careful preoperative assessment.
Severe morbidity, as defined in their article, was frequent at 15% and associated with a number of patient-specific features (high hematocrit/cyanosis, congestive heart failure, and number of previous operations), operation details (Fontan operation/conversion), and the cardiopulmonary bypass time. We would suggest that such analyses could be strengthened by the addition of a clear rationale for the choice of outcome measure(s) and the purpose of identifying patient characteristics associated with them. The identification of such risk factors is pursued for a variety of reasons, and although knowing that an association exists between cross-clamp time and severe postoperative morbidity may assist in postoperative management, this knowledge, for example, could not be used sensibly in a risk-adjusted audit of surgical outcomes.
In addition to the data reported by Giamberti and colleagues [1], there is an interest in other potential risk factors, such as cardiopulmonary exercise test data, the degree of pulmonary hypertension, and other outcome measures such as early reintervention, perioperative death outside the hospital, longer-term survival, and quality of life measures.
This is not meant in any way to be a criticism of the work by Giamberti and colleagues but rather is a reflection on this form of follow-up study in general. The tendency can be for the data reported to be driven by what is to hand in notes or on databases that are not necessarily designed with particular research questions in mind. Because it is early in the building of experience concerning the surgical management of these ACHD patients, a core data set or agreed reporting standards have not emerged.
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