Factors Associated With Mortality and Adverse Outcomes After Truncus Arteriosus Repair.

BACKGROUND: Truncus arteriosus repair is associated with higher morbidity and mortality compared with many other congenital heart operations. We sought to determine factors associated with mortality and adverse outcomes in infants undergoing truncus arteriosus repair. METHODS: We used the Pediatric Health Information System Database to identify infants aged < 90 days who underwent truncus arteriosus repair from 2004 to 2019. The primary outcome was hospital mortality. Secondary outcomes were prolonged postoperative length of stay (>30 days) and hospital readmission within 90 days. Multivariable logistic regression models were used to identify associated factors for adverse outcomes. RESULTS: A total of 1645 subjects were included. Hospital mortality occurred in 164 (10%). Factors independently associated with mortality included birth weight < 3 kg, admit age < 48 hours, truncal valve surgery, cardiac arrest, extracorporeal membrane oxygenation, acute kidney injury, cardiac catheterization, tracheostomy, and earlier era. Prolonged postoperative length of stay occurred in 508 patients (31%). Factors independently associated with prolonged postoperative length of stay included prematurity, DiGeorge syndrome, admit age < 48 hours, later surgical era, acute kidney injury, infection, cardiac catheterization, vocal cord paralysis, tracheostomy, and gastrostomy. Readmission within 90 days occurred in 511 of 1481 surviving patients (34%). DiGeorge syndrome, cleft lip/palate, cardiac catheterization, and extracorporeal membrane oxygenation were factors independently associated with hospital readmission. CONCLUSIONS: We identified multiple factors associated with hospital mortality and adverse outcomes in infants undergoing truncus arteriosus repair. This information is useful for quality improvement initiatives, perioperative counseling, and discharge planning.

Outcomes of Gastrostomy and Tracheostomy in Infants Undergoing Truncus Arteriosus Repair: Database Study Using the Pediatric Health Information System.

OBJECTIVES: We sought to determine the prevalence of and factors associated with gastrostomy tube placement and tracheostomy in infants undergoing truncus arteriosus repair, and associations between these procedures and outcome. DESIGN: Retrospective cohort study. SETTING: Pediatric Health Information System database. PATIENTS: Infants less than 90 days old who underwent truncus arteriosus repair from 2004 to 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Multivariable logistic regression models were used to identify factors associated with gastrostomy tube and tracheostomy placement and to identify associations between these procedures and hospital mortality and prolonged postoperative length of stay (LOS; > 30 d). Of 1,645 subjects, gastrostomy tube was performed in 196 (11.9%) and tracheostomy in 56 (3.4%). Factors independently associated with gastrostomy tube placement were DiGeorge syndrome, congenital airway anomaly, admission age less than or equal to 2 days, vocal cord paralysis, cardiac catheterization, infection, and failure to thrive. Factors independently associated with tracheostomy congenital airway anomaly, truncal valve surgery, and cardiac catheterization. Gastrostomy tube was independently associated with prolonged postoperative LOS (odds ratio [OR], 12.10; 95% CI, 7.37-19.86). Hospital mortality occurred in 17 of 56 patients (30.4%) who underwent tracheostomy versus 147 of 1,589 patients (9.3%) who did not ( p < 0.001), and median postoperative LOS was 148 days in patients who underwent tracheostomy versus 18 days in those who did not ( p < 0.001). Tracheostomy was independently associated with mortality (OR, 3.11; 95% CI, 1.43-6.77) and prolonged postoperative LOS (OR, 9.85; 95% CI, 2.16-44.80). CONCLUSIONS: In infants undergoing truncus arteriosus repair, tracheostomy is associated with greater odds of mortality; while gastrostomy and tracheostomy are strongly associated with greater odds of prolonged postoperative LOS.

Association Between Birth Weight Z-Scores and Early Outcomes Following Truncus Arteriosus Repair.

In infants undergoing truncus arteriosus (TA) repair, we sought to determine associations between fetal growth restrictions as measured by birth weight Z-score and early outcomes. We utilized the Pediatric Health Information System (PHIS) database to identify infants < 90 days old who underwent TA repair from 2004 to 2019. The primary exposure variable was birth weight Z-score, calculated based on gestational age at birth, gender, and birth weight. The primary outcome was postoperative hospital mortality. Secondary outcomes included major complications, prolonged postoperative length of hospital stay (LOS; > 30 days), and hospital readmission within 1 year. Generalized estimating equation (GEE) models were used to identify adjusted associations between birth weight Z-score, small for gestational age (SGA) status, and mortality and included were 1039 subjects. Median birth weight was 2960 g, gestational age at birth was 38 weeks, and birth weight Z-score was - 0.47. SGA was present in 21% of subjects. Hospital mortality occurred in 104 patients (10%). By multivariable analysis, lower birth weight Z-score was associated with higher hospital mortality [for each unit decrease in birth weight Z-score below - 1.0, adjusted OR 1.71 (95% CI 1.10-4.25)]. SGA status was associated with increased hospital mortality (adjusted OR 2.17; 95% CI 1.39-3.40). Birth weight Z-scores and SGA status were not significantly associated with occurrence of cardiac arrest, ECMO use, gastrostomy tube placement, tracheostomy, seizures, infection, prolonged postoperative LOS, or hospital readmission. In infants undergoing TA repair, lower birth weight Z-scores and SGA status were strongly associated with increased hospital mortality.

An Interactive, Multimodal Curriculum to Teach Pediatric Cardiology to House Staff.

Pediatricians must be able to diagnose, triage, and manage infants and children with congenital heart disease. The pediatric cardiology division at the Medical University of South Carolina updated their curriculum for pediatric residents to a format supported by constructivist learning theory. The purpose of this study is to determine if shorter, interactive learning with fellow and faculty involvement improved pediatric cardiology knowledge demonstrated through test scores and resident satisfaction. A curriculum of short lectures and interactive workshops was delivered over 6 weeks in August and September 2018. Residents answered a 10-question pretest prior to the curriculum, followed by a post-test immediately after the last session and a delayed post-test 8 months later. Residents also provided summative feedback on the educational sessions. Sixty-six residents were eligible to participate in the curriculum with 44 (67%) completing the pretest, 40 (61%) completing the post-test, and 33 (50%) completing the delayed post-test. The mean score increased significantly from 56 to 68% between the pretest and post-test (p = 0.0018). The delayed post-test mean score remained high at 71% without significant change (p = 0.46). Overall feedback was positive highlighting the interactive nature of lectures and the participation of cardiology fellows. Using an interactive, multimodal educational series, pediatric residents had a significant increase in pediatric cardiology test scores and demonstrated good retention.

Preoperative in-hospital mortality in neonates with critical CHD.

OBJECTIVE: Data regarding preoperative mortality in neonates with critical CHD are sparse and would aid patient care and family counselling. The objective of this study was to utilise a multicentre administrative dataset to report the rate of and identify risk factors for preoperative in-hospital mortality in neonates with critical CHD across US centres. STUDY DESIGN: The Pediatric Health Information System database was utilised to search for newborns ≤30 days old, born 1 January 2009 to 30 June 2018, with an ICD-9/10 code for d-transposition of the great arteries, truncus arteriosus, interrupted aortic arch, or hypoplastic left heart syndrome. Preoperative in-hospital mortality was defined as patients who died prior to discharge without an ICD code for cardiac surgery or interventional catheterisation. RESULTS: Overall preoperative mortality rate was at least 5.4% (690/12,739) and varied across diagnoses (d-TGA 2.9%, TA 8.3%, IAA 5.5%, and HLHS 7.3%) and centres (0-20.5%). In multivariable analysis, risk factors associated with preoperative mortality included preterm delivery (<37 weeks) (OR 2.3, 95% CI: 1.8-2.9; p < 0.01), low birth weight (<2.5 kg) (OR 3.8, 95% CI: 3.0-4.7; p < 0.01), and genetic abnormality (OR 1.6, 95% CI: 1.2-2.2; p < 0.01). Centre average surgical volume was not a significant risk factor. CONCLUSION: Approximately 1 in 20 neonates with critical CHD suffered preoperative in-hospital mortality, and rates varied across diagnoses and centres. Better understanding of the factors that drive the variation (e.g. patient factors, preoperative care models, surgical timing) could help identify patient care improvement opportunities and inform conversations with families.

Role of direct laryngoscopy and bronchoscopy in recurrent croup.

OBJECTIVE: To determine risk factors in children with recurrent croup that predict moderate/severe findings on direct laryngoscopy and bronchoscopy and need for further operative interventions. STUDY DESIGN: Retrospective chart review cohort. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: Retrospective chart review of 103 patients diagnosed with recurrent croup who underwent diagnostic laryngoscopy and bronchoscopy from January 2004 to August 2013. Statistical analysis determined risk factors significantly associated with moderate/severe operative findings. A probability tree was formulated. RESULTS: Of 103 patients, 30.1% had history of intubation, 6.8% had a history of subglottic stenosis, 6.8% had a history of previous airway procedure, 11.7% consultations were inpatient, 64.1% had asthma, 47.6% had seasonal allergies, 60.2% had gastroesophageal reflux disease, 15.5% were aged ≤ 12 months, and 51.5% were ≤ 36 months. Statistically significant risk factors in predicting moderately/severely abnormal operative findings included consultation location (P = .010), history of intubation (P = .003), age younger than 36 months (P = .013), and seasonal allergies (P = .035). When using location of consultation, history of intubation, and age in a statistical model, diagnostic accuracy equaled 93.5%. Of children without history of intubation but who underwent inpatient otolaryngology consultation, 28.6% had moderate/severe findings. Likewise, 41.2% of children with a history of intubation who were younger than 36 months of age had moderate/severe findings. CONCLUSION: Moderate to severe operative findings are encountered in only 8.7% of children with recurrent croup. Using statistical modeling, 2 high-risk groups are (1) patients without a history of intubation but inpatient consultation and (2) patients with a history of intubation and age younger than 36 months.