RESUMO
BACKGROUND: Iatrogenic complete AV block (ICAVB) has long been noted as a major complication after congenital heart surgery (CHS), contributing to complex postoperative care and potentially affecting patient outcomes. METHODS: A retrospective review of the Pediatric Health Information System database from 1/1/04-09/30/23. All patients who underwent a Society of Thoracic Surgeons benchmark procedure were included. International Classification of Diseases 9th and 10th editions were utilized to identify diagnoses and procedures. All patients with a diagnosis of CAVB and placement of permanent pacemaker after CHS but in the same hospitalization were identified as ICAVB patients. RESULTS: A total of 42,332 patients were identified with 17,106(41%) female, 23,042(55%) Non-Hispanic White and median age of 5.4[IQR:0.4-25.8] months. Of those, 246(0.6%) had iatrogenic CAVB. The procedure with highest incidence of iatrogenic CAVB was the arterial switch operation with ventricular septal defect repair (ASO+VSD) (74/1552, 4.5%). On multivariable analysis, ASO+VSD had the highest adjusted odds of iatrogenic CAVB (OR:5.41 (95%CI:3.57-8.19), p<0.001) when compared to isolated VSD repair. A diagnosis of endocarditis was significantly associated with iatrogenic CAVB. Center volume was not associated with iatrogenic CAVB. Iatrogenic CAVB was associated with a 121% (95%CI:98.5-146.8) increase in length of stay (p<0.001) and increased in-hospital mortality (OR:2.26 (95%CI:1.34-3.82), p<0.001). CONCLUSIONS: The overall incidence of iatrogenic CAVB following CHS is low. However, certain procedures have incidences as high as 4.5%. Iatrogenic CAVB is associated with increased post-operative mortality and length of stay. Further work is needed to identify drivers of variation between centers to improve overall outcomes.
RESUMO
OBJECTIVE: The pathway to become a congenital heart surgeon (CHS) is challenging and unpredictable. Previous voluntary manpower surveys have shed partial light on this problem but have not included all trainees. We believe that this arduous journey merits more attention. METHODS: To examine the real-life challenges of recent participants in Accreditation Council for Graduate Medical Education-accredited CHS training programs, we conducted phone interviews with all graduates of approved programs from 2021 to 2022. This institutional review board approved survey focused on issues including preparation, length of training, debt burden, and employment. RESULTS: All 22 (100%) graduates during the study period were interviewed. Age at fellowship completion was a median 37 years (range, 33-45 years). Pathways to fellowship included traditional general surgery with adult cardiac (43%), abbreviated general surgery ("4 + 3," 19%) and integrated-6 (38%). Time spent on any pediatric related rotation before CHS fellowship was a median 4 months (range, 1-10 months). During CHS fellowship, graduates reported medians of 100 (range, 75-170) total cases and 8 (range, 0-25) neonatal cases as the primary surgeon. Debt burden at completion was a median of $179,000 (range, $0-$550,000). Maximal financial compensation during training before and during CHS fellowship were medians of $65,000 (range, $50,000-$100,000) and $80,000 (range, $65,000-$165,000), respectively. Six (27.3%) are currently in roles in which they cannot practice independently (5 [22.7%] faculty instructors, 1 [4.5%] CHS clinical fellowship). Median salary in first job is $450,000 (range, $80,000-$700,000). CONCLUSIONS: Graduates of CHS fellowships are old, and training is highly variable. Aptitude screening and pediatric-focused preparation are minimal. Debt burden is onerous. Further attention to refining training paradigms and compensation are justified.