2640 Meters Closer to the Stars: Does High Altitude Affect Fontan Results?

BACKGROUND: Risk factors for and postoperative results of the Fontan operation in patients living at high altitude (>2500 meters above sea level) in the Andean region remain unknown. This study was conducted to evaluate immediate postoperative outcomes and to assess short- and long-term functional class after the Fontan operation. METHODS: From June 2003 to February 2019, 104 patients receiving the Fontan procedure at 2640 meters (8661 feet) above sea level were retrospectively studied. Preoperative catheterization, intraoperative variables, and postoperative outcomes were described. Functional class was evaluated in patients living permanently below (group I) and at or higher than 2500 meters (8202 feet) above sea level (group II). Risk factors for mortality were analyzed. RESULTS: Median age at operation was 8.5 ± 4.4 years; pulmonary artery pressure, 16.2 ± 3.6 mm Hg; end-diastolic systemic ventricular pressure, 13.3 ± 3.8 mm Hg; and pulmonary vascular resistance index, 2.1 (interquartile range, 07-3.7) Wood units. Chest tube duration was 8.5 (6-12) days. Mortality was 4.8%, with 0 in the last 5 years. Higher preoperative pulmonary pressure (16.2 ± 3.6 mm Hg vs 21.2 ± 3.40 mm Hg; P = .01), aortic cross-clamp time (P < .001), and renal failure (P < .01) were associated with mortality. Functional class improved to class I in 86.4%. Overall survival was 90.7% at 10 years of follow-up. CONCLUSIONS: Increased pulmonary pressure and pulmonary vascular resistance index are directly related to high altitude. The Fontan-Kreutzer operation performed at high altitude in the Andean region is feasible with good results. We routinely fenestrate all cases to avoid dysfunction in the early postoperative period. Functional status is adequate after the operation.

Access to paediatric cardiac surgery in Colombia: a population-based study.

OBJECTIVES: Globally congenital heart disease mortality is declining, yet the proportion of infant deaths attributable to heart disease rises in Colombia and other middle-sociodemographic countries. We aimed to assess the accessibility of paediatric cardiac surgery (PCS) to children <18 years of age in 2016 in the South American country of Colombia. METHODS: In Bogotá, Colombia, a multi-national team used cross-sectional and retrospective cohort study designs to adapt and evaluate 4 health system indicators at the national level: first, the population with timely geographic access to an institution providing PCS; second, the number of paediatric cardiac surgeons; third, this specialized procedure volume and its national distribution; and fourth, the 30-day perioperative mortality rate after PCS in Colombia. RESULTS: Geospatial mapping approximates 64% (n = 9 894 356) of the under-18 Colombian population lives within 2-h drivetime of an institution providing PCS. Twenty-eight cardiovascular surgeons report performing PCS, 82% (n = 23) with formal training. In 2016, 1281 PCS procedures were registered, 90% of whom were performed in 6 of the country's 32 departments. National non-risk-adjusted all-cause 30-day perioperative mortality rate after PCS was 2.73% (n = 35). CONCLUSIONS: Colombia's paediatric population had variable access to cardiac surgery in 2016, largely dependent upon geography. While the country may have the capacity to provide timely, high-quality care to those who need it, our study enables future comparative analyses to measure the impact of health system interventions facilitating healthcare equity for the underserved populations across Colombia and the Latin American region.

Cost-effectiveness analysis of newborn pulse oximetry screening to detect critical congenital heart disease in Colombia.

BACKGROUND: In many countries, economic assessments of the routine use of pulse oximetry in the detection of Critical Congenital Heart Disease (CCHD) at birth has not yet been carried out. CCHDs necessarily require medical intervention within the first months of life. This assessment is a priority in low and medium resource countries. The purpose of this study was to assess the cost-effectiveness (CE) relation of pulse oximetry in the detection of cases of CCHD in Colombia. METHODS: A full economic assessment of the cost-effectiveness type was conducted from the perspective of society. A decision tree was constructed to establish a comparison between newborn physical examination plus pulse oximetry, versus physical examination alone, in the diagnosis of CCHDs. The sensitivity and specificity of pulse oximetry were estimated from a systematic review of the literature; to assess resource use, micro-costing analyses and surveys were conducted. The time horizon of the economic evaluation was the first week after birth and until the first year of life. The incremental cost-effectiveness ratio (ICER) was determined and, to control for uncertainty, deterministic and probabilistic sensitivity analysis were made, including the adoption of different scenarios of budgetary impact. All costs are expressed in US dollars from 2017, using the average exchange rate for 2017 [$2,951.15 COP for 1 dollar]. RESULTS: The costs of pulse oximetry screening plus physical examination were $102; $7 higher than physical examination alone. The effectiveness of pulse oximetry plus the physical examination was 0.93; that is, 0.07 more than the physical examination on its own. The ICER was $100 for pulse oximetry screening; that is, if one wishes to increase 1% the probability of a correct CCHD diagnosis, this amount would have to be invested. A willingness to pay of $26.292 USD (direct medical cost) per probability of a correct CCHD diagnosis was assumed. CONCLUSIONS: At current rates and from the perspective of society, newborn pulse oximetry screening at 24 h in addition to physical examination, and considering a time horizon of 1 week, is a cost-effective strategy in the early diagnosis of CCHDs in Colombia.Trial registration "retrospectively registered".