Dan Mihai Dorobantu1, Ragini Pandey2, Mansour Taghavi Sharabiani3, Alireza Shahidzadeh Mahani4, Gianni Davide Angelini5, Robin Peter Martin2, Serban Constantin Stoica2. 1. Department of Cardiac Surgery, University Hospitals Bristol NHS Trust, Bristol, UK Department of Cardiology, 'Prof. C.C. Iliescu' Emergency Institute for Cardiovascular Diseases, Bucharest, Romania dan.dorobantu@bristol.ac.uk. 2. Department of Cardiac Surgery, University Hospitals Bristol NHS Trust, Bristol, UK. 3. Department of Cardiothoracic Surgery, Imperial College, London, UK. 4. Scientific Computing Group, Sentrana Inc., Washington, DC, USA. 5. Department of Cardiac Surgery, University Hospitals Bristol NHS Trust, Bristol, UK Department of Cardiothoracic Surgery, Imperial College, London, UK.
Abstract
OBJECTIVES: The systemic-to-pulmonary shunt (SPS) remains an important palliative therapy in many congenital heart defects. Unlike other surgical treatments, the mortality after shunt operations has risen. We used an audit dataset to investigate potential reasons for this change and to report national results. METHODS: A total of 1993 patients classified in 13 diagnoses underwent an SPS procedure between 2000 and 2013. Indication trends by era and also results before repair or next stage are reported. A dynamic hazard model with competing risks and modulated renewal was used to determine predictors of outcomes. RESULTS: The usage of SPS in Tetralogy of Fallot (ToF) has significantly decreased in the last decade, with cases of single ventricle (SV) and pulmonary atresia (PA) with septal communication increasing (P < 0.001 for trends). This is correlated with an increase of early mortality from 5.1% in the first half of the decade to 9.8% in the latter (P = 0.007 for trend). At 1.5 years, 13.9% of patients have died, 17.8% had a shunt reintervention and 68.3% of patients are alive and reintervention-free. Low weight, PA-intact septum, SV and central shunt type are among the factors associated with increased mortality, whereas PA-ventricular septal defect, corrected transposition, isomerism, central shunt and low weight are among those associated with increased reintervention, also having a dynamic effect on the relative risk when compared with ToF patients. Shunt reinterventions are not associated with worse outcomes when adjusted by other covariates, but they do have higher 30-day mortality if occurring earlier than 30 days from the index (P < 0.001). Patients operated in later years were found to have significantly lower survival at a distance from index. CONCLUSIONS: The observed historical rise in mortality for shunt operations relates to complex factors including changing practice for repair of ToF and for univentricular palliation. PA and SV patients are the groups of patients at the highest risk of death. Small size, shunt type and underlying anatomical defect are the main determinants of outcomes. Trends in indication and mortality seem to indicate that more severely ill patients benefit from shunting, but with an increase in mortality.
OBJECTIVES: The systemic-to-pulmonary shunt (SPS) remains an important palliative therapy in many congenital heart defects. Unlike other surgical treatments, the mortality after shunt operations has risen. We used an audit dataset to investigate potential reasons for this change and to report national results. METHODS: A total of 1993 patients classified in 13 diagnoses underwent an SPS procedure between 2000 and 2013. Indication trends by era and also results before repair or next stage are reported. A dynamic hazard model with competing risks and modulated renewal was used to determine predictors of outcomes. RESULTS: The usage of SPS in Tetralogy of Fallot (ToF) has significantly decreased in the last decade, with cases of single ventricle (SV) and pulmonary atresia (PA) with septal communication increasing (P < 0.001 for trends). This is correlated with an increase of early mortality from 5.1% in the first half of the decade to 9.8% in the latter (P = 0.007 for trend). At 1.5 years, 13.9% of patients have died, 17.8% had a shunt reintervention and 68.3% of patients are alive and reintervention-free. Low weight, PA-intact septum, SV and central shunt type are among the factors associated with increased mortality, whereas PA-ventricular septal defect, corrected transposition, isomerism, central shunt and low weight are among those associated with increased reintervention, also having a dynamic effect on the relative risk when compared with ToF patients. Shunt reinterventions are not associated with worse outcomes when adjusted by other covariates, but they do have higher 30-day mortality if occurring earlier than 30 days from the index (P < 0.001). Patients operated in later years were found to have significantly lower survival at a distance from index. CONCLUSIONS: The observed historical rise in mortality for shunt operations relates to complex factors including changing practice for repair of ToF and for univentricular palliation. PA and SV patients are the groups of patients at the highest risk of death. Small size, shunt type and underlying anatomical defect are the main determinants of outcomes. Trends in indication and mortality seem to indicate that more severely ill patients benefit from shunting, but with an increase in mortality.
Authors: Jill J Savla; Jennifer A Faerber; Yuan-Shung V Huang; Theoklis Zaoutis; Elizabeth Goldmuntz; Steven M Kawut; Laura Mercer-Rosa Journal: J Am Coll Cardiol Date: 2019-09-24 Impact factor: 24.094
Authors: Dan Mihai Dorobantu; Demetris Taliotis; Robert Michael Tulloh; Mansour Thagavi Azar Sharabiani; Eltayeb Mohamed Ahmed; Gianni Davide Angelini; Serban Constantin Stoica Journal: Open Heart Date: 2019-02-14
Authors: Stephanie Y Tseng; Vien T Truong; Daniel Peck; Sneha Kandi; Samuel Brayer; Don P Jason; Wojciech Mazur; Garick D Hill; Awais Ashfaq; Bryan H Goldstein; Tarek Alsaied Journal: J Am Heart Assoc Date: 2022-06-29 Impact factor: 6.106