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Risk stratification in paediatric open-heart surgery
Nicholas Kang1, Timothy Cole, Victor Tsang
1Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, London, UK.
Insights
Age, Risk Adjustment in Congenital Heart Surgery (RACHS-1) category, and bypass time are key predictors of mortality in pediatric open-heart surgery. These factors help in developing accurate risk models for clinical audit and performance comparison.
Area of Science:
- Pediatric Cardiac Surgery
- Surgical Outcomes Research
- Health Services Research
Background:
- Paediatric open-heart surgery carries inherent risks.
- Accurate risk stratification is crucial for clinical audit and performance evaluation.
- The Risk Adjustment in Congenital Heart Surgery (RACHS-1) method is a proposed tool for risk stratification.
Purpose of the Study:
- To identify independent risk factors for mortality in paediatric open-heart surgery.
- To develop predictive risk models for clinical audit.
- To validate the RACHS-1 method for open-heart operations.
Main Methods:
- Multiple logistic regression analysis of 1085 paediatric open-heart surgery cases.
- Inclusion of preoperative and operative variables such as age, RACHS-1 category, and bypass time.
- Outcome measure: in-hospital mortality.
Main Results:
- Age, RACHS-1 risk category, and bypass time were significant independent risk factors for in-hospital death.
- A risk model incorporating these factors achieved an area under the ROC curve of 0.86.
- A second model using only age and RACHS-1 category had an area under the ROC curve of 0.81.
Conclusions:
- Age, RACHS-1 category, and bypass time are significant predictors of mortality in paediatric open-heart surgery.
- The RACHS-1 method is validated for open-heart surgery, with acknowledged limitations.
- Developed risk models enable mortality prediction and facilitate surgical outcomes analysis.
Objective:
The aims of this study were to identify independent risk factors for mortality following paediatric open-heart surgery and to develop risk models for use in clinical audit based on identified risk factors. The study also tests the validity of the recently proposed Risk Adjustment in Congenital Heart Surgery (RACHS-1) method of risk stratification as applied to open-heart operations.
Methods:
A multiple logistic regression analysis was performed on all patients less than 18 years of age undergoing open-heart surgery at a single institution over a 3-year period. Preoperative and operative variables included for analysis were age at operation, weight, sex, American Society of Anaesthesiology (ASA) grade, RACHS-1 risk category, preoperative haemoglobin, bypass time, temperature, cross-clamp time, circulatory arrest time, blood transfusion on bypass and surgeon. The outcome measure was in-hospital death.
Results:
1085 consecutive open-heart cases were identified. There were 51 in-hospital deaths (4.7%). Variables identified as being independently significant risk factors for in-hospital death were age (P = 0.0002), RACHS-1 risk category (P < 0.0001), and bypass time. Based on these three variables, a risk model was constructed to predict mortality. The area under the receiver-operating-characteristic (ROC) curve for this model was 0.86. A second model was constructed ignoring bypass time. In this model, the significance of the 'preoperative' risk factors was (P = 0.0003) for age and (P < 0.0001), for RACHS-1 risk category. The area under the ROC curve was 0.81 for the second model.
Conclusions:
This study identifies age at operation, RACHS-1 risk category and bypass time as highly significant risk factors for mortality after paediatric open-heart surgery. It validates the RACHS-1 risk stratification method as applied to the subset of open-heart surgery, whilst accepting the limitations of such a system. The risk models formulated permit risk prediction and allow for analysis of surgical results. Such risk-adjustment is important when assessing performance and comparing outcomes amongst individuals or institutions.