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Could we still improve early and interim outcome after prosthetic systemic-pulmonary shunt? A risk factors analysis
Siamak Mohammadi1, Osama Benhameid, Andrew Campbell
1Department of Pediatric Cardiac Surgery, British Columbia Children's Hospital, Vancouver, BC, Canada. siamakmohammadi@yahoo.com
Insights
Systemic-to-pulmonary shunt (SPS) in children is associated with mortality risks, particularly in younger, smaller infants and those with complex heart conditions. Surgical approach and shunt characteristics influence outcomes, suggesting potential improvements with tailored strategies.
Area of Science:
- Pediatric Cardiac Surgery
- Congenital Heart Disease Research
- Surgical Outcomes Analysis
Background:
- Systemic-to-pulmonary shunts (SPS) are critical palliative procedures for complex congenital heart diseases.
- Identifying mortality risk factors in neonates and infants undergoing SPS is essential for improving surgical outcomes.
- Previous studies have focused on specific diagnoses, but a comprehensive analysis of in-hospital and interim mortality factors is needed.
Purpose of the Study:
- To identify factors associated with in-hospital and interim mortality in pediatric patients undergoing an isolated systemic-to-pulmonary shunt (SPS).
- To analyze the impact of surgical approach (sternotomy vs. thoracotomy) and shunt characteristics on mortality.
- To provide evidence-based recommendations for improving early and interim outcomes in this vulnerable population.
Main Methods:
- Retrospective analysis of 226 children undergoing isolated SPS between 1988 and 2005.
- Patient data included age, weight, diagnosis (e.g., pulmonary atresia, single ventricle), surgical approach, and shunt origin.
- Statistical analysis included univariate and logistic regression to identify risk factors for in-hospital and interim mortality.
Main Results:
- In-hospital mortality was 5.7%. Risk factors included younger age, lower body weight, specific diagnoses (PA-IS with RV hypoplasia), preoperative intubation, longer ventilation, and sternotomy approach.
- Sternotomy approach was associated with longer ventilation times despite similar shunt characteristics.
- Interim mortality was 7%. Younger age and thoracotomy approach were independent risk factors for death before second-stage surgery.
Conclusions:
- In-hospital mortality and prolonged ventilation after sternotomy-based SPS may be linked to pulmonary overcirculation.
- Optimizing shunt size and insertion origin in sternotomy cases can potentially improve early outcomes.
- Using a smaller shunt or altering the SPS insertion origin are recommended strategies for sternotomy approaches to enhance patient outcomes.
Objective:
To identify factors associated with in-hospital and interim mortality in children with a systemic-to-pulmonary shunt (SPS).
Methods:
Between January 1988 and April 2005, 226 children with a median age of 17 days, and weight of 3.4 kg, underwent an isolated SPS for pulmonary atresia (PA)-VSD/ tetralogy (n=124, 54.9%), functional single ventricle PA (n=35, 5.5%), PA-intact septum (IS, n=31, 13.7%), transposition of the great arteries VSD-PA (n=30, 13.3%), and double outlet right ventricle-PA (n=6, 2.6%). Surgery was performed through sternotomy (group S, n=46) or thoracotomy (group T, n=180). The origin of the SPS was either the innominate artery (n=38) or ascending aorta (n=8) in group S, and the subclavian artery (n=180) in group T.
Results:
In-hospital mortality was 5.7%. Univariate and logistic regression analysis revealed younger age (p=0.01), lower body weight (p<0.04), a diagnosis of PA-IS with severe right ventricle hypoplasia (p=0.005), preoperative intubation (p=0.03), increased length of intubation (p<0.0001), longer ICU stay (p<0.0001), and group S (p=0.03) as risk factors for in-hospital death. Group S had a longer median ventilation time (112 vs 30 h, p<0.0001) despite the similar median age, weight, mean indexed shunt size (1.19 vs 1.15 mm/kg, p=0.2), and the number of patients with antegrade pulmonary flow. Interim mortality was 7% (n=15), and younger age (p=0.03), and group T (p=0.03) were independent risk factors for death prior to second-stage surgery. Absence of antiplatelet agents or anticoagulants was not a risk factor for interim mortality.
Conclusions:
In-hospital mortality and longer ventilation time after SPS by sternotomy may be related to pulmonary over circulation due to shunt insertion origin and/or size, and pathologic features. Early and interim outcomes can be improved by using a smaller shunt or changing the SPS insertion origin when using a sternotomy approach.
