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Cardiac surgery in adults performed at children's hospitals: trends and outcomes
William T Mahle1, Paul M Kirshbom, Kirk R Kanter
1Children's Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30329, USA. mahlew@kidsheart.com
Insights
Adult cardiac surgery is increasingly performed at children's hospitals with good outcomes, primarily for pacemaker implantation and valve surgery. Further discussion is needed on optimal care for these congenital heart disease patients.
Area of Science:
- Cardiology
- Adult Congenital Heart Disease (ACHD)
- Pediatric Cardiology
- Cardiac Surgery
Background:
- The population of adults with congenital heart disease (ACHD) requiring cardiac surgery is growing.
- Pediatric centers possess significant experience in congenital heart disease operations, leading to debate about adult care.
- Optimal management strategies for ACHD patients undergoing cardiac surgery remain an area of active discussion.
Purpose of the Study:
- To report outcomes of cardiac surgery in adults (≥21 years) performed at children's hospitals.
- To analyze variations in the practice of adult cardiac surgery among pediatric institutions.
- To identify factors associated with performing adult cardiac surgery in children's hospitals.
Main Methods:
- Analysis of data from July 2005 to June 2007 from the Child Health Corporation of America (a consortium of 37 children's hospitals).
- Evaluation of institutional volume, cardiac procedure type, patient outcomes, and hospital charges for adult cardiac surgery.
- Assessment of individual institutional variables to determine associations with adult cardiac surgery practices.
Main Results:
- 719 adult cardiac surgeries were performed, with a median age of 26 years.
- Common procedures included pacemaker/defibrillator implantation (29.2%) and pulmonary valve replacement (16.8%).
- Hospital mortality was 1.9%, with over 30% of patients having comorbidities. Adult procedures constituted 0-10.9% of total cardiac operations across centers.
Conclusions:
- Children's hospitals are performing a substantial volume of adult cardiac surgical procedures with favorable outcomes.
- The majority of these procedures involve pacemaker/defibrillator implantation and semilunar valve surgery, not complex shunt lesions.
- The appropriateness of continuing adult cardiac surgery for ACHD patients in pediatric centers warrants further consideration and discussion.
Objective:
The number of adults with congenital heart disease who require cardiac surgery is projected to increase dramatically. Controversy exists as to whether such procedures should be performed in pediatric centers, which generally have the greatest experience with operations for congenital heart disease. We sought to report the outcomes for cardiac surgery performed in adults (>or=21 years of age) at children's hospitals and determine how these practices varied among institutions.
Methods:
Data from July 2005 to June 2007 from the Child Health Corporation of America, a consortium of 37 free-standing children's hospitals, were analyzed to determine the institutional volume, type of cardiac procedure, outcome, and hospital charges. Individual institutional variables were analyzed to determine which factors might be associated with the practice of performing adult cardiac surgery in children's hospitals.
Results:
During the study period, there were 719 admissions for cardiac surgery in adults at Child Health Corporation of America institutions. The median age at the time of operation was 26 years (range, 21-86 years). The most common surgical procedures were implantation or revision of a pacemaker or defibrillator (n = 207 [29.2%]), pulmonary valve replacement (n = 119 [16.8%]), aortic valve replacement (n = 59 [8.3%]), and Fontan revision (n = 37 [5.2%]). The median hospital length of stay was 6 days (range, 1-175 days). The hospital mortality was 1.9%. Comorbid conditions likely to require other subspecialty care were present in more than 30% of patients. Among the Child Health Corporation of America centers, adult operations as a proportion of overall cardiac operations varied from 0% to 10.9%. There was no relationship between overall cardiac surgical volume and proportion of adult cases performed in Child Health Corporation of America centers.
Conclusions:
A significant number of adult cardiac surgical procedures are being performed at children's hospitals with excellent results. The majority of procedures are not related to complex shunt lesions but rather pacemaker/defibrillator implantation and semilunar valve surgery. Whether adult patients with congenital heart disease should continue to undergo most cardiac surgery in children's hospitals is worthy of discussion.
