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Critical care outcomes in pulmonary atresia and intact ventricular septum undergoing single-ventricle palliation
Mark A Walsh1, Kentaro Asoh, Glen S Van Arsdell
1Department of Paediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Ontario, Canada.
Insights
Single-ventricle palliation for pulmonary atresia with intact ventricular septum has high early mortality. Pre-operative hemodynamic compromise and intra-operative issues increase the risk of death in these infants.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease
- Critical Care Medicine
Background:
- Pulmonary atresia with intact ventricular septum (PA/IVS) is a complex congenital heart defect.
- Single-ventricle palliation is a common surgical approach for severe congenital heart defects.
- Early outcomes and mortality risk factors require thorough investigation.
Purpose of the Study:
- To evaluate early outcomes in infants with PA/IVS undergoing single-ventricle palliation.
- To identify risk factors associated with mortality in this patient population.
Main Methods:
- Retrospective observational study design.
- Involved a tertiary pediatric critical care unit.
- Analyzed data from 19 infants between 2000 and 2008, including echocardiograms, cardiac catheterization, anesthesia, critical care management, and autopsy reports.
Main Results:
- Seven out of 19 infants died during the study period.
- Increased mortality risk was linked to lower arterial pH and systolic blood pressure at anesthesia induction, and surgical technical problems.
- Lower mixed venous saturation and tachyarrhythmia on critical care admission predicted the need for mechanical support.
Conclusions:
- Single-ventricle palliation for PA/IVS is associated with significant early mortality.
- Hemodynamic compromise prior to surgery, technical surgical issues, and intra-operative instability are key risk factors for mortality.
Objective:
To examine early outcomes for pulmonary atresia with intact ventricular septum undergoing single-ventricle palliation and to determine risk factors for mortality.
Design:
Retrospective observational study.
Setting:
Tertiary paediatric critical care unit.
Intervention:
Risk factors for mortality were sought for infants after the primary intervention whether surgical shunt or ductal stent.
Measurements And Main Results:
We reviewed outcomes of 19 infants with pulmonary atresia with intact ventricular septum undergoing single-ventricle palliation between July, 2000 and July, 2008. Echocardiograms, cardiac catheterisation findings, anaesthesia, and critical care management, as well as autopsy reports were reviewed. We modelled survival after surgery and looked for predictors of early mortality. A total of 19 infants underwent single-ventricle palliation and seven of these died. The risk of death was increased by a lower arterial pH at induction of anaesthesia (p = 0.01), a lower systolic blood pressure (p = 0.01), and technical problems during surgery (p = 0.03). On admission to the critical care unit, a lower mixed venous saturation (p = 0.02) and presence of tachyarrhythmia (p = 0.02) were associated with the need for mechanical support within the first 48 hours.
Conclusions:
There is a high early mortality for those who undergo single-ventricle palliation. It is higher for those who are haemodynamically compromised before surgery; technical problems, and haemodynamic instability during surgery also increase mortality.
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