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Can We Still Improve Survival Outcomes of Neonatal Biventricular Repairs?
Shuhua Luo1, Christoph Haller2, Chun-Po Steve Fan3
1Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Cardiovascular Surgery, West China Hospital of Sichuan University, Chengdu, China.
Insights
Neonatal biventricular repair survival has not improved in two decades. Focus on preventing sudden death, improving myocardial protection, and minimizing residual lesions to enhance outcomes in complex congenital heart disease surgery.
Area of Science:
- Pediatric Cardiac Surgery
- Congenital Heart Disease
- Neonatal Intensive Care
Background:
- Neonatal biventricular repair is a complex procedure for congenital heart defects.
- Survival rates and factors influencing outcomes require ongoing investigation.
- Identifying modifiable factors is crucial for improving survival and reducing reintervention rates.
Purpose of the Study:
- To analyze causes of death and predictors of mortality and reintervention in neonatal biventricular repair over two decades.
- To identify modifiable factors that can improve survival and reduce the need for reoperation.
- To assess changes in outcomes across different surgical eras.
Main Methods:
- Retrospective analysis of 991 neonates undergoing biventricular repair between 1995 and 2016.
- Cohort divided into three eras (1995-1999, 2000-2007, 2008-2016) to evaluate temporal trends.
- Kaplan-Meier survival analysis and Cox regression models used to identify predictors of mortality and reintervention.
Main Results:
- Significant survival improvement from era I to eras II and III (1-year survival: 82.1% to 89.6%), with no further improvement between eras II and III.
- Preoperative/postoperative extracorporeal membrane oxygenation and postoperative renal replacement were independent predictors of mortality.
- Atrioventricular septal defects and common atrial trunk predicted reintervention; reintervention rates were similar between eras II and III.
Conclusions:
- Overall survival after neonatal biventricular repair has remained stagnant despite improvements in earlier eras.
- Preventing sudden death, optimizing myocardial protection, and minimizing residual surgical lesions are key targets for improving outcomes.
- Further research is needed to address specific causes of mortality and reintervention in this high-risk population.
Background:
We sought to identify modifiable factors to improve survival of neonatal biventricular repair by analyzing the cause of death and predictors of mortality and reintervention in the last 2 decades.
Methods:
Between 1995 and 2016, 991 consecutive neonates were included. The cohort was divided by era: era I was from 1995 to 1999, era II 2000 to 2007, and era III 2008 to 2016. The Kaplan-Meier method was used to estimate freedom from death and reintervention. Univariable and multivariable Cox regression was applied to assess predictors for mortality or reintervention in the contemporary cohorts (2000-2016).
Results:
Median age was 8 days (range, 5-13), and median body weight at operation was 3.3 kg (range, 2.9-3.6). The most common diagnosis was transposition with intact ventricular septum (32%), followed by transposition with ventricular septal defect (14.5%), and simple left-to-right shunt lesion (10.9%). There was significant improvement in survival from era I to eras II and III but no difference between eras II and III (1 year: 82.1% vs 89.4% vs 89.6%, respectively; P < .001). The most common cause of death was sudden death in eras I and III and cardiac in era II. Multivariable analysis revealed preoperative (P = .005)/postoperative (P < .001) extracorporeal membrane oxygenation and postoperative renal replacement (P < .001) as independent predictors for mortality. The reintervention rates were comparable between eras II and III (P = .53). Atrioventricular septal defects and common atrial trunk were identified as predictors for reintervention.
Conclusions:
Survival after neonatal biventricular repair remained unchanged. Preventing sudden death, myocardial protection, and minimizing residual lesions are potential targets to improve outcomes.
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