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Development and Validation of an Extended Risk Model for Secondary Surgery Following Repair of Discrete Membranous
Jie Dong1,2,3, Ziping Li1,2,3, Yang Liu1,3
1Department of Pediatric Cardiac Surgery National Center for Cardiovascular Disease and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College Beijing China.
Insights
An improved risk model predicts secondary surgery in pediatric patients with discrete membranous subaortic stenosis. This model enhances patient surveillance and reintervention planning, especially 5-10 years post-repair.
Area of Science:
- Pediatric cardiology
- Cardiovascular surgery
- Medical risk modeling
Background:
- Long-term outcomes after discrete membranous subaortic stenosis (dMVS) repair are variable.
- Predicting secondary surgery is crucial for managing pediatric patients with dMVS.
Purpose of the Study:
- To develop and validate an extended risk model for predicting secondary surgery after dMVS repair in children.
- To improve risk stratification and guide postoperative surveillance.
Main Methods:
- Retrospective analysis of 235 pediatric patients undergoing dMVS repair (2008-2023).
- Evaluation of clinical and hemodynamic predictors to enhance a previously established model.
- Model performance assessed using discrimination, calibration, and reclassification metrics with internal validation.
Main Results:
- 10.6% of patients required secondary surgery during a median 6-year follow-up.
- The extended model, incorporating age <5 years and preoperative LVOT gradient, improved predictive performance (C-index 0.95).
- A nomogram-derived score identified high-risk patients, with risk accumulation peaking 5-10 years post-repair.
Conclusions:
- An extended risk model accurately predicts secondary surgery after dMVS repair.
- This model facilitates individualized postoperative surveillance and timely reintervention planning.
- Intensified monitoring is recommended during the 5-10 year high-risk window post-repair.
Background:
Long-term outcomes remain heterogeneous for patients with discrete membranous subaortic stenosis who underwent surgical repair. We aim to develop and validate an extended risk model for predicting secondary surgery following repair of discrete membranous subaortic stenosis in pediatric patients.
Methods:
We retrospectively analyzed 235 children undergoing discrete membranous subaortic stenosis repair between 2008 and 2023. The primary end point was secondary surgery for significant aortic regurgitation or recurrent left ventricular outflow tract obstruction. Building on our previously published model, we evaluated additional clinical and hemodynamic predictors and assessed model performance using discrimination, calibration, and reclassification metrics. Internal validation was performed using bootstrap resampling and temporal sensitivity analyses adjusted for surgical era.
Results:
During a median follow-up of 6.0 years, 25 patients (10.6%) required secondary surgery. The original Dong model demonstrated excellent discrimination (C-index 0.93). Incorporation of age <5 years and preoperative left ventricular outflow tract gradient significantly improved predictive performance (C-index 0.95) and risk reclassification at 5 and 10 years (net reclassification improvement 0.75 and 0.64, respectively). A nomogram-derived score (cutoff 32.0 points) stratified patients into low-risk (n=170) and high-risk (n=65) groups with marked separation. Risk accumulation was most pronounced between 5 and 10 years after initial repair, and findings were robust after adjustment for surgical era.
Conclusions:
An extended risk model integrating clinical, anatomic, and hemodynamic variables accurately predicts secondary surgery after discrete membranous subaortic stenosis repair. This approach enables individualized postoperative surveillance, particularly intensified monitoring during the 5- to 10-year high-risk window and supports timely reintervention planning.
