• Higher Risks With Major Residua in Children With Congenital Heart Disease Requiring Pre-Discharge Re-Intervention: Retrospective Analysis

    Children who survive congenital heart operations transplant-free, but who require reinterventions before they are discharged for their index hospitalization, have significantly worse long-term outcomes when they have persistent major residua, according to a retrospective analysis.

    The findings were published Monday online ahead of the June 28 issue of the Journal of the American College of Cardiology, by authors led by Aditya Sengupta, MD, from Boston Children’s Hospital.

    Residual lesions that require unplanned pre-discharge reinterventions – either catheter-based or surgical – after congenital heart operations are “not uncommon,” said the researchers, citing a survey of over 100,000 index operations from the Society of Thoracic Surgeons Congenital Heart Surgery Database that found this to be the case for 2.5% to 5.7% of patients.

    These re-interventions are “unsurprisingly” known to be independently associated with operative mortality and increased post-operative length of stay, the researchers said. “However, mid-term to long-term outcomes of patients requiring in-hospital reinterventions and who also survive to hospital discharge remain unknown.”

    The current study, therefore, set out to assess long-term outcomes for the high-risk cohort based on the severity of persistent residual lesions at discharge in a cohort of 408 patients who underwent congenital cardiac surgery and predischarge re-intervention between January 2011 and December 2019 at a quaternary referral center.

    The patients were retrospectively reviewed after Boston Children’s Hospital Institutional Review Board approval and patient waiver of consent, and clinical and echocardiographic data – including measurements by Residual Lesion Score (RLS) or Technical Performance Score (TPS) – were used.

    Echocardiographic criteria were used to assess the severity of persistent residual lesions at discharge, from grade 3, major persistent residua (n = 94), to grade 2, minor persistent residua (n = 196) to grade 1, no/trivial persistent residua.

    Median age was 10.1 years overall, ranging from a median of 5.2 years for the grade 3 patients, to 11.4 years in grade 2 and 10.6 years in grade 1. They were majority male (42.2% female), 73 (17.9%) of the coverall cohort had been born premature and 138 (33.8%) had a noncardiac anomaly.

    Peri-operative risk factors included CPR performed in 19 (4.7%) patients, shock in eight (2%) patients, mechanical support in nine (2.2%), malignant arrhythmia in 56 (13.7%), mechanical ventilation in 50 (12.3%), and stroke or seizure in 53 (13%). Those who died or underwent transplantation before discharge were excluded.

    Among the 408 patients, there were 58 (14.2%) post-discharge deaths or transplants and 208 (51%) late re-interventions at a median follow-up of 3 years (interquartile range: 1.1 to 6.8 years). Stratified by lesion grade, late re-interventions were required in 48 (40.7%) grade 1 patients, 92 (46.9%) grade 2, and 68 (72.3%) grade 3.

    On univariable analysis, those with the worst persistent residua at discharge – grade 3 patients – had a significantly higher risk of mortality or transplant than grade 1 patients, with no or trivial residua (hazard ratio [HR]: 4.1; 95% confidence interval [CI]: 1.8-9.5; P = 0.001).

    Multivariable analysis showed that persistent residual lesion severity of grade 2 (HR: 2.7; 95% CI: 1.2-6.4; P = 0.020) or grade 3 (HR: 4.8; 95% CI: 2.0-11; P < 0.001) was also associated with late mortality or transplant.

    The multivariable analysis also highlighted significant associated risk of late mortality or transplant for patients under 1 month of age (HR: 2.6; 95% CI: 1.2-5.8; P = 0.018), patients aged 1-12 months (HR: 2.2; 95% CI: 1.1-4.6; P = 0.028), prematurity (HR: 2.9; 95% CI: 1.6-5.3; P = 0.001), and presence of at least one major preoperative risk factor (HR: 1.9; 95% CI: 1.0-3.3; P = 0.037).

    “Among transplant-free survivors requiring predischarge reinterventions after congenital cardiac surgery, those with persistent major residua have significantly worse long-term outcomes [and survival],” the researchers concluded.

    “In addition, patients with persistent major residua also have a significantly greater risk for future reinterventions compared with those with no residua.

    “These high-risk patients warrant closer surveillance.”

    In an accompanying editorial, Charles B. Huddleston, MD, and Corinne Tan, MD, from SSM-Health Cardinal Glennon Children’s Hospital, St. Louis, stressed that: “Residual lesions are inescapable from the best of hands, especially as we become emboldened in undertaking care of the most complex of congenital heart patients.”

    The current study perhaps challenges the maxim: “The enemy of good is perfect,” the editorialists added.

    “For fear of stating the obvious, the key is to reach for the stars at the very first go and, if need be, reintervene as soon as we can.”

    Sources:

    Sengupta A, Gauvreau K, Kohlsaat K, et al. Long-Term Outcomes of Patients Requiring Unplanned Repeated Interventions After Surgery for Congenital Heart Disease. J Am Coll Cardiol 2022;79:2489-2499.

    Huddleston CB, Tan C. Reaching for the Stars With the Least Number of Interventions Possible. J Am Coll Cardiol 2022;79:2500-2501.

    Image Credit: georgerudy – stock.adobe.com

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