Risks of Noncardiac Operations and Other Procedures in Children With Complex Congenital Heart Disease

doi:10.1016/j.athoracsur.2012.09.023

The Annals of Thoracic Surgery

Volume 95, Issue 1, January 2013, Pages 204-211

https://doi.org/10.1016/j.athoracsur.2012.09.023 Get rights and content

Background

Children with complex congenital heart disease entail risk when undergoing noncardiac operations and other procedures requiring general anesthesia. To address concerns regarding intraoperative instability, need for postoperative mechanical ventilation, and postoperative hospital length of stay (LOS), we present our 5-year experience with 71 patients with complex congenital heart disease who underwent 252 surgical procedures.

Methods

We reviewed the records of all patients from July 2006 to January 2011 who underwent a cardiac procedure with a Risk Adjustment for Congenital Heart Surgery-1 score of 6, and included all who underwent noncardiac procedures during this interval. Perioperative data were gathered to identify patients at risk for induction and maintenance instability, need for postoperative mechanical ventilation, and postoperative hospital LOS. Univariate predictors of these outcome variables were evaluated and entered into stepwise regression algorithms to determine independent variables.

Results

We identified 252 procedures that were performed on 71 patients during the study interval. These procedures were performed under 173 general anesthesias. Using each general anesthesia as a case, induction instability was independently associated with stage of palliation before cavopulmonary shunt, case complexity, and preoperative use of angiotensin-converting enzyme inhibitor in a multivariate logistic regression. Maintenance instability was independently associated with case complexity and preoperative use of digoxin and inotropes. Among the 145 cases where the patient was not intubated before the procedure, postoperative need for mechanical ventilation was associated only with preoperative hospital LOS exceeding 14 days. Finally, the resulting linear regression model showed postoperative hospital LOS was independently associated with preoperative hospital LOS exceeding 14 days, presence of moderate ventricular dysfunction, preoperative use of an inotrope, and negatively associated with use of digoxin.

Conclusions

Within this population, we have identified independent risk factors for specific clinical outcomes. Patients before stage II palliation, undergoing more invasive procedures, and receiving inotropes, angiotensin-converting enzyme inhibitors, or digoxin appear to be at risk for intraoperative hemodynamic instability. Patients with preoperative hospital LOS exceeding 14 days appear to be at greater risk for requiring postoperative mechanical ventilation. Patients with preoperative LOS exceeding 14 days, with ventricular dysfunction, receiving inotropes, and not receiving digoxin appear to be at risk for protracted hospitalization. Application of these results should assist clinicians in assessing perioperative risk.

Section snippets

Material and Methods

After Institutional Review Board approval, we queried The Society of Thoracic Surgeons database for our institution between July 2006 and January 2011. This database provides a comprehensive list of all patients who have undergone cardiac operations at our institution. We searched for all patients who underwent a RACHS-1 category 6 procedure during the study interval and identified 113 patients. We reviewed the electronic medical record for each patient and collected data for each noncardiac

Study Population

Our search yielded 113 patients who had undergone RACHS-1 category 6 procedures at our institution from July 2006 to January 2011. During the study interval, 71 of these patients underwent at least one noncardiac procedure; all of these had single-ventricle hearts or were destined for a single-ventricle palliative approach. The most common primary cardiac diagnoses for these 71 patients were hypoplastic left heart syndrome (70.4%), unbalanced atrioventricular septal defect (12.7%), and

Comment

Children with CHD represent a high-risk population for anesthesia and surgical intervention. Awareness of this risk has prompted investigators to create large registries addressing the risk for perioperative cardiac arrest [2, 3]. In one of these reports, single ventricle was the most common congenital heart lesion associated with perioperative cardiac arrest [3]. Here, we further investigate this high-risk population by evaluating preoperative risk factors associated with less critical events:

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Anorectal malformations (ARM) and VACTERL association and severity of congenital heart diseases (CHD): Experience of 396 consecutive patients in a tertiary center
2024, Pediatrics and Neonatology
Congenital heart diseases (CHD) are the most frequently associated anomalies with anorectal malformations (ARM). Nevertheless, many specific aspects of CHD in ARM patients have yet to be studied. The aims of this study were to evaluate the prevalence and distribution of CHD in neonates-infants with ARM, and to explore whether the severity of ARM, and the presence of VACTERL association, had an impact on CHD rate, severity, and timing at first cardiac surgery.
All consecutive newborn-infants with ARM managed in our tertiary center (January-1999; December-2021) were collected from a prospective database and retrospectively analyzed. Prevalence and distribution of CHD in ARM patients were assessed. Patients were divided into groups depending on ARM severity and presence of VACTERL association. Pairwise comparison for CHD prevalence, severity, and timing at first cardiac surgery was performed between groups.
Of 396 ARM patients identified, those with severe ARM showed a higher number of overall CHD compared to patients with non-severe ARM (36.7 % vs. 25.2 %, p = 0.032). VACTERL + patients had a significantly higher prevalence of CHD (73.4 % vs. 16.4 %; p <0.001) and major CHD (51.7 % vs. 26.9 %; p = 0.008) when compared with VACTERL-patients. Furthermore, VACTERL + patients underwent first cardiac surgery at a significantly younger age than VACTERL-patients (5.2 ± 15.2 months vs. 11.9 ± 6.3, p = 0.039).
Patients with severe ARM had a higher number of CHD compared to patients with non-severe ARM. VATERL + patients had significantly more CHD and more severe CHD than VACTERL-patients. Early screening for CHD is strongly recommended in all newborns diagnosed with ARM before surgery.
III retrospective comparative study.
Perioperative Risk Assessment in Children With Congenital Heart Disease Undergoing Noncardiac Procedures
2023, Journal of Cardiothoracic and Vascular Anesthesia
To risk-stratify children with congenital heart disease undergoing noncardiac surgery or diagnostic procedures for perioperative cardiopulmonary complications using the authors’ established institutional guidelines.
A retrospective cohort study.
The study was conducted in an academic, tertiary-care children's hospital.
A total of 1,005 children, from birth to 19 years of age with a diagnosis of congenital heart disease, who underwent a noncardiac surgery or diagnostic procedure from January 2017 to December 2018, were included in the study.
None.
The incidence of a severe perioperative complication, defined as a perioperative cardiac arrest or death within 30 days of the procedure, was 1.6%. Age, an emergent surgery/procedure, a preoperative renal abnormality, preoperative mechanical ventilation, and a preoperative pericardial effusion were significant for severe perioperative complications, in the multivariate analysis. The area under the receiver operating characteristic curve for severe complications was 0.936. However, the area under the curve for moderate perioperative complications was 0.679, in which moderate complications were defined as (1) an escalation in anticipated postoperative disposition (from planned disposition), (2) an escalation in postoperative disposition (from preoperative location), (3) an escalation of preoperative airway support, (4) an administration of any intraoperative vasoactive medication/infusion, (5) a noncardiac surgery reoperation within 30 days of the procedure (if related to the primary procedure or change in physiology), or (6) unplanned readmission with 24 hours of the procedure.
A robust model for severe perioperative complications was developed within the authors’ institutional clinical guidelines, identifying 5 predictors for perioperative cardiac arrest or death. The usual markers of critical illness were not found to be predictive of a moderate perioperative complication, regardless of the level of anesthesiologist training, suggesting that many of these children with congenital heart disease undergoing noncardiac procedures can be treated by a general pediatric anesthesiologist rather than a pediatric cardiac anesthesiologist within an institution that has or can establish clinical guidelines for these children.
Perioperative outcomes in children with congenital heart disease when cared for by a Congenital Cardiac Anesthesiologist during Noncardiac Surgery
2021, Perioperative Care and Operating Room Management
Citation Excerpt :
Prior studies have examined the incidence of major adverse perioperative complications in children with CHD undergoing noncardiac surgery. It is clear that this risk is elevated in those children with major and severe CHD, as defined by the American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) functional classification system.8–13 A study by Faraoni et al. targeted the development of a risk stratification score for this population to help predict those patients with CHD at highest risk for adverse perioperative events.
Background: Congenital cardiac anesthesiologists are a limited resource, but their expertise may be beneficial to children with Congenital Heart Disease (CHD) undergoing procedures outside of the cardiac operating room. Our objective was to evaluate the incidence of adverse events in patients with CHD during noncardiac surgery when their perioperative care was coordinated and executed by a congenital cardiac anesthesiologist.
Methods: We conducted a retrospective cohort study at a tertiary care health system. Children with CHD were assigned one of three American College of Surgeons National Surgery Quality Improvement Program functional severity classifications (minor, major, or severe). Perioperative care was performed by a congenital cardiac anesthesiologist. Outcomes such as perioperative cardiac arrest, postoperative intubation, and survival data were compared to those reported in the literature.
Results: 131 patients with CHD underwent 171 noncardiac surgical procedures. Congenital cardiac anesthesiologists primarily cared for children with major (45%) or severe (45%) CHD undergoing noncardiac surgery. An intraoperative cardiac arrest occurred in a single patient (0.6%; 95% CI 0.0–3.2) with severe CHD. Patients with severe CHD accounted for most (66.7%) of the 3.5% (CI 1.3–7.5) of patients who required postoperative reintubation. The 30-day and overall mortality rates for patients with severe CHD remained high at 13.6% (95% CI 5.2–27.4) and 18.2% (95% CI 6.8–29.6) respectively.
Conclusions: Perioperative risk stratification, planning and care of pediatric patients with major or severe CHD by a dedicated team of congenital cardiac anesthesiologists is associated with a low rate of perioperative complications.
Non-cardiac surgical considerations in pediatric patients with congenital heart disease
2021, Seminars in Pediatric Surgery
Anesthesia in Pediatric Patients With Congenital Heart Disease Undergoing Noncardiac Surgery: Defining the Risk
2020, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
Sixty-four percent (n = 111) of the anesthetics were delivered before Stage 2 palliation. Identified risk factors were procedures performed before SCPA palliation, preoperative angiotensin enzyme inhibitor, digoxin, or inotrope administration, and higher surgical complexity score.25 Another single center series of 102 anesthetics for minor and major surgical procedures delivered to 70 patients with single ventricle physiology before Stage 2 palliation assessed mortality and major intraoperative events defined as: conversion from sedation to a general anesthetic, difficult airway, extubation requiring reintubation within 24 hours, desaturation or bradycardia >20% of baseline values, arrhythmias requiring treatment (medical or electrical), new inotropic support (hemodynamic instability), and any episodes of CA requiring chest compressions.26
The incidence of moderate to severe congenital heart disease (CHD) in the United States is estimated to be 6 per 1,000 live-born, full-term infants. Recent advances in pediatric cardiology, surgery, and critical care have improved significantly the survival rates of patients with CHD leading to an increase in prevalence in both children and adults. Children with CHD significant enough to require cardiac surgery frequently also undergo noncardiac surgical procedures. With this increased demand for procedures that require anesthesia, all anesthesiologists, and more specifically, pediatric anesthesiologists will encounter patients with repaired or unrepaired CHD and other cardiac diseases in their practice. They often are faced with the question, “Is this patient too high risk for anesthesia?” The objective of this literature review is to provide a greater understanding of patients at high risk and to quantify the risk for patients, their families, and clinicians. In addition, specific high-risk lesions (single ventricle, Williams-Beuren syndrome, pulmonary hypertension, cardiomyopathies, and ventricular assist devices) are described.
Noncardiac surgery in the congenital heart patient
2019, Seminars in Pediatric Surgery
Citation Excerpt :
The ideal timing of elective surgery in children with CHD is not well studied. Children undergoing staged palliation of single ventricle lesions are at increased risk prior to the second stage.16 Thus, these patients may tolerate anesthesia best after the second stage of palliation due to improved, obligatory pulmonary blood flow and the diminished consequences of positive pressure ventilation on shunt physiology.
More children with congenital heart disease are surviving and require noncardiac surgery. A high-yield summary of congenital heart anatomy and pathophysiology is presented to contextualize these patients for surgeons. Preoperative planning including risk stratification, anesthetic management and timing of elective surgery are discussed. Specific intraoperative considerations for particular cases, such as the use of laparoscopy and thoracic surgery, are reviewed. Postoperative outcomes and recommended management required to mitigate complications are summarized.

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Original articlePediatric cardiacRisks of Noncardiac Operations and Other Procedures in Children With Complex Congenital Heart Disease

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Study Population

Comment

Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Pediatr Surg

Mayo Clin Proc

Br J Anaesth

Influence of congenital heart disease on mortality after noncardiac surgery in hospitalized children

Pediatrics

Perioperative cardiac arrests in children between 1988 and 2005 at a tertiary referral center: a study of 92,881 patients

Anesthesiology

Anesthesia-related cardiac arrest in children with heart disease: data from the Pediatric Perioperative Cardiac Arrest (POCA) registry

Anesth Analg

Perioperative management of infants undergoing fundoplication and gastrostomy after stage I palliation of hypoplastic left heart syndrome

Pediatr Cardiol

Original article
Pediatric cardiac
Risks of Noncardiac Operations and Other Procedures in Children With Complex Congenital Heart Disease