Reducing mortality and infections after congenital heart surgery in the developing world.

BACKGROUND: There is little information about congenital heart surgery outcomes in developing countries. The International Quality Improvement Collaborative for Congenital Heart Surgery in Developing World Countries uses a registry and quality improvement strategies with nongovernmental organization reinforcement to reduce mortality. Registry data were used to evaluate impact. METHODS: Twenty-eight sites in 17 developing world countries submitted congenital heart surgery data to a registry, received annual benchmarking reports, and created quality improvement teams. Webinars targeted 3 key drivers: safe perioperative practice, infection reduction, and team-based practice. Registry data were audited annually; only verified data were included in analyses. Risk-adjusted standardized mortality ratios (SMRs) and standardized infection ratios among participating sites were calculated. RESULTS: Twenty-seven sites had verified data in at least 1 year, and 1 site withdrew. Among 15,049 cases of pediatric congenital heart surgery, unadjusted mortality was 6.3% and any major infection was 7.0%. SMRs for the overall International Quality Improvement Collaborative for Congenital Heart Surgery in Developing World Countries were 0.71 (95% confidence interval [CI] 0.62-0.81) in 2011 and 0.76 (95% CI 0.69-0.83) in 2012, compared with 2010 baseline. SMRs among 7 sites participating in all 3 years were 0.85 (95% CI 0.71-1.00) in 2011 and 0.80 (95% CI 0.66-0.96) in 2012; among 14 sites participating in 2011 and 2012, the SMR was 0.80 (95% CI 0.70-0.91) in 2012. Standardized infection ratios were similarly reduced. CONCLUSIONS: Congenital heart surgery risk-adjusted mortality and infections were reduced in developing world programs participating in the collaborative quality improvement project and registry. Similar strategies might allow rapid reduction in global health care disparities.

Subaortic membrane and aorto-septal angle: an echocardiographic assessment and surgical outcome.

BACKGROUND: Development of a subaortic membrane is not fully understood. Recurrence after surgical removal continues to be high. We sought to assess the differences in aorto-septal angles (AoSA) to possibly explain alterations within the left ventricular outflow tract, hence in subaortic membrane formation. METHODS: A total of 113 patients who underwent subaortic membrane resection were matched by age and sex with 113 controls. The subaortic membrane resection group included isolated subaortic membranes (n = 34, group I), associated with ventricular septal defect (n = 29, group II), or patent ductus arteriosus (n = 50, group III). RESULTS: Mean (± standard deviation) AoSA (in degrees) were not different between subaortic membrane groups I, II, and III but were steeper than their control groups (126.2 ± 9.2 vs 138.6 ± 7.0, 129.2 ± 9.9 vs 137.7 ± 10.0, and 126.2 ± 8.1 vs 135 ± 8.5, respectively; all Ps < .05). Additionally, group II had lower preoperative gradients (28.8 ± 20.7 mm Hg) compared to groups I and III (67.0 ± 32.9 and 66.2 ± 33.1 mm Hg, respectively, P < .001). Follow-up ranged from 3 to 132 months. In 22 (32%) patients, a subaortic membrane recurred. Early postoperative residual gradients and development of aortic regurgutation were associated with the need for reoperation (P < .05). CONCLUSIONS: These findings suggest a contributing role of the AoSA in the development of subaortic membrane. Further rheological experiments are warranted. Whether the steeper the angle the higher the risk of recurrence may be revealed by longer follow-up periods.

Antibiotic sandwich patch for ventricular septal defect complicated by endocarditis.

Infective endocarditis in patients with ventricular septal defects can prove life threatening due to acute heart failure or septic embolization. Persistent postoperative risk is bacterial colonization of prosthetic material. We designed the Antibiotic Sandwich Patch to reduce this risk, using a double layer of autologous pericardium containing antibiotic powder. Five patients were managed with this technique for closure of ventricular septal defects complicated by acute infective endocarditis. No colonization of the patches occurred after a median follow up of 1.5 years. This technique reduced the risk of bacterial colonization of the antibiotic sandwich patch, offering an additional surgical option.

Persistent institutional difficulties in surgery for transposition of the great arteries in guatemala: analysis with the aristotle basic and comprehensive scores.

Background. Neonates with complex congenital cardiac lesions are largely inadequately managed in Guatemala. Methods. Between 1997 and 2009, 79 patients who underwent operations for transposition of the great arteries were identified; 51 (63.3%) had an arterial switch operation (ASO) and 28 (36%) an atrial switch operation (ATSO). The Aristotle Basic Complexity score (ABC score) and the Aristotle Comprehensive Complexity score (ACC score) have been used to aid in the evaluation of quality of care associated with pediatric cardiac surgery by adjusting for operative complexity. Results. In-hospital mortality was 47% for the ASO and 25% for the ATSO group; 36.7% were beyond 1 month of age and many exhibited increased preoperative risk factors. The mean ABC score was 9.75 ± 0.89 and the ACC score was 12.12 ± 2.7, with a mean 2.36-point increase (P < .05). Comparing survivors and nonsurvivors with both scores, significant differences were identified (ABC: P < .04 and ACC: P < .02). Conclusion. During this 13-year period, a low volume of surgery for transposition of the great arteries (TGA) was performed at our institution with a relatively high surgical mortality. Many patients with TGA in Guatemala are either never referred for surgery or referred late. Strategies to improve outcomes for neonates with TGA in Guatemala must include increases in early diagnosis countrywide and prompt referral to our unit. Based on the larger number of neonates with TGA that would be referred to our center, we anticipate that this strategy should substantially improve surgical outcomes and favor overall team-related skills.

Pediatric cardiac surgery: a challenge and outcome analysis of the Guatemala effort.

A large underserved population of children with congenital cardiac malformation (CCM) exists in many developing countries. In recent years, several strategies have been implemented to supplement this need. These strategies include transferring children to first-world countries for surgical care or the creation of local pediatric cardiovascular surgical programs. In 1997, an effort was made to create a comprehensive pediatric cardiac care program in Guatemala. The objective of this study is to examine the outcome analysis of the Guatemala effort. The goals of our new and first pediatric cardiac care program were to: 1) provide diagnosis and treatment to all children with a CCM in Guatemala; 2) train of local staff surgeons, 3) established a foundation locally and in the United States in 1997 to serve as a fundraising instrument to acquire equipment and remodeling of the pediatric cardiac unit and also to raise funds to pay the hospital for the almost exclusively poor pediatric cardiac patients. The staff now includes 3 surgeons from Guatemala, trained by the senior surgeon (A.R.C.), seven pediatric cardiologists, 3 intensivists, and 2 anesthesiologists, as well as intensive care and ward nurses, respiratory therapists, echocardiography technicians, and support personnel. The cardiovascular program expanded in 2005 to 2 cardiac operating rooms, 1 cardiac catheterization laboratory, 1 cardiac echo lab, 4 outpatients clinics a 6-bed intensive care unit and a 4-bed stepdown unit, a 20 bed general ward (2 beds/room) and a genetics laboratory. Our center has become a referral center for children from Central America. A total of 2,630 surgical procedures were performed between February 1997 and December 2007, increasing the number of operations each year. Postoperative complication occurred in 523 of 2,630 procedures (20%). A late follow-up study was conducted of all the patients operated from 1997 to 2005. Late mortality was 2.7%. Development of a sustainable pediatric cardiac program in emerging countries presents many difficult challenges. Hard work, perseverance, adaptability, and tolerance are useful aptitudes to develop a viable PCP in an "emerging" country. We are not in favor of Medical-Surgical Safari efforts, unless these efforts include training of a local team and eventual unit independence. It helps if an experienced (+/- senior/retired!) surgeon leads this effort on a full-time, pro bono basis. Local and international fund raising is essential to complement vastly insufficient government subsidies.

Improvement in congenital heart surgery in a developing country: the Guatemalan experience.

BACKGROUND: In 1997, an effort was made to disseminate US pediatric cardiac surgical practices to create a new comprehensive program in Guatemala. The objective of this study was to describe the improvement of the program by exploring the reduction in risk-adjusted in-hospital mortality. METHODS AND RESULTS: A retrospective cohort study of surgical procedures performed in Guatemala from February 1997 to July 2004 was conducted. Data were divided into 3 time periods (1997 to 1999, 2000 to 2002, and 2003 to 2004) and compared with a US benchmark (2000 Kids' Inpatient Database of 27 states and 313 institutions). The risk adjustment for congenital heart surgery (RACHS-1) method was used to adjust for case mix. Mortality rates, standardized mortality ratios, and 95% confidence intervals were calculated. A total of 1215 surgical procedures were included. Median age was 3.1 years (range, 1 day to 17.9 years). The overall mortality was 10.7% (n=130). The RACHS-1 method showed better discrimination than in prior reports (area under receiver operating characteristic curve=0.854). A decreasing trend in mortality rate was observed in every RACHS-1 risk category over the 3 time periods. When compared against the US benchmark, the reduction in risk-adjusted mortality was noted by a decrease of standardized mortality ratio from 10.0 (95% confidence interval, 7.2 to 13.7) in 1997-1999, to 7.8 (95% confidence interval, 5.9 to 10.0) in 2000-2002, and to 5.7 (95% confidence interval, 3.8 to 8.3) in 2003-2004. CONCLUSIONS: In a short time period, mortality after congenital heart surgery has been reduced substantially in Guatemala. Measurement of risk-adjusted mortality is a useful method to assess pediatric cardiac program improvement in the developing world.

Low-dose oral sildenafil for patients with pulmonary hypertension: a cost-effective solution in countries with limited resources.

INTRODUCTION: Pulmonary arterial hypertension, both primary and secondary, continues to pose a therapeutic problem. In this study, we evaluate the efficacy and safety of a low-dose of oral sildenafil in 10 patients with pulmonary arterial hypertension. METHODS: We administered a single daily dose of 0.5 milligrams per kilogram of sildenafil for 3 months to 10 patients with pulmonary arterial hypertension. Their average age was 26.8 years. Diagnoses were primary pulmonary arterial hypertension in 3 patients, and secondary pulmonary arterial hypertension due to congenital cardiac disease in the remaining 7 patients. Outcome measures included the clinical state, the mean pulmonary arterial pressure, and the indexed pulmonary vascular resistance; the latter two assessed at the beginning and at the end of the treatment period by cardiac catheterization. We also analysed the cost of the treatment. RESULTS: Oral treatment was well tolerated, and resulted in an improvement of the functional capacity in 9 of the 10 patients. Pulmonary arterial pressure decreased from 70 to 60 millimetres of mercury (p equal to 0.05), and indexed pulmonary vascular resistance decreased from 21.8 to 15.8 Wood units per square metre (p equal to 0.006). The mean cost per patient for 3 months on oral treatment with sildenafil was 120.99 American dollars. CONCLUSIONS: A low dose of 0.5 milligrams per kilogram per day of oral sildenafil, instead of 1 to 4 milligrams per kilogram per day, provided early clinical and haemodynamic improvements, and proved less expensive. Additional experience is now required to define more reliably the true long-term benefits of this therapy.

Factors determining access to surgery for children with congenital cardiac disease in Guatemala, Central America.

BACKGROUND: Surgical intervention for children with congenital cardiac disease in the developing world often occurs late. Our objective was to identify factors that placed Guatemalan children at risk for delayed care. METHODS: We investigated the medical and socioeconomic background of 178 children under the age of 18 years who received their first corrective surgery for congenital cardiac disease at the Unidad de Cirugía Cardiovascular de Guatemala in 2002. A retrospective review of medical records was performed. Each case was stratified into one of three surgical classes based upon customary practice in the United States of America. The outcome we measured was age at surgery, adjusting for the surgical class. Logistic regression was performed and odds ratios calculated. RESULTS: In univariate analyses, patients presented later for surgery if they were from rural areas (p equals 0.001), did not have social security membership (p equals 0.004), or paid any amount towards the cost of their surgery (p less than 0.001). Age at surgery was also positively correlated with the distance of the home of the patient from the surgical centre (p equals 0.002). For the subset of patients who applied for financial assistance, we found that children presented later for surgery if they required institutional support (p equals 0.001), or came from households of larger size (p less than 0.001). CONCLUSIONS: Guatemalan children with congenital cardiac disease may be at risk for delayed surgical care if they come from rural areas, areas distant from the surgical centre, or from families without membership of social security.

Radiofrequency catheter ablation of supraventricular tachycardia in children and adolescents : feasibility and cost-effectiveness in a low-income country.

The objective of this study is to provide results and costs of catheter ablation in children and adolescents in a low-income country. Reports from first-world countries have demonstrated the cost-effectiveness of radiofrequency catheter ablation (RFCA) compared to medical treatment of supraventricular tachycardia (SVT). The study included 28 patients younger than 18 years of age with SVT in a pediatric cardiology unit in Guatemala. All patients underwent RFCA. Clinical outcome and cost-effectiveness of RFCA compared to continued medical treatment were the end points. Twenty-four patients had successful ablation (85.7%). Mean age at RFCA was 11.42 +/- 3.49 years. Three patients underwent a second ablation, increasing the success rate to 96.4%. One remaining patient is awaiting a second procedure. At a mean follow-up of 13.69 +/- 7.16 months, all 27 patients who had a successful ablation remained in sinus rhythm. Mean cost per procedure was 4.9 times higher than that of medical treatment. However, the estimated cost of catheter ablation equal that of medical therapy after 5.1 years and is 3.4 times less after 20 years. Radiofrequency catheter ablation of SVT in children and adolescents is safe and cost-effective compared to medical therapy. Resources must be judiciously allocated, especially in low-income countries, to treat the largest number of pediatric patients.

Pulmonary artery hypertension: is it really a contraindicating factor for early extubation in children after cardiac surgery?

BACKGROUND: One of the perceived major contraindications to early extubation after pediatric cardiac surgery is preoperative pulmonary arterial hypertension (PAH). The objective of this study is to present the results of early extubation (within 6 hours after open heart surgery) in children who had varying degrees of preoperative pulmonary arterial hypertension. METHODS: We reviewed the charts of 100 consecutive children who underwent subaortic ventricular septal defect closure and also had preoperative PAH. Outcomes measured included early extubation rate, clinical status of patients, and hospital costs. RESULTS: The median age at surgery was 2.5 years (range, 0.4 to 30). Sixty-five patients were extubated successfully in the operating room; 25 additional patients were extubated in the intensive care unit within 6 hours from surgery, increasing the early extubation rate from 65% to 90%. Postoperative complications were present in 12 patients; 10 of these patients required mechanical ventilation for more than 6 hours, and 1 of them died postoperatively in septic shock. Two patients required reintubation 25 and 26 hours, respectively, after initial extubation in the operating room, for causes unrelated to pulmonary hypertensive crises or ventilatory failure. The mean cost of procedures in patients who had successful early extubation was USD 3,786.50 +/- 302.45. Every additional day in the intensive care unit, in case of delayed extubation, increased the overall cost of the procedure by 10%. CONCLUSIONS: Pulmonary artery hypertension does not seems to be a contraindicating factor to early extubation in patients who underwent ventricular septal defect closure, and may be considered a feasible way to decrease postoperative intensive care unit stay and hospital costs.

The right-sided window ductus: a rare anatomical entity.

A rare type of patent ductus arteriosus called window ductus was identified in association with a right aortic arch in a 1-year-old child who was referred for closure of a membranous ventricular septal defect.

Surgical versus percutaneous occlusion of ostium secundum atrial septal defects: results and cost-effective considerations in a low-income country.

OBJECTIVES: We compared the effectiveness and cost of percutaneous occlusion using an Amplatzer septal occluder (ASO) (AGA Medical Corp., Golden Valley, Minnesota) device compared with surgical closure of an ostium secundum atrial septal defect (ASD II) in Guatemala. BACKGROUND: The percutaneous occlusion of ASD II in first-world nations seems to offer better clinical results and lower cost compared with surgical closure. METHODS: We reviewed the clinical course of 111 patients referred to our institution for closure of isolated ASD II. Successful closure was assessed immediately after the procedures and at 12 months. Actual hospital costs were calculated for every patient who underwent either of the two procedures. RESULTS: Eighty-three patients with ASD II (75%) were selected for percutaneous occlusion with the ASO device, and the remaining 28 patients (25%) underwent surgical closure. In the device group, in 72 patients (86.7%) devices were successfully deployed. At immediate and 12-month follow-up, the complete closure rate was 87.5% (63 of 72 patients) and 97.2% (70 of 71 patients), respectively. In the surgical group, all patients had successful closure immediately after the procedure and at 12 months. Surgical closure offered a 27% cost savings in comparison with percutaneous occlusion (U.S. 3,329.50 dollars +/- 411.30 dollars and U.S. 4,521.03 dollars +/- 429.71 dollars; p < 0.001, respectively). Cost of the device (U.S. 2,930.00 dollars) proved to be the main cause for this difference. CONCLUSIONS: We confirmed the clinical advantages of percutaneous occlusion over surgical closure of ASD II. However, percutaneous occlusion costs were higher compared with surgical closure. In Guatemala, where health care resources are limited, ASD II closure with the ASO device did not prove to be cost-effective.

A Gore-Tex 'new-innominate' vein: a surgical option for complicated bilateral cavopulmonary shunts.

A bilateral bidirectional cavopulmonary shunt was performed in a cyanotic 14-month-old girl who had tricuspid and pulmonary valve atresia, with right pulmonary artery (RPA) hypoplasia (3 mm), bilateral superior vena cavae and a ductus arteriosus-dependent pulmonary blood flow. Because of 62% postoperative arterial oxygen saturation and a right superior vena cava (RSVC) pressure of 30 mmHg, a 5 mm Gore-Tex tube was interposed to connect the two superior venae cavae. The creation of a 'new-innominate' vein allowed decompression of the right superior vena cava and an increase in arterial oxygen saturation to 86%.

Congenital cardiac disease in children with Down's syndrome in Guatemala.

BACKGROUND: Congenital cardiac disease is the greatest cause of death in patients with Down's syndrome during the first two years of life, with from two-fifths to two-thirds of those with Down's syndrome also having congenital cardiac malformations. The lesions within the heart can be single or multiple. Our objective was to evaluate the frequency and type of such congenital cardiac malformations in patients born with Down's in Guatemala, and to provide baseline information for further research. METHODS: We reviewed all patients with Down's syndrome who underwent a cardiologic screening examination between January, 1997, and December, 2003, in the only department dealing with Paediatric Cardiology in Guatemala. RESULTS: Of the 349 patients reviewed, 189 (54.1 per cent) also had an associated congenital cardiac malformation. The median age at diagnosis was 6 months, with a range from 2 to 13 months. In 152 patients (80.4 per cent), the cardiac lesion was isolated, while 37 patients (19.6 per cent) had multiple defects. The most common single defect was patency of the arterial duct, found in 54 of the 189 patients (28.6 per cent), followed by ventricular septal defect in 27.5 per cent, atrial septal defect in 12.7 per cent, and atrioventricular septal defect with common atrioventricular junction in 9.5 per cent. The most frequent concomitant malformation found co-existing with other congenital cardiac lesions was patency of the arterial duct, found in 17.5 per cent. CONCLUSIONS: As far as we are aware, ours is the first epidemiologic study concerning the frequency and type of congenital cardiac disease found in Guatemalan children with Down's syndrome. The high frequency of patency of the arterial duct, and the differential distribution of the cardiac malformations associated with Down's syndrome among Guatemalan children, differ from what has been reported in the United States of America, Europe, and Asia. This difference warrants further research.

The role of vasopressin in treating systemic inflammatory syndrome complicated by right ventricular failure.

Severe right ventricular failure complicated a postoperative systemic inflammatory response in a 33-year-old woman after surgical repair of congenital cardiac malformations. Volume loading, and high doses of catecholamines, failed to produce improvement, but treatment with vasopressin improved all haemodynamic parameters, and also allowed reduction of the other inotropes. After 10 days, the patient was discharged in stable condition from the intensive care unit.

Modified extrapleural ligation of patent ductus arteriosus: a convenient surgical approach in a developing country.

BACKGROUND: Minimally invasive surgery for the closure of a large patent ductus arteriosus (PDA) using an extrapleural technique offers an alternative to other minimally invasive approaches such as video-assisted thoracoscopic surgery or interventional cardiologic procedures. METHODS: Between August 1999 and December 2003, 513 patients with PDA were admitted to Unidad de Cirugia Cardiovascular de Guatemala, of whom 327 (64%) were considered surgical candidates. Of these, 218 (67%) were selected for surgical extrapleural (SEP) closure initially by weight (< 10 kg) and a ductal diameter at the pulmonary end of greater than 4 mm. Subsequently, we included also patients who weighed more than 10 kg. Median age at operation was 51 months (range 5 days to 38 years). RESULTS: Median operating time was 32 minutes (range 23 to 52 minutes). All 218 patients had SEP closure and were extubated in the operating room. There were no hospital deaths. Two patients required a blood transfusion. Two additional patients bled postoperatively, requiring reoperation. A pneumothorax occurred in 3 patients that required a chest tube. The 6-month follow-up revealed residual ductal shunts in 2 patients that were closed percutaneously with a coil. The treatment of the remaining 295 patients included a surgical transpleural (STP) approach in 109 (37%) and transcatheter closure in 186 (63%), with a coil in 110 (37%) and an Amplatzer device in 76 (26%). CONCLUSIONS: Minimally invasive closure of a PDA through a short, 3-cm to 5-cm skin and muscle-sparing posterior thoracotomy and an SEP approach provides a convenient and safe technique with a low incidence of complications and also a cost-saving option compared with other invasive techniques.