Quality outcomes of ACHD patients undergoing cardiovascular procedures and hospital admissions in a free-standing children's hospital.

OBJECTIVES: Describe quality outcomes of adults with congenital heart disease (ACHD) undergoing cardiovascular procedures and admissions in a free-standing children's hospital with a multi-disciplinary ACHD program and compared with pediatric outcomes. BACKGROUND: A challenge for the U.S. healthcare system is where to treat the >1 million ACHD patients (pts): adult hospitals without CHD care, or pediatric hospitals without adult services. METHODS: We reviewed all CHD pts ≥ 18 yrs of age from 2002-2007. Procedural and hospital related morbidity and mortality were recorded. ANOVA and t-test compared adult with pediatric pts. RESULTS: Overall, 782 pts, mean age of 29.8 ± 9.9 yrs, encountered 1490 procedures/admissions. For 178 cardiac surgeries (72% reoperations), mortality was 1.8% and complication rate was 7.3%. There was 0% mortality for 412 cardiac catheterizations, 311 electrophysiological procedures, 401 transesophageal echocardiograms (TEE), 244 exercise tests (ETT) and 54 medical admissions. Major adverse event rate was 0.6% for cardiac catheterization and electrophysiological procedures. No adverse events occurred during TEE and ETT. Only 4 pts required transfer to an adult institution (0.25%). There was no significant difference in mortality or adverse events between pediatric and adult CHD pts, p>0.05. CONCLUSIONS: The optimal setting to provide ACHD care remains a complex issue. Our study is the first to demonstrate 1) a low incidence of morbidity and mortality for ACHD pts undergoing cardiovascular procedures or admissions at a free-standing children's hospital, 2) outcomes comparable to pediatric CHD pts. Future models incorporating ACHD programs within pediatric heart centers should be considered to care for this complex population.

Completion angiography after cardiac surgery for congenital heart disease: complementing the intraoperative imaging modalities.

Residual structural pathology after cardiac surgery for congenital heart disease may complicate postoperative recovery. Completion angiograms obtained in the operating room may facilitate early detection and therapy of residual structural abnormalities. Our objective here is to report our institutional experience performing completion angiograms after cardiopulmonary bypass surgery. Between October 2007 and August 2008, 31 patients underwent completion angiograms after 32 cardiac surgical procedures. The median age was 7.5 months (range, 50 days to 31.2 years) and the median weight was 6.5 kg (range, 3.1-153 kg). Type of procedure, angiographic findings, and therapeutic decision were retrospectively reviewed. Procedures (proc) evaluated through completion angiography included comprehensive stage II or Glenn (n = 13), aortic arch reconstruction/conduit (n = 3), repair/palliation of tetralogy of Fallot or pulmonary atresia with ventricular septal defect (n = 4), PVR or conduit replacement (n = 5), and others (n = 7). Unexpected pathology was identified in 18 of 32 (56.3%) proc, which included left pulmonary artery (LPA) stenoses (n = 15), right pulmonary artery (RPA) stenoses (n = 11), and stenosis impairing coronary blood flow (after DKS; n = 1). In 9 of 32 (28.1%) proc, findings may have led to a change in therapeutic management. This included surgical revision (n = 1), 'Hybrid' therapy in the same setting (n = 2: LPA stent, 1; RPA balloon, 1), early catheterization within 3 months (n = 4), and change in medical management (n = 2: change in anticoagulation, 1; early CT, 1). Complications related to completion angiography were seen in only a single procedure (LPA staining). In conclusion, completion angiograms using a dedicated Hybrid cardiac operating suite may aid in early diagnosis and therapy of postsurgical abnormalities. They complement other methods of intraoperative imaging and may reduce the potential need for early surgical or transcatheter reintervention.

Hybrid balloon pulmonary valvuloplasty in a 700-g infant: Thinking outside the box.

This report describes a unique Hybrid approach to balloon pulmonary valvuloplasty in a 700-g premature infant with pulmonary valve stenosis and very poor right ventricular function.