Washington State's model of physician leadership in cardiac outcomes reporting.

BACKGROUND: In 1993, the cardiac surgery community in Washington State opposed an effort by the state Health Care Authority (HCA) to identify "centers of excellence" for selective contracting of coronary artery bypass grafting (CABG) procedures, and proposed an alternate model that would create a statewide cardiac outcomes registry under physician governance to be used by all institutions for internal quality improvement activities. METHODS: A prospective pilot data collection effort, which examined preoperative and postoperative patient-reported health status, served as the basis for evaluating the capacity of a physician-led organization to develop a collaborative atmosphere and facilitate universal hospital participation. RESULTS: A surgical steering group met on a regular basis and reached consensus on governance issues, protocols for standardized data collection, and policies regarding data dissemination. All 14 centers that performed bypass surgery in the state participated. Patients who were surveyed reported statistically significant improvements in physical, emotional, and anginal-specific health status after bypass surgery. Baseline patient characteristics and longitudinal outcomes were compared across institutions. CONCLUSIONS: Based on the feasibility of this collaborative outcomes reporting program, the HCA revised its policy regarding selective contracting and has helped to support an ongoing physician-led and -governed cardiac outcomes reporting system that is particularly notable for the subsequent integration of both CABG surgery and catheterization-based procedures into one standardized registry.

Staged repair of interrupted aortic arch with ventricular septal defect compared with primary repair in infancy.

Interrupted aortic arch is a poor prognosis cardiac anomaly with nearly 100 percent mortality if not recognized and treated early. The associated intracardiac lesions often lead to death if only the arch defect is repaired. Several recent reports have described patients with interrupted aortic arch who were treated as infants by primary repair of the arch defect with simultaneous repair of the intracardiac lesions. The improved survival data from these series have been attributed to the simultaneous repair of both lesions. We report herein on nine patients with both interrupted aortic arch and ventricular septal defect seen at Children's Hospital and Medical Center in Seattle from 1979 to 1987. Three patients had partial expression of DiGeorge's syndrome. All patients underwent primary repair of the interrupted aortic arch with concomitant pulmonary artery banding during infancy (mean age 18 days, range 2 days to 4 months). Operative mortality was 11 percent (1 of 9 patients). Eight patients had eventual repair of the ventricular septal defect (mean age 18 months, range 6 to 29 months) with one death occurring at 5 months postoperatively (12 percent mortality). The overall mortality of these nine patients was 22 percent. Staged repair of interrupted aortic arch with associated ventricular septal defect can be performed with results comparable to simultaneous primary repair in infancy. The improved survival from either approach is more likely to be attributable to improved perioperative stabilization, particularly the use of prostaglandin E.

Effect of pH and PCO2 on pulmonary and systemic hemodynamics after surgery in children with congenital heart disease and pulmonary hypertension.

Fourteen children with congenital heart disease and associated pulmonary hypertension (preoperative mean pulmonary artery pressure (MPAP) 48 mm Hg +/- 1 SEM were examined to determine the effect of arterial carbon dioxide tension (PaCO2) and pH on pulmonary and systemic hemodynamics after surgical repair. Baseline measurements were obtained with hyperventilation to PaCO2 20 to 30 mm Hg (pH 7.56 +/- 0.01 mm Hg). The addition of carbon dioxide to inspired gas to achieve a PaCO2 40 to 45 mm Hg (pH 7.35 +/- 0.01) resulted in a significant increase in MPAP, from 32 +/- 5 mm Hg to 47 +/- 8 mm Hg (p less than 0.05). An increase in mean cardiac index (CI) from 2.7 +/- 0.3 L/min/m2 to 3.3 +/- 0.3 L/min/m2 (p less than 0.05) explained in part the associated increase in MPAP. For a subgroup of eight patients with postoperative MPAP greater than 30 mm Hg (at pH 7.35 to 7.40), pulmonary vascular resistance index (PVRI) also significantly increased (p less than 0.05) as PaCO2 was increased, implying a direct pulmonary vasodilating effect of alkalosis. Removal of carbon dioxide from inspired gas returned hemodynamic values to baseline. The higher the MPAP at physiologic pH the greater the absolute amount of MPAP reduction and PVRI reduction (p less than 0.05) with alkalosis. No complications from alkalosis were seen. We suggest that a trial of hypocarbic alkalosis in the child with severe residual pulmonary hypertension after surgical repair of congenital heart disease is warranted to reduce right ventricular afterload.

Healing basis and surgical techniques for complete revascularization of the left ventricle using only the internal mammary arteries.

Long-term follow-up data from several leading centers concerning patients undergoing coronary artery bypass clearly demonstrate the superiority of the internal mammary artery (IMA) with patency rates of 83 to 94% at 7 to 12 years compared with the saphenous vein and its patency rates of 41 to 53%. Our experimental studies provide a biological basis for understanding this difference. Thin-walled arterial autografts undergo no histological change after being implanted in the arterial system, while venous autografts undergo major changes with an initial scattered loss of endothelium and marked thickening due to a proliferative reaction. The challenge to the cardiac surgeon is to revascularize the entire left ventricle with the IMAs. We have found this possible in most patients with advanced three-vessel disease by using both IMAs either as in situ grafts or free grafts with as many sequential anastomoses as necessary to achieve full revascularization. Our use of the term in situ refers to the graft's origin from the subclavian artery as opposed to a free IMA graft arising from another site.

A five- to seven-year experience with externally-supported Dacron prostheses in axillofemoral and femoropopliteal bypass.

We have examined the clinical results of 56 externally-supported (EXS) Dacron grafts in the axillofemoral position and 117 in the femoropopliteal position. Results have been analyzed from two perspectives: primary patency concerns only those grafts that had never occluded; extended patency refers to all open grafts including those whose continued patency is the result of thrombectomy. The 5-to 7-year life-table patency rates are: axillofemoral 8 mm and 6 mm bypass: primary 75% and extended 97%; above-knee femoropopliteal 6 mm bypass: primary 78% and extended 93%; below-knee 6 mm femoropopliteal bypass: primary 41% and extended 91%. In contrast, the results for the 5 mm grafts used for femoropopliteal bypass were inferior to the 6 mm grafts: femoropopliteal 5 mm bypasses had an above-knee primary patency rate of 44% and an extended rate of 55%, with a below-knee primary patency rate of 15% and an extended rate of 32%. Rendering the noncrimped porous Dacron prosthesis kink and compression resistant by an external support coil appears to increase its potential for successful use, especially in 8 mm axillofemoral and 6 mm femoropopliteal bypasses.

Surgical repair of anatomically corrected malposition of the great arteries.

Anatomically corrected malposition of the great arteries is a rare malformation in which the aorta and pulmonary artery arise from their appropriate ventricles but in an abnormal spatial relationship. This report describes 2 patients with anatomically corrected malposition who underwent closure of a ventricular septal defect and placement of a right ventricle-pulmonary artery conduit. A review of the literature indicates that surgical results have been good (92% survival) in those patients with situs solitus and atrioventricular concordance [S,D,L]. However, when there is atrioventricular discordance, that is, [S,L,D] or [I,D,L], hypoplastic right heart structures, or both conditions, the outcome after palliative procedures has been poor (29% survival). The results of surgical treatment should improve as this entity is recognized earlier and prompt surgical treatment is undertaken.

Thrombolytic therapy for delayed occlusion of knitted Dacron bypass grafts in the axillofemoral, femoropopliteal and femorotibial positions.

Selective intra-arterial streptokinase therapy successfully reopened ten axillofemoral and lower extremity Dacron bypass grafts that had undergone delayed closure from two to 47 months after implantation. In four, completion arteriograms revealed no runoff obstruction acquired since implantation; additional runoff obstruction had developed in the remaining six. All of the grafts without obstruction have remained open from two to 11 months. Three of the six grafts with obstruction have remained open from two and one-half to four months after specific surgical correction of the obstructive lesion. We conclude that intra-arterial streptokinase therapy is an effective means to reopen knitted Dacron grafts that have undergone delayed closure in the axillofemoral and above-knee femoropopliteal positions.

Tetralogy of Fallot: selective staged management.

One hundred twenty-four patients with tetralogy of Fallot have undergone either primary total repair (61), shunt and later repair (30), or an initial shunt (33). The mean ratio of pulmonary anulus to descending thoracic aorta increased from 0.80 +/- 0.25 before the shunt to 1.22 +/- 0.26 before the repair (p less than 0.0001). The mean ratio in the primary repair group was 1.23 +/- 0.25. A transannular patch was necessary in only six of 91 patients (6.6%). Postrepair right ventricular/left ventricular pressure ratio averaged 0.50 +/- 0.11 in the shunt plus repair group and 0.43 +/- 0.12 in the primary repair group. Only four patients had a right ventricular/left ventricular pressure ratio less than 0.65. A significant inverse linear relationship existed between this ratio and the pulmonary anulus size measured at operation and normalized for the patient's height (p less than 0.01). Postoperative complications occurred in 21% of patients after a shunt and 20% of patients after open heart repair. The early mortality was 0.8% (1/124). An initial shunt in patients with a small pulmonary anulus can result in an increased anulus size and better hemodynamic result with frequent avoidance of a transannular patch. Staged repair may result in improved overall mortality rates.

Pulsed Doppler echocardiographic evaluation of ventricular septal defect patches.

Doppler echocardiography has been shown to have high sensitivity and specificity for noninvasive detection of the flow disturbance of ventricular septal defect. After surgery for ventricular septal defect, one might expect loss of the ventricular septal defect flow disturbance. We used two-dimensional and pulsed Doppler echocardiography to evaluate 30 children undergoing surgery for ventricular septal defect to determine postoperative Doppler findings and the effect of ventricular septal defect patch material on those findings. Twenty-one patients had Dacron patches and nine pericardial patches. Doppler examinations were performed immediately after surgery and at intervals thereafter. The patches were imaged on two-dimensional echocardiograms and the Doppler method was used to evaluate flow at the patches. Doppler echocardiography was also used to estimate volume flow in the aorta and pulmonary artery to estimate postoperative ratio of pulmonary to systemic flow (Qp/Qs). Immediately after surgery 93% of patients had a flow disturbance detected by Doppler echocardiography in the region of the surgically placed patch. On postoperative day 1, 62% of Dacron-patched defects and 66% of pericardial patched defects showed evidence of residual shunting on Doppler examination. By the third postoperative day, this prevalence fell to 23% and 44%, respectively. By 2 weeks after surgery there was evidence of residual shunting in only two patients. In 26 of 30 early postoperative Qp/Qs estimates were under 1.6/1; all but two of these lost the Doppler-detected flow disturbance by 2 weeks after surgery. In three of 30 Qp/Qs estimates exceeded 1.9/1; two of these three required reoperation.(ABSTRACT TRUNCATED AT 250 WORDS)

Endothelial cell rounding associated with long-term implantations of left ventricular assist devices.

Culture endothelial cells have been utilized experimentally to inhibit thrombosis on cardiovascular prostheses. Grown on the internal surfaces of selected synthetic materials and implanted into autologous calves, prelinings have also proven to be a useful means to examine the influence of the in vivo environment on the endothelium. Initial short-term (less than 7 days) studies with left ventricular assist devices (LVADs) have demonstrated severe cell loss in endothelial prelinings as a result of continuous substrate flexure. These observations now have been extended to two chronic LVAD implantations of 28 and 125 days. By 28 days substantial regeneration of the endothelial layer had occurred to overlay the thrombus deposited as a result of prelining denudation. The morphologic characteristics of the endothelial linings in these two specimens have been studied. The most striking feature of the LVAD linings was the rounded appearance of the endothelial cells. These observations have led to the speculation that endothelial cells exposed to continuous mechanical strain assume an altered appearance. In addition, preliminary results utilizing a specially-built in vitro apparatus have demonstrated that endothelial rounding accompanied by intercellular separations may result from periodic stretching of the substrate material supporting the cells.

Results of combined left ventricular aneurysmectomy and coronary artery bypass: 1974 to 1980.

Left ventricular aneurysm repair with coronary artery bypass grafting was performed in 104 patients from 1974 through 1980. The patients' mean age was 57 years. Preoperatively, 48 percent were in New York Heart Association functional class III and 31 percent were in class IV. Stenosis of multiple vessels was common, as was a reduced ejection fraction (24 percent had an ejection fraction of less than 30 percent). Thrombus was present in 47 percent of resected aneurysms. Bypass grafting was performed to all graftable coronary vessels. Actuarial survival rates were 89.3 percent at 1 year, 86.1 percent at 2 years, and 74.5 percent (standard error 5.1 percent) at 5 years. One year postoperatively, 86 percent of the surviving patients were in class I, 11 percent class II, 1 percent class III, and 2 percent class IV. Patients who presented with angina alone had an excellent result, with 95 percent hospital survival. Congestive heart failure was an ominous finding, since four of five patients who developed it before discharge died in the hospital, and 38 percent of those who went into heart failure after discharge have died.

Severe left main coronary arterial stenosis with right coronary arterial occlusion: results of bypass graft surgery.

A detailed study was made of preoperative, operative and postoperative data from 69 patients with severe (70 percent or greater) luminal narrowing of the left main coronary artery and occlusion of the right coronary artery who underwent bypass surgery from December 1970 through December 1978. Preoperatively, 40.6 percent of patients were in functional class III and 55.1 percent in class IV. Ninety-six percent of those tested had a positive electrocardiographic treadmill test. Coronary bypass grafting was accomplished using standard techniques in all patients. An average of 2.7 grafts/patient were placed. The hospital mortality rate was 4.3 percent, and an additional 4.3 percent died before the end of 1 year. A history of congestive heart failure was a significant predictor (p less than 0.05) of postoperative mortality. An intraaortic balloon pump was not inserted in 64 patients, and our experience suggests that it was a necessary preoperative adjunct. A postoperative treadmill test was negative in 92 percent of those patients tested. Of those surviving 1 year postoperatively, 89 percent were in functional class I and 8 percent in class II. This study demonstrates a surgical mortality rate comparable with that of patients with left main coronary stenosis alone and a significantly better survival rate than that of similar patients treated medically.

Esophageal atresia and tracheoesophageal fistula. Review of thirteen years' experience.

A review of the treatment of esophageal atresia (EA) was undertaken to examine current methods of management and to ascertain the influence of prematurity and associated medical defects on survival. One hundred patients with EA presented at The Children's Orthopedic Hospital and Medical Center, Seattle, between 1967 and 1979. Eighty-two percent had a blind proximal esophageal pouch and distal tracheoesophageal fistula (TEF). Ninety-two patients were initially treated by gastrostomy. Fifty-nine patients were born at term and had no major medical problems. They underwent either primary or delayed (up to 1 week) repair of the esophagus. The survival rate was 93% and surgical mortality was 3%. Twenty-two patients born prematurely or having major medical problems underwent a staged repair. Survival in the staged group was 55% with a surgical mortality of 27%. Overall survival for the entire series was 79% (79/100). The use of air rather than contrast material for the radiographic diagnosis of EA was associated with fewer subsequent pulmonary abnormalities. There was an 18% incidence of minor anastomotic leaks, regardless of technique. The route of approach (transpleural, retropleural) did not influence mortality or morbidity in this series. There were more than three times as many significant strictures among patients who had double-layer anastomoses (18%) as among those who had single-layer repairs (5%). The surgical treatment of infants with EA has reached a level in which associated illness, anomalies, or prematurity are now the most significant determinants of survival.

A healable filamentous Dacron surgical fabric. Experimental studies and clinical experience.

A strong, lightweight, highly compliant Dacron surgical fabric of warp-knit, velour construction has been developed as an outgrowth of research on filamentous tubular vascular prostheses. This material has excellent suturability and conformability, high preclotting efficiency, and is imprinted with calibration marks at 2 cm intervals. Experimentally, iliac artery and descending thoracic aorta patch grafts of this material were completely healed 28 days after implantation in dogs. Light and electron microscopy showed excellent healing. This paper reports clinical results of 119 patches implanted in 109 patients who have been followed for a mean of 26.4 months (range: 16--34 months). Of these, 20 patches were used in arterial reconstructions, and 99 were used in the heart for repair of 95 congenital and four acquired defects. The 20 patch angioplasties were performed in the carotid artery (four patches), subclavian artery, (one patch), common femoral artery, profunda femoris artery, or superficial femoral artery (10 patches), and in the popliteal artery (five patches). This new surgical fabric is easily adaptable to complex angioplasties and for repair of intracardiac abnormalities. No complications intrinsic to the surgical fabric have been observed in clinical use of this material in 109 patients.

Tracheal resection in infancy.

Tracheal resection, commonly used in adults, has not been applied to the infant age group because of concerns regarding subsequent tracheal growth. Upper tracheal narrowing in infants may often be satisfactorily treated, but patients with long segment distal tracheal stenosis do not respond to usual therapy and rarely survive. In this case, resection of the distal third of the trachea was accomplished successfully and the trachea appears capable of normal growth in the area of the anastamosis.

Axillofemoral bypass: a critical reappraisal of its role in the management of aortoiliac occlusive disease.

Two hundred twenty-four consecutive patients (361 graft limbs) who underwent bypass grafting with the USCI Sauvage filamentous velour Dacron arterial prosthesis for aortoiliac occlusive disease over the 9 year period 1970 to 1979 are reviewed. Eighty-four axillofemoral (23 percent of patients), 210 aortofemoral (47 percent of patients), and 67 femorofemoral grafts (30 percent of patients) had cumulative patency rates of 72.1, 91.1, and 86.4 percent, respectively. Experimental and clinical factors influencing the patency of axillofemoral grafts are discussed, and the concept of an improved porous Dacron prosthesis specific for the axillofemoral site is presented.

Cardiac surgery under age two years. A review.

To assess the current status and risks of both open and closed cardiac procedures for congenital heart disease in patients under the age of 2 years, we reviewed all cardiac catheterizations and cardiac operations done from January, 1974, through December, 1977, at The Children's Orthopedic Hospital and Medical Center in Seattle, Washington. In this interval 370 patients under 2 years of age were catheterized. Eighty open procedures were performed in patients under 2 years of age, with seven hospital deaths. One hundred twenty-four closed heart procedures were performed on children under the age of 2 years, with eight deaths, for a hospital mortality rate of 6.5 percent. This review of consecutive cases over a 4 year period suggests that the judicious application of palliation or open repair using current techniques can lead to an overall mortality rate of between 6 and 7 percent for both open and closed heart procedures in children under 2 years of age. Since all deaths except one in the open-heart group occurred in patients with the most complex multiple defects, it seems reasonable to suggest that improved intraoperative and postoperative techniques have lowered the time for repair of straightforward congenital heart defects to under 2 years of age.

Radical enlargement of the aortic root and outflow tract to allow valve replacement.

A method of radical enlargement of the aortic root and outflow tract is described. The technique consists of incising the aortic annulus, the anterior mitral leaflet, and the superior aspect of the left atrium. Valve replacement is then possible, with patch reconstruction of the resulting defects.