Composite risk factors predict survival after transplantation for congenital heart disease.

OBJECTIVE(S): Previous studies have shown that individual risk factors are poor predictors of mortality after heart transplantation in patients with congenital heart disease. We developed composite risk factor groups to better predict mortality after cardiac transplantation. METHODS: We conducted a cross-sectional retrospective analysis of all heart transplants performed for congenital heart disease at a single congenital heart transplant center between 1996 and 2011. Patient, procedural, and hospital course data were obtained through a review of medical records. Univariate analyses were performed using the Fisher exact test for categorical data and the Mann-Whitney U test for continuous variables. Overall mortality was examined using Kaplan-Meier estimates for univariate analysis and Cox regression analysis for multivariate analysis. A comparison of patients with functional single ventricles (SVs) versus biventricular (BV) hearts was performed. Mean follow-up duration for the whole group was 51 ± 43 months (median, 43 months). RESULTS: Forty-six patients underwent heart transplantation during the study period. Mean age at transplant was 9.0 ± 9.1 years; 45% (n = 21) were in the SV group and 55% (n = 25) were in the BV group. The SV group had significantly more previous sternotomies (P = .006) and longer bypass times (266 ± 78 vs 207 ± 64 minutes; P = .001). High panel-reactive antibody levels (>10%) were also more common in the SV group (38% vs 13%; P = .08). Overall hospital mortality was 4.3% (n = 2, both SVs). There was no significant difference in operative mortality (10% SV vs 0% BV; P = .20) or major morbidity (33% SV vs 44% BV; P = .51) between the 2 groups. High-risk groups identified by univariate analysis were patients with an SV diagnosis + dialysis (P < .0005), SV + mechanical assist device (VAD)/extracorporeal membrane oxygenation (ECMO) (P = .026), or VAD/ECMO + renal insufficiency (P = .006)/VAD/ECMO + dialysis (P < .0005), and SV + reoperation (P = .016). By multivariate analysis, preoperative renal insufficiency (P = .038) and the composite SV + dialysis (P = .005) were predictors of overall mortality. Although survival at 2 years was lower in the SV cohort (73% vs 96%; P = .16), this benefit was not apparent (63% vs 69%) at late follow-up. CONCLUSIONS: Preoperative renal insufficiency and SV + dialysis are strong predictors of overall mortality and identify high-risk congenital heart transplant recipients. Although individual risk factors may not predict survival, a composite of factors may be more useful in identifying the high-risk recipient.

Laryngopharyngeal dysfunction after the Norwood procedure.

OBJECTIVE: We sought to evaluate the incidence and significance of recurrent laryngeal nerve and swallowing dysfunction after a Norwood procedure compared with that after biventricular aortic arch reconstruction. METHODS: From April 2003 through December 2004, 36 neonates underwent a Norwood procedure; 33 of 36 had postoperative fiberoptic laryngoscopy and modified barium swallow. Study results were used to guide the transition from nasogastric tube to oral feeding and placement of gastrostomy tubes. During the same time period, 18 neonates underwent aortic arch reconstruction as part of a biventricular repair. RESULTS: After a Norwood procedure, laryngoscopy showed left true vocal fold (cord) paralysis in 3 (9%) of 33 patients. The results of a modified barium swallow were abnormal in 16 (48%) of 33 patients, with aspiration in 8 (24%) of 33 patients. Of the 3 patients with vocal fold paralysis, 2 had a normal modified barium swallow result, and 1 had aspiration. Gastrostomy tubes were placed in 6 (18%) of 33 patients, all with an abnormal modified barium swallow result. Hospital stay was longer in patients with an abnormal modified barium swallow result: 34 +/- 13 versus 22 +/- 7 days (P < .01). After biventricular repair with aortic arch reconstruction, left true vocal fold paralysis occurred in 4 (25%) of 16 patients; results of a modified barium swallow were abnormal in 10 (59%) of 17 patients, with aspiration in 6 (35%) of 17 patients (all nonsignificant vs patients undergoing the Norwood procedure). Follow-up laryngoscopy in 4 patients with vocal fold paralysis showed no change in 3 of 4 patients and improvement in 1 patient. Follow-up modified barium swallow showed resolution of aspiration in 11 (85%) of 13 patients. Hospital survival was 32 (89%) of 36 patients for the Norwood procedure and 18 (100%) of 18 patients for biventricular repair. There has been 1 sudden death before second-stage palliation. CONCLUSIONS: After a Norwood procedure, swallowing dysfunction occurs in 48% of patients, with aspiration in 24%, and results in increased length of hospital stay. Left recurrent laryngeal nerve injury, seen in 9% of patients, is an uncommon cause of swallowing dysfunction. Postoperative aspiration generally resolves over time, whereas vocal fold paralysis does not. Systematic evaluation of swallowing function allows appropriate tailoring of feeding regimens and might contribute to decreased hospital and interstage mortality.

Lateral tunnel versus extracardiac conduit Fontan procedure: a concurrent comparison.

BACKGROUND: The aim of this study was to compare the outcomes of the lateral tunnel (LT) and extracardiac conduit (ECC) Fontan procedures at a single institution over the same time period. METHODS: From November 1995 through October 2002, 70 Fontan procedures were performed: 37 LT and 33 ECC. All were fenestrated; 96% were staged with a prior superior cavopulmonary connection. Compared with the ECC patients, the LT patients were younger (2.7 +/- 1.1 vs 3.9 +/- 2.5 years; p = 0.01), had a higher incidence of hypoplastic left heart syndrome (57% vs 21%; p < 0.01), and a longer aortic cross-clamp time (55 +/- 13 vs 26 +/- 15 min; p < 0.01). Weight, gender, preoperative cardiac catheterization values, and cardiopulmonary bypass time did not differ between the two groups. RESULTS: Operative mortality was 2.8%, 1 patient in each group (p = 1.0). Over the first 24 hours following operation the mean Fontan pressure, transpulmonary gradient, and common atrial pressure did not differ between LT and ECC patients. The median duration of mechanical ventilation (LT 12 vs ECC 18 hours), intensive care unit stay (LT 2 vs ECC 3 days), chest tube drainage (LT 10 vs ECC 8 days), and hospital stay (LT 11 vs ECC 12 days) did not differ. The ECC patients had a higher incidence of sinus node dysfunction both in the postoperative period (27% vs LT 8%; p = 0.09), and persisting at hospital discharge (10% vs LT 0%; p = 0.02). Mean follow-up was 3.6 +/- 1.6 years in LT, and 3.0 +/- 2.2 years in ECC patients (p = 0.2). There was one late death. Actuarial survival at 5 years is 97% for LT, and 91% for ECC patients (p = 0.4); 96% of patients are in NYHA class I, and 4% in class II, with no difference between groups. Sinus node dysfunction was seen during follow-up in 15% LT vs 28% ECC patients (p = 0.2). CONCLUSIONS: The LT and ECC approaches had comparable early and mid-term outcomes, including operative morbidity and mortality, postoperative hemodynamics, resource use, and mid-term survival and functional status. ECC patients had a higher incidence of sinus node dysfunction early after operation.