Early identification of divergent performance in congenital cardiac surgery.

OBJECTIVES: Heterogeneous caseload and poorly quantified risk stratification make it difficult to monitor outcomes in congenital cardiac surgery. Reliance on formal statistical hypothesis testing may lead to substantial delays before a pattern of poor outcome can be established. Here, we report alternative methods for alerting surgeons to potential problems at an earlier stage. METHODS: Graphical methods developed for monitoring adult cardiac surgery have been adapted for use in congenital cardiac surgery. To illustrate their potential, we have retrospectively examined mortality data for a single surgeon involving 315 cases. Partial risk adjustment has been carried out according to patient's age and the open/closed categorization of the surgical procedure. Additional information has been derived by ranking procedures in order of their complexity and displaying the proportion of the surgeon's cases in each complexity stratum. RESULTS: The display of a surgeon's mortality data adjusted for age and open/closed category provides an easily understood chart of performance and allows one to identify periods when performance appears divergent, relative to the surgeon's own overall standards. Cases carried out during such periods can then be scrutinized by alternative methods. One such method is to examine caseload complexity during the periods of apparent divergent performance compared with other periods. CONCLUSIONS: These methods, while in no way representing formal statistical tests, provide a means that can alert surgeons to potential problems and help to identify sequences of cases that might benefit from further scrutiny.

Assessment of mortality rates for congenital heart defects and surgeons' performance.

BACKGROUND: In the absence of reliable national data, we have collected results of all operations for congenital heart defects from five departments to assess mortality rates and compare them among surgeons and departments. METHODS: Data relating to all operations (2,718) carried out at the five centers during a period from April 1, 1997 through March 31, 1999. Clearly defined criteria were agreed for the classification of patients into various subgroups. RESULTS: The overall hospital mortality was 4.4% (95% confidence intervals 3.7%-5.3%). Mortality for open-operations was 12.6% in neonates, 5.1% in infants, and 3.5% in children. Mortality rates were 1.1% for coarctation, 0.4% ventricular septal defect, 4.1% atrioventricular septal defect, 2.9% Fallot, 0.9% switch, and 15.6% truncus arteriosus. Although individual surgeons' mortality rates ranged from 1.8% to 7.5%, none of the 12 surgeons' data were above 95% confidence intervals. For individual surgeons, the change in mortality rates between the 2 years ranged between -3.3% and +3.8%. CONCLUSIONS: With 2 years' data available, estimates of mortality rates are more precise as reflected by tighter confidence intervals. There were relatively small data sets for individual hospitals and surgeons, which made statistical evaluation difficult. For setting standards, data from more departments for a longer period will be required. Statistical methods alone cannot be used as a sole arbiter of what is considered acceptable performance.

Databases for congenital heart disease: A beginner's guide.

We discuss the reasons for collecting data on operations for congenital heart defects. Computerized databases facilitate the collection, storage, and retrieval of such data. We outline the basic criteria for selecting a suitable database to cater to the particular needs of a surgeon or a department and stress the importance of the accuracy of the data held in a database. We explain the relative advantage of simple versus complex database systems. We conclude with a summary of the steps required for a practicing congenital heart surgeon to set up and operate a simple database. Copyright 2000 by W.B. Saunders Company

Repair of atrial septal defect through a right thoracotomy.

Fifty-four patients underwent repair of atrial septal defects through a right thoracotomy between January 1985 and December 1991. The average patient was 5.7 years old. Defects repaired included 51 secundum, 2 sinus venosus, and 1 ostium primum defect. The average bypass time was 24 minutes. There was no operative or late mortality, and no morbidity directly related to the thoracotomy approach. The right thoracotomy incision is a safe and effective alternative to a median sternotomy for repair of atrial septal defects. The cosmetic result is superior to that of median sternotomy or bilateral submammary incision.

Surgical repair of aorto-right ventricular tunnel in an infant.

A rare case of aorta to right ventricle tunnel with associated pulmonary stenosis was corrected on cardiopulmonary bypass in a 3-month-old infant. Both the aortic and ventricular openings were closed with a patch. Although the repair was successful and the child was discharged from the hospital, septicemia developed and she died later. Early repair of this defect is recommended.