Perioperative Outcomes of Major Noncardiac Surgery in Adults with Congenital Heart Disease
ABSTRACT An increasing number of patients with congenital heart disease are surviving to adulthood. Consensus guidelines and expert opinion suggest that noncardiac surgery is a high-risk event, but few data describe perioperative outcomes in this population.
By using the Nationwide Inpatient Sample database (years 2002 through 2009), the authors compared patients with adult congenital heart disease (ACHD) who underwent noncardiac surgery with a non-ACHD comparison cohort matched on age, sex, race, year, elective or urgent or emergency procedure, van Walraven comborbidity score, and primary procedure code. Mortality and morbidity were compared between the two cohorts.
A study cohort consisting of 10,004 ACHD patients was compared with a matched comparison cohort of 37,581 patients. Inpatient mortality was greater in the ACHD cohort (407 of 10,004 [4.1%] vs. 1,355 of 37,581 [3.6%]; unadjusted odds ratio, 1.13; P = 0.031; adjusted odds ratio, 1.29; P < 0.001). The composite endpoint of perioperative morbidity was also more commonly observed in the ACHD cohort (2,145 of 10.004 [21.4%] vs. 6,003 of 37,581 [16.0%]; odds ratio, 1.44; P < 0.001). ACHD patients comprised an increasing proportion of all noncardiac surgical admissions over the study period (P value for trend is <0.001), and noncardiac surgery represented an increasing proportion of all ACHD admissions (P value for trend is <0.001).
Compared with a matched control cohort, ACHD patients undergoing noncardiac surgery experienced increased perioperative morbidity and mortality. Within the limitations of a retrospective analysis of a large administrative dataset, this finding demonstrates that this is a vulnerable population and suggests that better efforts are needed to understand and improve the perioperative care they receive.
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ABSTRACT: To determine whether adult congenital heart disease patients (ACHD) undergoing catheter-based electrophysiology (EP) procedures have an increased risk for complications compared with adults without congenital heart disease.Journal of Cardiothoracic and Vascular Anesthesia 09/2014; 29(2). DOI:10.1053/j.jvca.2014.05.016 · 1.48 Impact Factor
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ABSTRACT: Objective Prior investigations have suggested that the rapidly growing population of adults with congenital heart disease is at increased risk of perioperative morbidity and mortality, but information is limited on the nature of those perioperative factors that may relate to adverse outcomes. We sought to use a national claims database to describe the contribution of perioperative factors to adverse outcomes and compare contributing factors in cardiac vs. noncardiac operations.DesignThe study is a retrospective in-depth structured analysis of cases from the Anesthesia Closed Claims Project database.SettingWe examined the largest national anesthesia malpractice claims database.PatientsWe included all claims cases involving adult patients with congenital heart disease (CHD).InterventionsPatients in this retrospective analysis were classified by type of surgery (cardiac or noncardiac).Outcome MeasuresPerioperative factors contributing to an adverse event were assessed by an expert panel of cardiac anesthesiologists.ResultsOf 21 confirmed cases, 11 (52%) involved cardiac procedures and 10 (48%) noncardiac procedures. The most common factors contributing to the adverse event in cardiac cases were surgical technique (73% of cases) and intraoperative anesthetic care (55%), whereas in noncardiac cases, postoperative monitoring/care (50%), CHD (50%) and preoperative assessment or optimization (40%) were most common. The factors contributing to the patient injury differed similarly: in cardiac cases, the most common factors were intraoperative anesthetic care (55%) and surgical technique (45%) compared with postoperative monitoring/care (50%) and CHD (50%) in noncardiac cases.Conclusions Within the limitations of a small number of events in a claims-based database, this study offers advantages of being a national, structured analysis of real cases to provide detailed information on phenomena that are otherwise abstract and hypothesized by expert opinion. These results should help affirm the role of anesthesiologists in acquiring and executing expertise as consultants in perioperative medicine for adults with congenital heart disease patients.Congenital Heart Disease 05/2014; 10(1). DOI:10.1111/chd.12188 · 1.20 Impact Factor
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ABSTRACT: Background: Guidelines recommend that adults with congenital heart disease (CHD) undergo noncardiac surgery in regionalized centers of expertise, but no studies have assessed whether this occurs in the United States. We hypothesized that adults with CHD are less likely than children to receive care at specialized CHD centers. Methods: Using a comprehensive state ambulatory surgical registry (California Ambulatory Surgery Database, 2005-2011), we calculated the proportion of adult and pediatric patients with CHD who had surgery at a CHD center, distance to the nearest CHD center, and distance to the facility where surgery was performed. Results: Patients with CHD accounted for a larger proportion of the pediatric population (n = 11,254, 1.0%) than the adult population (n = 10,547, 0.07%). Only 2,741 (26.0%) adults with CHD had surgery in a CHD center compared to 6,403 (56.9%) children (p<0.0001). Adult CHD patients who had surgery at a non-specialty center (11.9 +/- 15.4 miles away) lived farther from the nearest CHD center (37.9 +/- 43.0 miles) than adult CHD patients who had surgery at a CHD center (23.2 +/- 28.4 miles; p<0.0001). Pediatric CHD patients who had surgery at a non-specialty center (18.0 +/- 20.7 miles away) lived farther from the nearest CHD center (35.7 +/- 45.2 miles) than pediatric CHD patients who had surgery at a CHD center (22.4 +/- 26.0 miles; p<0.0001). Conclusions: Unlike children with CHD, most adults with CHD (74%) do not have outpatient surgery at a CHD center. For both adults and children with CHD, greater distance from a CHD center is associated with having surgery at a non-specialty center. These results have significant public health implications in that they suggest a failing to achieve adequate regional access to specialized ACHD care. Further studies will be required to evaluate potential strategies to more reliably direct this vulnerable population to centers of expertise.PLoS ONE 09/2014; 9(9):e106730. DOI:10.1371/journal.pone.0106730 · 3.53 Impact Factor