Skip to main content Accessibility help

Higher programmatic volume in paediatric heart surgery is associated with better early outcomes

  • Andrzej Kansy (a1), Tjark Ebels (a2), Christian Schreiber (a3), Jeffrey P. Jacobs (a4) (a5), Zdzislaw Tobota (a1) and Bohdan Maruszewski (a1)...



Previous analyses have suggested an association between centre volume and in-hospital mortality, post-operative complications, and mortality in those patients who suffer from a complication. We sought to determine the nature of this association using a multicentre cohort.


All the patients, aged 18 years or younger, undergoing heart surgery at centres participating in the European Congenital Heart Surgeons Database (2003–2013) were included. Programmes were grouped as follows: small <150; medium 150–250; large 251–349; very large >350. Multivariable logistic regression was used to identify the differences between groups with the adjusted in-hospital mortality, onset of any and/or major complication, and in-hospital mortality in those patients with any and/or major complication. The outcomes were adjusted for patient specific risk factors and surgical risk factors.


The data set consisted of 119,345 procedures performed in 99 centres. Overall, in-hospital mortality was 4.63%; complications occurred in 23.4% of the patients. In-hospital mortality in patients with complications was 13.82%. Multivariable logistic regression showed that the risk of in-hospital death was higher in low- and medium-volume centres (p<0.001). The rate of the occurrence of any post-operative complication in small, medium, and large programmes was lower compared with very large centres (p<0.001). Low- and medium-volume centres were associated with significantly higher mortality in patients with any complication (p<0.001).


Our analysis showed that the risk of in-hospital mortality was lower in higher-volume centres. Although the risk of complications is higher in high-volume centres, the mortality associated with complications that occurred in these centres was lower.


Corresponding author

Correspondence to: A. Kansy, The Children’s Memorial Health Institute, Department for Pediatric Cardiothoracic Surgery, Al. Dzieci Polskich 20, 04-830 Warsaw, Poland. Tel: +48228157346; Fax: +48228157340; E-mail:


Hide All
1.Reames, BN, Ghaferi, AA, Birkmeyer, JD, Dimick, JB. Hospital volume and operative mortality in the modern era. Ann Surg 2014; 260: 244251.
2.Jenkins, KJ, Newburger, JW, Locke, JE, Davis, RB, Coffman, GA, Iezzoni, LI. In-hospital mortality for surgical repair of congenital heart defects: preliminary observations of variation by hospital caseload. Pediatrics 1995; 95: 323330.
3.Hannan, EL, Racz, M, Kavey, RE, Quaegebeur, JM, Williams, R. Pediatric cardiac surgery: the effect of hospital and surgeon volume on in-hospital mortality. Pediatrics 1998; 101: 963969.
4.Sollano, JA, Gelijns, AC, Moskowitz, AJ, et al. Volume-outcome relationships in cardiovascular operations: New York State, 1990-1995. J Thorac Cardiovasc Surg 1999; 117: 419428; discussion 428–430.
5.Welke, KF, Diggs, BS, Karamlou, T, Ungerleider, RM. The relationship between hospital surgical case volumes and mortality rates in pediatric cardiac surgery: a national sample, 1988–2005. Ann Thorac Surg 2008; 86: 889896; discussion 889–896.
6.Welke, KF, O’Brien, SM, Peterson, ED, Ungerleider, RM, Jacobs, ML, Jacobs, JP. The complex relationship between pediatric cardiac surgical case volumes and mortality rates in a national clinical database. J Thorac Cardiovasc Surg 2009; 137: 11331140.
7.Checchia, PA, McCollegan, J, Daher, N, Kolovos, N, Levy, F, Markovitz, B. The effect of surgical case volume on outcome after the Norwood procedure. J Thorac Cardiovasc Surg 2005; 129: 754759.
8.Hirsch, JC, Gurney, JG, Donohue, JE, Gebremariam, A, Bove, EL, Ohye, RG. Hospital mortality for Norwood and arterial switch operations as a function of institutional volume. Pediatr Cardiol 2008; 29: 713717.
9.Pasquali, SK, Jacobs, JP, He, X, et al. The complex relationship between center volume and outcome in patients undergoing the Norwood operation. Ann Thorac Surg 2012; 93: 15561562.
10.Hornik, CP, He, X, Jacobs, JP, et al. Relative impact of surgeon and center volume on early mortality after the Norwood operation. Ann Thorac Surg 2012; 93: 19921997.
11.Karamlou, T, Jacobs, ML, Pasquali, S, et al. Surgeon and center volume influence on outcomes after arterial switch operation: analysis of the STS Congenital Heart Surgery Database. Ann Thorac Surg 2014; 98: 904911.
12.Pasquali, SK, Li, JS, Burstein, DS, et al. Association of center volume with mortality and complications in pediatric heart surgery. Pediatrics 2012; 129: e370e376.
13.Silber, JH, Williams, SV, Krakauer, H, Schwartz, JS. Hospital and patient characteristics associated with death after surgery. A study of adverse occurrence and failure to rescue. Med Care 1992; 30: 615629.
14.Kansy, A, Ebels, T, Schreiber, C, Tobota, Z, Maruszewski, B. Association of center volume with outcomes. Analysis of verified data of EACTS Congenital Database. Ann Thorac Surg 2014; 98: 21592164.
15.European Congenital Heart Surgeons Database. Retrieved May, 2015, from
16.STS Congenital Heart Surgery Database. Retrieved December 29, 2014, from
17.O’Brien, SM, Clarke, DR, Jacobs, JP, et al. An empirically based tool for analyzing mortality associated with congenital heart surgery. J Thorac Cardiovasc Surg 2009; 138: 11391153.
18.Jacobs, ML, O’Brien, SM, Jacobs, JP, et al. An empirically based tool for analyzing morbidity associated with operations for congenital heart disease. J Thorac Cardiovasc Surg 2013; 145: 10461057.



Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed