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Joint programmes are an alternative model that may aid in improving congenital cardiac surgery outcomes while avoiding the potential resource and accessibility challenges that could result from regionalisation. This study aims to characterise current joint programmes, identify factors that are associated with joint programme success and failure, and gauge attitudes within the profession regarding joint programmes as an alternative.
A multiple choice survey with 23 standard questions for all programmes and additional 42 additional questions for each participant hospital in a joint programme was addressed to paediatric cardiac surgeons in the United States of America. Questions were designed to qualitatively and quantitatively characterise congenital cardiac surgery joint programmes.
Of the 34 unique congenital cardiac surgery programmes identified in this survey, 14 have participated in a joint programme and 50% of those joint programmes existed for more than 10 years. Most joint programmes (86%) participate or participated in a model where the hospital participants are engaged in a “mother–daughter” relationship in both perception and case volume distribution. In three out of four defunct joint programmes, there were case complexity limitations placed on partner institutions, but the now independent partner institutions operate with no limitation on complexity. Most (71%) hospital participants in a joint programme felt that the joint programme produced better outcomes than two separate programmes; however, among those who participate or have participated in a joint programme, only 18% felt that joint programmes were the optimal model for delivery of congenital cardiac surgical care.
Computational fluid dynamics has been applied to the design, refinement, and assessment of surgical procedures and medical devices. This tool calculates flow patterns and pressure changes within a virtual model of the cardiovascular system. In the field of paediatric cardiac surgery, computational fluid dynamics is being used to elucidate the optimal approach to staged reconstruction of specific defects and study the haemodynamics of the resulting anatomical configurations after reconstructive or palliative surgery. In this paper, we review the techniques and principal findings of computational fluid dynamics studies as applied to a few representative forms of congenital heart disease.
Joint programmes, as opposed to regionalisation of paediatric cardiac care, may improve outcomes while preserving accessibility. We determined the prevalence and nature of joint programmes.
We sent an online survey to 125 paediatric cardiac surgeons in the United States in November, 2009 querying the past or present existence of a joint programme, its mission, structure, function, and perceived success.
A total of 65 surgeon responses from 65 institutions met the criteria for inclusion. Of the 65 institutions, 22 currently or previously conducted a joint programme. Compared with primary institutions, partner institutions were less often children's hospitals (p = 0.0004), had fewer paediatric beds (p = 0.005), and performed fewer cardiac cases (p = 0.03). Approximately 47% of partner hospitals performed fewer than 50 cases per year. The median distance range between hospitals was 41–60 miles, ranging from 5 to 1000 miles. Approximately 54% of partner hospitals had no surgeon working primarily on-site, and 31% of the programmes conducted joint conferences. Approximately 67% of the programmes limited the complexity of cases at the partner hospital, and 83% of the programmes had formal contracts between hospitals. Of the six programmes whose main mission was to increase referrals to the primary hospital, three were felt to have failed. Of the nine programmes whose mission was to increase regional quality, eight were felt to be successful.
Joint programmes in paediatric cardiac surgery are common but are heterogeneous in structure and function. Programmes whose mission is to improve the quality of regional care seem more likely to succeed. Joint programmes may be a practical alternative to regionalisation to achieve better outcomes.
Background: We describe the recent results in a large cohort of patients with functionally single ventricle who underwent various modifications of cavopulmonary connections. Methods: Using the database at our institution, we identified all children who underwent cavopulmonary connection operations between June 1995 and June 1997. Demographic data, surgical history, and perioperative course were reviewed. Results: We performed 130 consecutive operations in 113 patients. The procedures included superior cavopulmonary connections in the form of the HemiFontan procedure in 45 instances, and bidirectional Glenn procedures in 11, and bilateral superior cavopulmonary connections in 7. The median age of these patients was 7.0 months. We completed Fontan operations using a fenestrated lateral tunnel on 47 occasions, and using an extracardiac conduit 9 times, 5 of which were fenestrated. A lateral tunnel without fenestration was constructed inone patient. The median age for these procedures was 19.5 months. In the remaining 10 instances, we revised Fontan procedures at a median age of 8 years. Diagnoses included hypoplastic left heart syndrome in 43 patients, double outlet right ventricle in 22, heterotaxy in 13, tricuspid atresia in 13, and a miscellaneous group accounting for the other 22. One death (0.7%) occurred within 30 days of surgery. Clinical seizures occurred in 7 children (5.3%), 6 had no residual neurologic deficits. Atrial pacing was needed in 14 children (10.7%) because of transient junctional rhythm, and 2 received treatment for supraventricular tachycardia. Pleural effusions were diagnosed radiographically after 31 of 130 (24%) procedures. Diuretic therapy resolved the effusion in 21 of these, with only 6 children requiring thoracostomy catheter drainage, and 4 undergoing thoracentesis alone. The median length of stay on the intensive care unit was 2 days, with a range from 1 to 30 days, and median stay in hospital was 6 days, with a range from 3 to 58 days. Conclusion: Mortality and perioperative morbidity after cavopulmonary connections have decreased dramatically in the current era. The long-term results of staged reconstruction for functionally single ventricle, nonetheless, await ongoing study.
Tetralogy of Fallot with pulmonary atresia and diminutive or absent intrapericardial pulmonary arteries is a rare congenital abnormality, with high morbidity and mortality. Despite great advances in surgical- and catheter-based therapies, management remains challenging and controversial. We describe the surgical methods and the results from our institution.
We performed a retrospective study of the medical records of patients included in our institutional database with tetralogy and pulmonary atresia, concentrating on those predominantly managed by our programme over their lifetime. We obtained demographics and records of all catheterisations and operations, and established mortality. We assessed the current state of those surviving in terms of clinical function at their most recent clinical evaluation and right ventricular function by echocardiography.
We assessed 38 patients, with 89% follow-up. The mean number of catheterisations for each patients was 5, with a range from 1 to 15. The mean number of operations was 2.2, with a range from 1 to 6. Unifocalisation had been performed in 26 patients, with 12 undergoing procedures to recruit the native pulmonary vasculature. Of the overall cohort, eight patients died. The ventricular septal defect had been closed in all but two patients. Most patients have no or mild exercise intolerance. Right ventricle dysfunction has been a continuing hazard for 15 years.
An individualised approach, using unifocalisation as well as aggressive attempts to recruit the available native pulmonary vasculature, achieves outcomes in the intermediate term superior to the natural history of the lesions, and comparable with those of other studies.
Congenital unilateral pulmonary venous atresia is a rare anatomical defect. Patients present with pulmonary symptoms, and diagnosis may be ellusive. Pulmonary arterial wedge angiography is the gold standard with which to achieve diagnosis, and surgical intervention is often required for symptomatic patients.
Florida is the fourth largest state in the United States of America. In 2004, 218,045 live babies were born in Florida, accounting for approximately 1744 new cases of congenital heart disease. We review the initial experience of The Society of Thoracic Surgeons Congenital Heart Surgery Database with a regional outcomes report, namely the Society of Thoracic Surgeons Florida Regional Report.
Eight centres in Florida provide services for congenital cardiac surgery. The Children’s Medical Services of Florida provide a framework for quality improvement collaboration between centres. All congenital cardiac surgical centres in Florida have voluntarily agreed to submit data to the Society of Thoracic Surgeons Database. The Society of Thoracic Surgeons and Duke Clinical Research Institute prepared a Florida Regional Report to allow detailed regional analysis of outcomes for congenital cardiac surgery.
The report of 2007 from the Society of Thoracic Surgeons Congenital Heart Surgery Database includes details of 61,014 operations performed during the 4 year data harvest window, which extended from 2003 through 2006. Of these operations, 6,385 (10.5%) were performed in Florida. Discharge mortality in the data from Florida overall, and from each Florida site, with 95% confidence intervals, is not different from cumulative data from the entire Society of Thoracic Surgeons Database, both for all patients and for patients stratified by complexity.
A regional consortium of congenital heart surgery centres in Florida under the framework of the Children’s Medical Services has allowed for inter-institutional collaboration with the goal of quality improvement. This experience demonstrates, first, that the database maintained by the Society of Thoracic Surgeons can provide the framework for regional analysis of outcomes, and second, that voluntary regional collaborative efforts permit the pooling of data for such analysis.
As the overall mortality declines following repair of complex congenital cardiac malformations, attention has focused on reducing the lasting morbidity of these interventions, particularly the observed neurodevelopmental deficiencies. Both cardiopulmonary bypass and deep hypothermic circulatory arrest produce transient alterations in cerebral hemodynamics and metabolism. In studies performed in animals, deep hypothermic circulatory arrest, as compared to cardiopulmonary bypass alone, has been shown to produce excess injury to, and death of, neuronal and glial cells.1 In neonates, deep hypothermic circulatory arrest of greater duration than one hour is a risk factor for early post-operative seizures, and for subsequent neurodevelopmental deficits.2 The Boston Circulatory Arrest Study suggests that, at follow-up of eight years, infants subjected to greater than 41 minutes of deep hypothermic circulatory arrest had excess deficits in full-scale, verbal and performance intelligence quotient, the Mayo apraxia test, and grooved pegboard testing.3 The independent adverse effects of deep hypothermic circulatory arrest have encouraged clinicians to develop the alternative technique of intermittent global perfusion, or continuous regional perfusion at low flow perfusion, in an attempt to reduce the degree of injury to the central nervous system.4–7
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