Could we still improve early and interim outcome after prosthetic systemic-pulmonary shunt? A risk factors analysis.
OBJECTIVE
To identify factors associated with in-hospital and interim mortality in children with a systemic-to-pulmonary shunt (SPS).


METHODS
Between January 1988 and April 2005, 226 children with a median age of 17 days, and weight of 3.4 kg, underwent an isolated SPS for pulmonary atresia (PA)-VSD/ tetralogy (n=124, 54.9%), functional single ventricle PA (n=35, 5.5%), PA-intact septum (IS, n=31, 13.7%), transposition of the great arteries VSD-PA (n=30, 13.3%), and double outlet right ventricle-PA (n=6, 2.6%). Surgery was performed through sternotomy (group S, n=46) or thoracotomy (group T, n=180). The origin of the SPS was either the innominate artery (n=38) or ascending aorta (n=8) in group S, and the subclavian artery (n=180) in group T.


RESULTS
In-hospital mortality was 5.7%. Univariate and logistic regression analysis revealed younger age (p=0.01), lower body weight (p<0.04), a diagnosis of PA-IS with severe right ventricle hypoplasia (p=0.005), preoperative intubation (p=0.03), increased length of intubation (p<0.0001), longer ICU stay (p<0.0001), and group S (p=0.03) as risk factors for in-hospital death. Group S had a longer median ventilation time (112 vs 30 h, p<0.0001) despite the similar median age, weight, mean indexed shunt size (1.19 vs 1.15 mm/kg, p=0.2), and the number of patients with antegrade pulmonary flow. Interim mortality was 7% (n=15), and younger age (p=0.03), and group T (p=0.03) were independent risk factors for death prior to second-stage surgery. Absence of antiplatelet agents or anticoagulants was not a risk factor for interim mortality.


CONCLUSIONS
In-hospital mortality and longer ventilation time after SPS by sternotomy may be related to pulmonary over circulation due to shunt insertion origin and/or size, and pathologic features. Early and interim outcomes can be improved by using a smaller shunt or changing the SPS insertion origin when using a sternotomy approach.
Mohammadi
Siamak
S
Department of Pediatric Cardiac Surgery, British Columbia Children's Hospital, Vancouver, BC, Canada. siamakmohammadi@yahoo.com
Benhameid
Osama
O
Campbell
Andrew
A
Potts
Jim
J
Joza
Jacqueline
J
Al-Habib
Hamad
H
Sett
Suvro
S
Le Blanc
Jacques
J
D000293:Adolescent; D000367:Age Factors; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000379:methods; D001835:Body Weight; D002648:Child; D002675:Child, Preschool; D004812:Epidemiologic Methods; D006330:Heart Defects, Congenital / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D011651:Pulmonary Artery / Q000601:surgery; D018633:Pulmonary Atresia / Q000503:physiopathology / Q000601:surgery*; D011652:Pulmonary Circulation; D012086:Reoperation; D013249:Sternum / Q000601:surgery; D013908:Thoracotomy / Q000009:adverse effects; D016896:Treatment Outcome