title: Surgical technical performance scores are predictors of late mortality and unplanned reinterventions in infants after cardiac surgery.
abstract: OBJECTIVE
  We have previously shown that surgical Technical Performance Scores (TPS) are important predictors of early postoperative morbidity across a wide spectrum of procedures and that intraoperative recognition and intervention of residual defects resulted in improved outcomes. We hypothesized that these scores would also be important predictors of midterm outcomes.
  
  
  METHODS
  Neonates and infants aged younger 6 months were prospectively followed from the index surgery for a minimum of 1 year. The TPS were calculated using previously published criteria, including intraoperative course, predischarge echocardiograms or catheterizations, and clinical data, and graded as optimal, adequate, or inadequate. Case complexity was determined by the Risk Adjustment for Congenital Heart Surgery-1 category. The primary outcome was mortality, and the secondary outcome was the need for unplanned reinterventions. Outcomes were analyzed using nonparametric methods and a logistic regression model.
  
  
  RESULTS
  A total of 166 patients were included in our study, with 7 early deaths. The remaining 159 patients (Risk Adjustment for Congenital Heart Surgery-1 category 4-6, 76 [48%]; neonates, 78 [49%]) were followed for a minimum of 1 year after surgery. There were 14 late deaths or late transplantations and 55 late reinterventions. On univariate analysis, the TPS were associated with mortality (P < .001) and reintervention (P = .04). On logistic regression analysis, inadequate TPS was associated with late mortality (P < .001; odds ratio, 7.2; 95% confidence interval, 2.2-23.6), and Risk Adjustment for Congenital Heart Surgery-1 category (P = .004; odds ratio, 3.7; 1.5-8.8) at index surgery was associated with need for late unplanned reintervention.
  
  
  CONCLUSIONS
  Technical performance affects midterm survival after infant heart surgery. Inadequate TPS can be used to prospectively identify patients at ongoing risk of demise and the need for reintervention. An aggressive approach to diagnosing and treating residual lesions at the initial operation is warranted.
authors.affiliation: Department of Cardiac Surgery, Children's Hospital Boston and Harvard Medical School, Boston, MA, USA. meena.nathan@cardio.chboston.org
authors.forename: Meena
authors.initials: M
authors.lastname: Nathan
authors.forename: John M
authors.initials: JM
authors.lastname: Karamichalis
authors.forename: Hua
authors.initials: H
authors.lastname: Liu
authors.forename: Sitaram
authors.initials: S
authors.lastname: Emani
authors.forename: Christopher
authors.initials: C
authors.lastname: Baird
authors.forename: Frank
authors.initials: F
authors.lastname: Pigula
authors.forename: Steven
authors.initials: S
authors.lastname: Colan
authors.forename: Ravi R
authors.initials: RR
authors.lastname: Thiagarajan
authors.forename: Emile A
authors.initials: EA
authors.lastname: Bacha
authors.forename: Pedro
authors.initials: P
authors.lastname: Del Nido
mesh_terms: D000367:Age Factors; D001900:Boston; D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000401:mortality*; D016009:Chi-Square Distribution; D002983:Clinical Competence; D005500:Follow-Up Studies; D006330:Heart Defects, Congenital / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D016027:Heart Transplantation / Q000401:mortality; D006439:Hemodynamics; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D016015:Logistic Models; D015999:Multivariate Analysis; D016017:Odds Ratio; D010043:Outcome and Process Assessment, Health Care; D018579:Patient Selection; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality* / Q000503:physiopathology / Q000601:surgery*; D011446:Prospective Studies; D019984:Quality Indicators, Health Care; D012086:Reoperation; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome