title: Alternative strategies in newborns and infants with major co-morbidities to improve congenital heart surgery outcomes at an emerging programme.
abstract: BACKGROUND
  Debilitating patient-related non-cardiac co-morbidity cumulatively increases risk for congenital heart surgery. At our emerging programme, flexible surgical strategies were used in high-risk neonates and infants generally considered in-operable, in an attempt to make them surgical candidates and achieve excellent outcomes.
  
  
  METHODS
  Between April, 2010 and November, 2013, all referred neonates (142) and infants (300) (average scores: RACHS 2.8 and STAT 3.0) underwent 442 primary cardiac operations: patients with bi-ventricular lesions underwent standard (n=294) or alternative (n=19) repair/staging strategies, such as pulmonary artery banding(s), ductal stenting, right outflow patching, etc. Patients with uni-ventricular hearts followed standard (n=96) or alternative hybrid (n=34) staging. The impact of major pre-operative risk factors (37%), standard or alternative surgical strategy, prematurity (50%), gestational age, low birth weight, genetic syndromes (23%), and major non-cardiac co-morbidity requiring same admission surgery (27%) was analysed on the need for extracorporeal membrane oxygenation, mortality, length of intubation, as well as ICU and hospital length of stays.
  
  
  RESULTS
  The need for extracorporeal membrane oxygenation (8%) and hospital survival (94%) varied significantly between surgical strategy groups (p=0.0083 and 0.028, respectively). In high-risk patients, alternative bi- and uni-ventricular strategies minimised mortality, but were associated with prolonged intubation and ICU stay. Major pre-operative risk factors and lower weight at surgery significantly correlated with prolonged intubation, hospital length of stay, and mortality.
  
  
  CONCLUSIONS
  In our emerging programme, flexible surgical strategies were offered to 53/442 high-risk neonates and infants with complex CHDs and significant non-cardiac co-morbidity, in order to buffer risk and achieve patient survival, although at the cost of increased resource utilisation.
authors.affiliation: 1Department of Pediatrics,University of Mississippi Medical Center,Jackson,Mississippi,United States of America.
authors.forename: Jannika
authors.initials: J
authors.lastname: Dodge-Khatami
authors.affiliation: 2Pediatric and Congenital Heart Surgery,The Children's Heart Center,University of Mississippi Medical Center,Jackson,Mississippi,United States of America.
authors.forename: Ali
authors.initials: A
authors.lastname: Dodge-Khatami
authors.affiliation: 3Pediatric and Fetal Cardiology,The Children's Heart Center,University of Mississippi Medical Center,Jackson,Mississippi,United States of America.
authors.forename: Jarrod D
authors.initials: JD
authors.lastname: Knudson
authors.affiliation: 4Center of Biostatistics and Bioinformatics,University of Mississippi Medical Center,Jackson,Mississippi,United States of America.
authors.forename: Samantha R
authors.initials: SR
authors.lastname: Seals
authors.affiliation: 3Pediatric and Fetal Cardiology,The Children's Heart Center,University of Mississippi Medical Center,Jackson,Mississippi,United States of America.
authors.forename: Avichal
authors.initials: A
authors.lastname: Aggarwal
authors.affiliation: 3Pediatric and Fetal Cardiology,The Children's Heart Center,University of Mississippi Medical Center,Jackson,Mississippi,United States of America.
authors.forename: Mary B
authors.initials: MB
authors.lastname: Taylor
authors.affiliation: 2Pediatric and Congenital Heart Surgery,The Children's Heart Center,University of Mississippi Medical Center,Jackson,Mississippi,United States of America.
authors.forename: Jorge D
authors.initials: JD
authors.lastname: Salazar
mesh_terms: D015897:Comorbidity; D005260:Female; D005865:Gestational Age; D006330:Heart Defects, Congenital / Q000601:surgery*; D017052:Hospital Mortality; D006801:Humans; D007223:Infant; D007230:Infant, Low Birth Weight; D007231:Infant, Newborn; D007234:Infant, Premature; D007362:Intensive Care Units; D007902:Length of Stay; D016014:Linear Models; D008297:Male; D008922:Mississippi; D012307:Risk Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects*
keywords: CHD; intensive care; neonates; outcomes