Characteristics and operative outcomes for children undergoing repair of truncus arteriosus: A contemporary multicenter analysis

Abstract

Objective: We sought to describe characteristics and operative outcomes of children who underwent repair of truncus arteriosus and identify risk factors for the occurrence of major adverse cardiac events (MACE) in the immediate postoperative period in a contemporary multicenter cohort.Methods: We conducted a retrospective review of children who underwent repair of truncus arteriosus between 2009 and 2016 at 15 centers within the United States. Patients with associated interrupted or obstructed aortic arch were excluded. MACE was defined as the need for postoperative extracorporeal membrane oxygenation, cardiopulmonary resuscitation, or operative mortality. Risk factors for MACE were identified using multivariable logistic regression analysis and reported as odds ratios (ORs) with 95% confidence intervals (CIs).Results: We reviewed 216 patients. MACE occurred in 44 patients (20%) and did not vary significantly over time. Twenty-two patients (10%) received postoperative extracorporeal membrane oxygenation, 26 (12%) received cardiopulmonary resuscitation, and 15 (7%) suffered operative mortality. With multivariable logistic regression analysis (which included adjustment for center effect), factors independently associated with MACE were failure to diagnose truncus arteriosus before discharge from the nursery (OR, 3.1; 95% CI, 1.3-7.4), cardiopulmonary bypass duration>150 minutes (OR, 3.5; 95% CI, 1.5-8.5), and right ventricle-topulmonary artery conduit diameter >50 mm/m 2 (OR, 4.7; 95% CI, 2.0-11.1).

Commentary: Assessing risk factors after truncus arteriosus repair—The devil is in the details

“…They examined a fairly comprehensive list of demographic, anatomic, surgical, and clinical variables for potential association with MACE and identified the following 3 significant factors that predicted poor outcome: failure to diagnose truncus arteriosus before discharge from the nursery, cardiopulmonary bypass (CPB) duration longer than 150 minutes, and a right ventricle-to-pulmonary artery (RVPA) conduit diameter ratio greater than 50 mm/m 2 . 1 Mastropietro and colleagues 1 concluded that those factors were potentially modifiable and that tackling them could subsequently lead to improved repair outcomes in this challenging population.…”

“…[4][5][6][7] Interestingly, those traditional variables were not found to be significant in this current study by Mastropietro and colleagues. 1 The identification of any modifiable risk factor should naturally stimulate a change in the treatment approach that would alleviate that risk factor and consequently improve outcomes. The devil is usually in the details, however, and the answer of how to use new findings to alter the management strategy for the best is usually not as clear and instead is hidden in little specifics that are commonly not available to the readers.…”

Commentary: Timing (and size) is everything?

“…6 Perhaps this belief should be reexamined for patients with specific anatomic substrates. Mastropietro and colleagues 4 were purposefully nondescriptive regarding the potential technical and physiologic reasons for this association, but its deviation from previous data is worthy of recognition.…”

Commentary: Clear as mud: Truncus arteriosus and major adverse cardiac events

“…Moreover, given that failure to diagnose before discharge was a risk factor for MACE (but not for mortality), it is likely that neonates without prenatal diagnosis may represent a much larger population across the United States than suggested by the study of Mastropietro and colleagues. 1 The association of larger indexed conduit size with MACE, with an inflection point at 50 mm/m2, is mentioned many times throughout the paper. Indexing a conduit to body surface area, as opposed to indexing to patient weight or normalization with z scores, is uncommon in the neonatal population.…”

“…4 Mastropietro and colleagues. 1 should have explored natural cubic splines or other polynomial transformations that might have clarified the ''optimum physiologic window'' of conduit size. Indeed, this exact concept was harnessed in the initial Congenital Heart Surgeons' Society article that prospectively investigated determinants of conduit dysfunction in 241 infants younger than 2 years at initial conduit implantation.…”