Could we still improve early and interim outcome after prosthetic systemic-pulmonary shunt? A risk factors analysis

Mohammadi, Siamak; Benhameid, Osama; Campbell, Andrew; Potts, Jim; Joza, Jacqueline; Al-Habib, Hamad; Sett, Suvro; Le Blanc, Jacques
September 2008
European Journal of Cardio-Thoracic Surgery;Sep2008, Vol. 34 Issue 3, p545
Academic Journal
Abstract: 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 3.4kg, 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 30h, p <0.0001) despite the similar median age, weight, mean indexed shunt size (1.19 vs 1.15mm/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.


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