Heart surgery

Congenital heart surgery in adults: opt for pediatric specialists?

Hospitals specializing in adult cardiac surgery were not necessarily the ones providing the best care for adults with congenital heart disease (CC), according to national data.

Since most adults needing coronary artery surgery went to high-volume hospitals for coronary artery bypass grafting (CABG) or valve surgery in adults, pediatric congenital heart centers performed less than 12% of over 50,000 such operations recorded in the National Readmissions Database (NRD). ) from 2010 to 2017.

While mortality rates were similar between the two facility types (2.17% versus 2.67%, respectively; adjusted OR 1.06, 95% CI 0.80-1.40), pediatric centers were associated with superior clinical outcomes after coronary artery surgery in adults according to other parameters:

  • Fewer perioperative complications (adjusted OR 0.85, 95% CI 0.73-0.99)
  • Less leave away from home (adjusted OR 0.67, 95% CI 0.51-0.87)
  • Reduction in emergent readmissions at 90 days (adjusted OR 0.69, 95% CI 0.55-0.85)

The finding of shorter hospital stays and similar adjusted costs also suggests better surgical and perioperative management — “value-based care” — in pediatric CHD centers, said medical student Catherine Williamson, BS , from the University of California, Los Angeles, at the Virtual Meeting of the Society of Thoracic Surgeons.

These are notable findings at a time when more and more children with coronary artery disease are surviving into adulthood; the number of adults with coronary artery disease, a group with unique anatomical complexities, has doubled over the past decade, Williamson noted.

“Which hospital is the best for the care of these patients? I would say the nature of patients diagnosed with adult coronary heart disease, the procedures and the associated risks vary widely. We find processes with multiple specialists working together to sharing their expertise and making care truly an ideal approach,” said session commentator Stephanie Fuller, MD, of Children’s Hospital of Philadelphia.

Williamson suggested that centralizing care at specialist pediatric centers could improve outcomes for adults with coronary artery disease. However, there are concerns that this could undermine access to high-quality care for marginalized groups, namely the underinsured and those on low incomes, she acknowledged.

The retrospective cohort study analyzed adult coronary heart surgeries at high-volume centers participating in the NRD, including 45,652 procedures at high-volume adult heart surgery sites (top tertile hospitals in CAP or surgical in adults) and 6,074 in high-volume pediatric centers. sites (upper tertile in congenital operations in children).

The average patient age was 56.7 years in the adult centers and 48.7 years in the pediatric centers; 48.1% and 50.5% were women.

Pediatric CHD centers performed slightly higher risk procedures (RACHS-1 score 1.13 vs 1.53, P

Factors associated with treatment in a pediatric center were a higher RACHS-1 score, household income in the highest quartile, and private insurance.

Williamson cautioned that the NRD lacked key granular clinical and anatomical information and did not allow his group to adapt to the surgeon’s individual experience. Additionally, these administrative databases may be influenced by local billing practices.

There was also room for bias, since patients had to survive to discharge to be included in the database. Bicuspid aortic valve surgeries were not included in this analysis, Fuller observed.

  • Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. To follow

Disclosures

Williamson did not disclose anything.

Fuller said he consulted with WL Gore.