What Can the Database Tell Us About Reoperation?

AATS/STS Congenital Heart Disease Postgraduate Symposium May 5, 2013 What Can the Database Tell Us About Reoperation? Jeffrey P. Jacobs, M.D. All Children s Hospital Johns Hopkins Medicine The Congenital Heart Institute of Florida (CHIF) Saint Petersburg, Tampa, and Orlando, Florida, United States of America

Disclosure 1. Chair of the STS Congenital Heart Surgery Database Taskforce 2. Chair of the STS Database Task Force on Longitudinal Follow-up and Linked Registries 3. Chair of the STS Database Public Reporting Task Force

Q48. In the STS Congenital Heart Surgery Database, what is the most common reoperation in adults with congenital heart disease? a. Arrhythmia surgery - atrial, Surgical Ablation b. Conduit reoperation c. Fontan revision or conversion (Re-do Fontan) d. Pacemaker procedure e. Valve replacement, Pulmonic (PVR)

JDearani JA, Connolly HM, Martinez R, Fontanet H, Webb GD. Caring for adults with congenital cardiac disease: successes and challenges for 2007 and beyond. In 2007 Supplement to Cardiology in the Young: Controversies and Challenges Facing Paediatric Cardiovascular Practitioners and their Patients, Anderson RH, Jacobs JP, and Wernovsky G, editors. Cardiology in the Young 2007 Sep;17 Suppl 2:87-96.

The Report of the 2010 STS Congenital Heart Surgery Practice and Manpower Survey undertaken by the Society of Thoracic Surgeons Workforce on Congenital Heart Surgery 125 centers in the United States of America perform pediatric and congenital heart surgery 8 centers in Canada perform pediatric and congenital heart surgery Jacobs ML, Daniel M, Mavroudis C, Morales DLS, Jacobs JP, Fraser CD, Turek JW, Mayer JE, Tchervenkov C, Conte JV. Report of the 2010 Society of Thoracic Surgeons Congenital Heart Surgery Practice and Manpower Survey. The Annals of Thoracic Surgery, 2011;92:762 9, August 2011.

STS Database Penetrance in USA The aggregate report from Fall 2012 Harvest of the STS Congenital Heart Surgery Database includes data from: 108 Congenital Heart Surgery hospitals in North America, 105 in the United States of America 3 in Canada.

STS Database Penetrance in USA STS Congenital Heart Surgery Database: 84% Programs in USA STS Congenital Heart Surgery Database: >90% of Operations in USA

Growth in the STS Congenital Heart Surgery Database 120 100 Participating Centers 80 60 40 20 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Participating Centers 16 18 21 34 47 58 68 79 93 101 105 Jacobs JP, Jacobs ML, Mavroudis C, Lacour-Gayet FG, Tchervenkov CI. Executive Summary: The Society of Thoracic Surgeons Congenital Heart Surgery Database - Seventeenth Harvest (July 1, 2008 June 30, 2012). The Society of Thoracic Surgeons (STS) and Duke Clinical Research Institute (DCRI), Duke University Medical Center, Durham, North Carolina, United States, Fall 2012 Harvest.

Growth in the STS Congenital Heart Surgery Database 140000 Operations per averaged 4 year data collection cycle 120000 100000 Operations 80000 60000 40000 20000 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Operations 12787 16461 28351 37093 45635 61014 72002 91639 103664 114041 130823 Jacobs JP, Jacobs ML, Mavroudis C, Lacour-Gayet FG, Tchervenkov CI. Executive Summary: The Society of Thoracic Surgeons Congenital Heart Surgery Database - Seventeenth Harvest (July 1, 2008 June 30, 2012). The Society of Thoracic Surgeons (STS) and Duke Clinical Research Institute (DCRI), Duke University Medical Center, Durham, North Carolina, United States, Fall 2012 Harvest.

300000 Growth in the STS Congenital Heart Surgery Database Cumulative operations over time. 250000 Cumulative Operations 200000 150000 100000 50000 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Cumulative Operations 4237 9747 16537 26404 39988 58181 79399 98406 119266 148110 179697 213416 257932 Jacobs JP, Jacobs ML, Mavroudis C, Lacour-Gayet FG, Tchervenkov CI. Executive Summary: The Society of Thoracic Surgeons Congenital Heart Surgery Database - Seventeenth Harvest (July 1, 2008 June 30, 2012). The Society of Thoracic Surgeons (STS) and Duke Clinical Research Institute (DCRI), Duke University Medical Center, Durham, North Carolina, United States, Fall 2012 Harvest.

Jacobs JP, Maruszewski B, Kurosawa H, Jacobs ML, Mavroudis C, Lacour-Gayet FG, Tchervenkov CI, Walters H 3rd, Stellin G, Ebels T, Tsang VT, Elliott MJ, Murakami A, Sano S, Mayer JE Jr, Edwards FH, Quintessenza JA. Congenital heart surgery databases around the world: do we need a global database? Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2010;13(1):3-19.PMID: 20307856

www.eactscongenitaldb.org

The Japan Congenital Cardiovascular Surgery Database (JCCVSD) Jacobs JP, Maruszewski B, Kurosawa H, Jacobs ML, Mavroudis C, Lacour-Gayet FG, Tchervenkov CI, Walters H 3rd, Stellin G, Ebels T, Tsang VT, Elliott MJ, Murakami A, Sano S, Mayer JE Jr, Edwards FH, Quintessenza JA. Congenital heart surgery databases around the world: do we need a global database? Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2010;13(1):3-19.PMID: 20307856

The STS-CHSD was queried for all index operations in the four year analytic window of 2007-2011, inclusive. Operations were excluded if: 1. STAT Mortality Category was not available 2. Key data elements were missing: Procedure Mortality status at hospital discharge Number of prior CPB cardiothoracic operations 3. Patient was less than or equal to 2,500g undergoing PDA ligation as their primary procedure.

As a surrogate for reoperation, we stratified operations in the STS-CHSD by the variable: Number of Prior CPB Cardiothoracic Operations.

This analysis is based on 92,603 index cardiac operations performed in the four year analytic window of 2007-2011, inclusive, 61,930 index cardiac operations with zero prior CPB cardiothoracic operations and 30,673 index cardiac operations with one or more prior CPB cardiothoracic operations.

Mortality Stratified by Number of Prior CPB Cardiothoracic Operations 6 5 Mortality 4 3 5.07 2 3.98 4.08 3.31 1 2.38 1.67 2.41 0 0 1 2 3 4 5 6 or more Mortality 3.98 2.38 1.67 2.41 3.31 4.08 5.07

Mean Postoperative Length of Stay Stratified by Number of Prior CPB Cardiothoracic Operations 16 14 12 Mean PLOS 10 8 6 14.83 10.84 10.92 11.7 12.22 12.99 14.07 4 2 0 0 1 2 3 4 5 6 or more Mean PLOS 14.83 10.84 10.92 11.7 12.22 12.99 14.07

Procedure (All Patients) Bidirectional cavopulmonary anastomosis Number Mortality Mortality (%) 2480 33 1.3% Valve replacement, Pulmonic (PVR) 1970 8 0.4% Fontan, TCPC, External conduit, Fenestrated 1870 24 1.8% Conduit reoperation 1732 14 0.8% Pacemaker procedure 1642 5 0.3% Fontan, TCPC, External conduit, Nonfenestrated Pacemaker implantation, Permanent 1403 22 1.6% 927 13 1.4%

Procedure (Neonates) Arterial switch operation (ASO) Number Mortality Mortality (%) 48 1 2.1% Shunt, Systemic to pulmonary, Modified Blalock-Taussig Shunt 38 5 13.2% Norwood procedure 37 8 21.6% TAPVC repair 18 10 55.6% Arterial switch and VSD repair 18 0 0.0% Aortic arch repair 11 2 18.3% PA banding (PAB) 11 4 36.4%

Procedure (Infants) Bidirectional cavopulmonary anastomosis (BDCPA) (bidirectional Glenn) Superior Cavopulmonary anastomosis(es) + PA reconstruction Bilateral bidirectional cavopulmonary anastomosis (BBDCPA) (bilateral bidirectional Glenn) Number Mortality Mortality (%) 2271 29 1.3% 807 19 2.4% 314 7 2.2% HemiFontan 311 8 2.6% TOF repair, Ventriculotomy, Transanular patch 266 2 0.8%

Procedure (Children) Fontan, TCPC, External conduit, Fenestrated Number Mortality Mortality (%) 1852 29 1.7% Conduit reoperation 1435 10 0.7% Fontan, TCPC, External conduit, Nonfenestrated 1375 20 1.6% Valve replacement, Pulmonic (PVR) 1186 6 0.5% Pacemaker procedure 1173 2 0.2% Fontan, TCPC, Lateral tunnel, Fenestrated Pacemaker implantation, Permanent 887 6 0.7% 690 4 0.6%

Procedure (Adults) Valve replacement, Pulmonic (PVR) Number Mortality Mortality (%) 764 2 0.3% Pacemaker procedure 427 1 0.2% Conduit reoperation 185 3 1.6% Arrhythmia surgery - atrial, Surgical Ablation 176 6 3.4% Fontan revision or conversion (Re-do Fontan) Pacemaker implantation, Permanent 149 15 10.1% 148 3 2.0% Conduit placement, RV to PA 121 4 3.3%

Science tells us what we can do; Guidelines what we should do; & Registries what we are actually doing.