JACC: CARDIOVASCULAR INTERVENTIONS
VOL. 7, NO. 12, 2014
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 1936-8798/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jcin.2014.06.022
Cardiac Catheterization in the Early Post-Operative Period After Congenital Cardiac Surgery George T. Nicholson, MD,* Dennis W. Kim, MD, PHD,* Robert N. Vincent, MD,* Brian E. Kogon, MD,y Bruce E. Miller, MD,z Christopher J. Petit, MD*
ABSTRACT OBJECTIVES This study sought to demonstrate that early cardiac catheterization, whether used solely as a diagnostic modality or for the use of transcatheter interventional techniques, can be used effectively and with an acceptable risk in the post-operative period. BACKGROUND Cardiac catheterization offers important treatment for patients with congenital heart disease. Early post-operative cardiac catheterization is often necessary to diagnose and treat residual anatomic defects. Experience with interventional catheterization to address post-operative concerns is limited. METHODS This was a retrospective cohort study. The medical and catheterization data of pediatric patients who underwent a cardiac catheterization #30 days after congenital heart surgery between November 2004 and July 2013 were reviewed. Patients who underwent right heart catheterization and endomyocardial biopsy after heart transplantation were excluded. RESULTS A total of 219 catheterizations (91 interventional procedures, 128 noninterventional catheterizations) were performed on 193 patients. Sixty-five interventions (71.43%) were dilations, either balloon angioplasty or stent implantation. There was no difference in survival to hospital discharge between those who underwent an interventional versus noninterventional catheterization (p ¼ 0.93). One-year post-operative survival was comparable between those who underwent an intervention (66%) versus diagnostic (71%) catheterization (p ¼ 0.58). There was no difference in the incidence of major or minor complications between the interventional and diagnostic catheterization cohorts (p ¼ 0.21). CONCLUSIONS Cardiac catheterization, including transcatheter interventions, can be performed safely in the immediate post-operative period after congenital heart surgery. (J Am Coll Cardiol Intv 2014;7:1437–43) © 2014 by the American College of Cardiology Foundation.
C
ardiac catheterization is often uniquely
is significant institutional variability with regard to
valuable in the evaluation and treatment of
access and timely referral for EPOCC. There is limited
patients
reported experience with cardiac catheterization in
with
congenital
heart
disease.
Although the safety of catheterization in the non-
the early post-operative period (5–7).
acute setting has been described (1–4), early post-
At our institution, patients are often referred for
operative cardiac catheterization (EPOCC) is often
cardiac catheterization in the early post-operative
regarded as high risk, particularly when patients are
period to determine the significance of a residual
unstable or when interventions are anticipated. There
cardiac lesion noted by noninvasive means (e.g.,
From the *Division of Pediatric Cardiology, Department of Pediatrics, Children’s Healthcare of Atlanta/Emory University School of Medicine, Atlanta, Georgia; yDivision of Cardiothoracic Surgery, Department of Pediatrics, Children’s Healthcare of Atlanta/Emory University School of Medicine, Atlanta, Georgia; and the zDivision of Pediatric Cardiac Anesthesia, Department of Pediatrics, Children’s Healthcare of Atlanta/Emory University School of Medicine, Atlanta, Georgia. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received April 18, 2014; revised manuscript received May 20, 2014, accepted June 13, 2014.
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Nicholson et al.
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 7, NO. 12, 2014 DECEMBER 2014:1437–43
Cardiac Catheterization Early Post-Operative
ABBREVIATIONS
echocardiography) or to assess physiology
CATHETERIZATION PROCEDURE. Demographic data
AND ACRONYMS
and/or anatomy in the struggling post-
collected included weight at catheterization (in kilo-
operative patient. We reviewed our institu-
grams), age at catheterization (years), and primary
tional experience with perioperative cardiac
cardiac diagnosis. We also reported the initial surgical
catheterization in this patient group. The
procedure performed, the interval from surgery to
cardiac catheterization
purpose of this study is to describe the safety
EPOCC (days), the indication(s) for EPOCC (cyanosis,
IQR = interquartile range
and overall outcomes of cardiac catheteriza-
low cardiac output, or other), the diagnosis of a ge-
tion procedures performed within 30 days
netic syndrome, the need for mechanical ventilation
after congenital heart surgery. We hypothesized that
before EPOCC, the need for inotropic support, extra-
early cardiac catheterization, whether used solely as a
corporeal membrane oxygenation (ECMO) use at time
diagnostic modality or as a percutaneous interven-
of catheterization, in-hospital mortality, and 1-year
tion, can be used effectively and with an acceptable
survival post-surgery. Catheterization data collected
risk in the post-operative period.
included the procedure performed, the intervention
ECMO = extracorporeal membrane oxygenation
EPOCC = early post-operative
involving a surgical anastomotic site, procedural mortality, the need for blood transfusion during the
METHODS
catheterization, and procedural complications (mi-
STUDY PATIENTS. This is a single-center, retrospec-
tive cohort study. Medical and catheterization data of all pediatric patients who underwent a cardiac
nor/major). Major complications included death, stroke, cardiopulmonary arrest, and the need for unplanned emergent surgery/procedure/ECMO support
catheterization #30 days after congenital heart sur-
as a result of complication.
gery at Children’s Healthcare of Atlanta between
STATISTICAL ANALYSIS. Continuous variables were
November 2004 and July 2013 were reviewed. Patients were included if they underwent either a diagnostic or interventional cardiac catheterization #30 days
reported as median and interquartile range (IQR). The data were initially analyzed with a univariate followed by a multivariate regression analysis when
after surgical repair/palliation for congenital heart
applicable. The primary outcome measure was pro-
disease. Patients who underwent right heart cathe-
cedural complication. Covariates and factors were
terization and endomyocardial biopsy as routine sur-
assessed using either a Wilcoxon rank sum test or a
veillance after orthotopic heart transplantation were
chi-square test, when applicable. Secondary end-
excluded. This study was approved by the institutional
points included hospital discharge survival and 1-year
review board.
survival. Kaplan-Meier log-rank univariate analysis was performed for time-dependent outcomes, and multivariable analysis was performed using Cox regression with SPSS Version 21.0 software (IBM,
T A B L E 1 Patient Characteristics
Armonk, New York).
Total (N ¼ 193)
Interventional (n ¼ 65)
Diagnostic (n ¼ 128)
p Value
RESULTS
Patient characteristics Age, yrs
0.32 (0.01–18.48) 0.31 (0.01–17.14)
Weight, kg
5.20 (3.40–8.50)
0.35 (0.01–18.48)
0.45
During the study period, there were a total of 7,755
6 (0–30)
8 (0–29)
5 (1–30)
0.01
surgical cases at our institution. A total of 219 early
Mechanical ventilator support
131
47
84
0.35
Inotropic support
129
39
90
0.16
procedures, 128 noninterventional catheterizations)
ECMO
22
8
14
0.77
were performed on 193 of these patients. At the time
Genetic syndrome
45
11
34
0.14
of EPOCC, the median age was 0.32 years (IQR: 0.05
Single ventricle
96 (50)
45 (69)
51 (40)