Analysis and evaluation of risk factors associated with poor prognoses of children with tetralogy of Fallot during perioperative period_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

XIE Wen ^1,2 , CAI Xiaowei ² , YAO Zeyang ^1,2 , LIU Xiaobing ² , WANG Ximeng ³ , LIU Furong ² , LIU Tao ⁴ , TENG Yun ² , CHEN Zewen ² , QIU Hailong ² , JI Erchao ^1,2 ,  ZHUANG Jian ^1,2

1. Department of Cardiac Surgery, Guangdong Provincial People’s Hospital, School of Medicine, South China University of Technology, Guangzhou, 510080, P.R.China;
2. Guangdong Provincial Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, 510100, P.R.China;
3. Department of Epidemiology, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, 510080, P.R.China;
4. Brown University, Rhode Island, RI 02912, USA;

Corresponding author：

ZHUANG Jian, Email: zhuangjian5413@tom.com

Keywords：

Tetralogy of Fallot; risk factors; poor prognoses; surgery

DOI：

10.7507/1007-4848.202012055

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Objective To quest the risk factors of poor prognoses in children with tetralogy of Fallot (TOF) during perioperative period and evaluate its clinical application values.Methods A retrospective analysis of the clinical data of 119 children who underwent one-stage correction of TOF in Guangdong Provincial People's Hospital from September 2016 to January 2019. The cohort includes 75 males and 44 females, with ages ranging from 3.2-137.1 (13.2±1.4) months and weights ranging from 4.6-21.0 (8.3±0.2) kg. Perioperative poor prognosis was defined as duration of mechanically assisted ventilation >48 h or secondary intubation, vasoactive-inotropic score (VIS) within 48 h >40, postoperative length of stay >14 d, and the occurrence of the major adverse events. Major adverse events were defined as early death, malignant arrhythmia, low cardiac output syndrome, non-fatal cardiac arrest, postoperative reintervention, diaphragm paralysis, and other clinical complications. Univariate and multivariate logistic analyses were used to analyze the correlation between risk factors and poor prognoses.Results There was 1 perioperative death, and 9 with major adverse events. Variables selected by Least Absolute Shrinkage and Selection Operator (LASSO) included 2 preoperative variables (McGoon index, aortic root diameter index) and 4 intra-operative variables [left-right direction of bicuspid pulmonary valve, total length of right ventricular outflow tract (RVOT) incision index, pulmonary valve with commissurotomy, and minimum temperature in cardiopulmonary bypass (CPB)]. Univariate and multivariate logistic analyses were used to the above factors, respectively. The variables with statistical significance (P≤0.05) were McGoon index, aortic root diameter index, left-right direction of bicuspid pulmonary valve, and minimum temperature in CPB. A nomogram was established based on the above factors, and the results showed that the left-right direction of bicuspid pulmonary valve was more risky than the tricuspid pulmonary valve and the anterior-posterior direction of bicuspid pulmonary valve. The lower the McGoon index, the higher aortic root diameter, and the lower temperature in CPB, the higher risk of poor prognostic events in children with TOF.Conclusion The left-right direction of the pulmonary bicuspid valve has a higher risk of poor prognosis than the tricuspid pulmonary valve and the anterior-posterior direction of bicuspid pulmonary valve. With the smaller McGoon index and the larger aortic root diameter, the risk of poor prognoses in children with TOF is higher. The temperature in CPB being lower than medium-low temperature obviously relates to the high incidence of poor prognostic events, which can be used as an auxiliary reference standard for decision-making in pediatric TOF surgery in the future.

Citation： XIE Wen, CAI Xiaowei, YAO Zeyang, LIU Xiaobing, WANG Ximeng, LIU Furong, LIU Tao, TENG Yun, CHEN Zewen, QIU Hailong, JI Erchao, ZHUANG Jian. Analysis and evaluation of risk factors associated with poor prognoses of children with tetralogy of Fallot during perioperative period. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2021, 28(6): 682-690. doi: 10.7507/1007-4848.202012055 Copy

1.	van der Linde D, Konings EE, Slager MA, et al. Birth prevalence of congenital heart disease worldwide: A systematic review and meta-analysis. J Am Coll Cardiol, 2011, 58(21): 2241-2247.
2.	Villafañe J, Feinstein JA, Jenkins KJ, et al. Hot topics in tetralogy of Fallot. J Am Coll Cardiol, 2013, 62(23): 2155-2166.
3.	Lillehei CW, Cohen M, Warden HE, et al. Direct vision intracardiac surgical correction of the tetralogy of Fallot, pentalogy of Fallot, and pulmonary atresia defects; report of first ten cases. Ann Surg, 1955, 142(3): 418-442.
4.	Starr JP. Tetralogy off Fallot: yesterday and today. World J Surg, 2010, 34(4): 658-668.
5.	Savla JJ, Faerber JA, Huang YV, et al. 2-year outcomes after complete or staged procedure for tetralogy of Fallot in neonates. J Am Coll Cardiol, 2019, 74(12): 1570-1579.
6.	van den Bosch E, Bogers AJJC, Roos-Hesselink JW, et al. Long-term follow-up after transatrial-transpulmonary repair of tetralogy of Fallot: influence of timing on outcome. Eur J Cardiothorac Surg, 2020, 57(4): 635-643.
7.	d'Udekem Y, Galati JC, Rolley GJ, et al. Low risk of pulmonary valve implantation after a policy of transatrial repair of tetralogy of Fallot delayed beyond the neonatal period: the Melbourne experience over 25 years. J Am Coll Cardiol, 2014, 63(6): 563-568.
8.	Padalino MA, Pradegan N, Azzolina D, et al. The role of primary surgical repair technique on late outcomes of tetralogy of Fallot: A multicentre study. Eur J Cardiothorac Surg, 2020, 57(3): 565-573.
9.	Rajagopal SK, Thiagarajan RR. Perioperative care of children with tetralogy of Fallot. Curr Treat Options Cardiovasc Med, 2011, 13(5): 464-474.
10.	Mercer-Rosa L, Elci OU, DeCost G, et al. Predictors of length of hospital stay after complete repair for tetralogy of Fallot: A prospective cohort study. J Am Heart Assoc, 2018, 7(11): e008719.
11.	Reddy SL, Grayson AD, Griffiths EM, et al. Logistic risk model for prolonged ventilation after adult cardiac surgery. Ann Thorac Surg, 2007, 84(2): 528-536.
12.	Lomivorotov VV, Efremov SM, Kirov MY, et al. Low-cardiac-output syndrome after cardiac surgery. J Cardiothorac Vasc Anesth, 2017, 31(1): 291-308.
13.	Jia Q, Cen J, Zhuang J, et al. Significant survival advantage of high pulmonary vein index and the presence of native pulmonary artery in pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries: Results from preoperative computed tomography angiography. Eur J Cardiothorac Surg, 2017, 52(2): 225-232.
14.	Schultz C, Moelker A, Tzikas A, et al. The use of MSCT for the evaluation of the aortic root before transcutaneous aortic valve implantation: The Rotterdam approach. EuroIntervention, 2010, 6(4): 505-511.
15.	万俊义, 王恩宁, 蒋世良, 等. 计算机断层摄影术在经皮肺动脉瓣植入术的应用及评价. 中国循环杂志, 2017, 32(5): 489-492.
16.	Liu H, Zheng SQ, Li XY, et al. Derivation and validation of a nomogram to predict in-hospital complications in children with tetralogy of Fallot repaired at an older age. J Am Heart Assoc, 2019, 8(21): e013388.
17.	Pexieder T. Conotruncus and its septation at the advent of the molecular biology era. Dev Mech Heart Dis, 1995: 227-247.
18.	Hegde SV, Lensing SY, Greenberg SB. Determining the normal aorta size in children. Radiology, 2015, 274(3): 859-865.
19.	Groh MA, Meliones JN, Bove EL, et al. Repair of tetralogy of Fallot in infancy. Effect of pulmonary artery size on outcome. Circulation, 1991, 84(5 Suppl): Ⅲ206-Ⅲ212.
20.	Tan JL, Davlouros PA, McCarthy KP, et al. Intrinsic histological abnormalities of aortic root and ascending aorta in tetralogy of Fallot: Evidence of causative mechanism for aortic dilatation and aortopathy. Circulation, 2005, 112(7): 961-968.
21.	Keskin M. Evaluation of short and long-term outcomes of children with tetralogy of Fallot. SDU J Health Sci Institut, 2020, 11(3).
22.	Li S, Zhang Y, Li S, et al. Risk Factors Associated with prolonged mechanical ventilation after corrective surgery for tetralogy of Fallot. Congenit Heart Dis, May-Jun 2015, 10(3): 254-262.
23.	Caputo M, Bays S, Rogers CA, et al. Randomized comparison between normothermic and hypothermic cardiopulmonary bypass in pediatric open-heart surgery. Ann Thorac Surg, 2005, 80(3): 982-988.
24.	Liu Y, Xing J, Li Y, et al. Chronic hypoxia-induced Cirbp hypermethylation attenuates hypothermic cardioprotection via down-regulation of ubiquinone biosynthesis. Sci Transl Med, 2019, 11(489): eaat8406.
25.	Filseth OM, How OJ, Kondratiev T, et al. Post-hypothermic cardiac left ventricular systolic dysfunction after rewarming in an intact pig model. Crit Care, 2010, 14(6): R211.
26.	Goetzenich A, Schroth SC, Emmig U, et al. Hypothermia exerts negative inotropy in human atrial preparations: In vitro-comparison to rabbit myocardium. J Cardiovasc Surg (Torino), 2009, 50(2): 239-245.
27.	Qing M, Wöltje M, Schumacher K, et al. The use of moderate hypothermia during cardiac surgery is associated with repression of tumour necrosis factor-alpha via inhibition of activating protein-1: An experimental study. Crit Care, 2006, 10(2): R57.
28.	Vida VL, Angelini A, Guariento A, et al. Preserving the pulmonary valve during early repair of tetralogy of Fallot: Anatomic substrates and surgical strategies. J Thorac Cardiovasc Surg, 2015, 149(5): 1358-1363.
29.	Chacko BR, Chiramel GK, Vimala LR, et al. Spectrum of pulmonary valve morphology and its relationship to pulmonary trunk in tetralogy of Fallot. Indian J Radiol Imaging, 2017, 27(1): 65-69.

1. van der Linde D, Konings EE, Slager MA, et al. Birth prevalence of congenital heart disease worldwide: A systematic review and meta-analysis. J Am Coll Cardiol, 2011, 58(21): 2241-2247.
2. Villafañe J, Feinstein JA, Jenkins KJ, et al. Hot topics in tetralogy of Fallot. J Am Coll Cardiol, 2013, 62(23): 2155-2166.
3. Lillehei CW, Cohen M, Warden HE, et al. Direct vision intracardiac surgical correction of the tetralogy of Fallot, pentalogy of Fallot, and pulmonary atresia defects; report of first ten cases. Ann Surg, 1955, 142(3): 418-442.
4. Starr JP. Tetralogy off Fallot: yesterday and today. World J Surg, 2010, 34(4): 658-668.
5. Savla JJ, Faerber JA, Huang YV, et al. 2-year outcomes after complete or staged procedure for tetralogy of Fallot in neonates. J Am Coll Cardiol, 2019, 74(12): 1570-1579.
6. van den Bosch E, Bogers AJJC, Roos-Hesselink JW, et al. Long-term follow-up after transatrial-transpulmonary repair of tetralogy of Fallot: influence of timing on outcome. Eur J Cardiothorac Surg, 2020, 57(4): 635-643.
7. d'Udekem Y, Galati JC, Rolley GJ, et al. Low risk of pulmonary valve implantation after a policy of transatrial repair of tetralogy of Fallot delayed beyond the neonatal period: the Melbourne experience over 25 years. J Am Coll Cardiol, 2014, 63(6): 563-568.
8. Padalino MA, Pradegan N, Azzolina D, et al. The role of primary surgical repair technique on late outcomes of tetralogy of Fallot: A multicentre study. Eur J Cardiothorac Surg, 2020, 57(3): 565-573.
9. Rajagopal SK, Thiagarajan RR. Perioperative care of children with tetralogy of Fallot. Curr Treat Options Cardiovasc Med, 2011, 13(5): 464-474.
10. Mercer-Rosa L, Elci OU, DeCost G, et al. Predictors of length of hospital stay after complete repair for tetralogy of Fallot: A prospective cohort study. J Am Heart Assoc, 2018, 7(11): e008719.
11. Reddy SL, Grayson AD, Griffiths EM, et al. Logistic risk model for prolonged ventilation after adult cardiac surgery. Ann Thorac Surg, 2007, 84(2): 528-536.
12. Lomivorotov VV, Efremov SM, Kirov MY, et al. Low-cardiac-output syndrome after cardiac surgery. J Cardiothorac Vasc Anesth, 2017, 31(1): 291-308.
13. Jia Q, Cen J, Zhuang J, et al. Significant survival advantage of high pulmonary vein index and the presence of native pulmonary artery in pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries: Results from preoperative computed tomography angiography. Eur J Cardiothorac Surg, 2017, 52(2): 225-232.
14. Schultz C, Moelker A, Tzikas A, et al. The use of MSCT for the evaluation of the aortic root before transcutaneous aortic valve implantation: The Rotterdam approach. EuroIntervention, 2010, 6(4): 505-511.
15. 万俊义, 王恩宁, 蒋世良, 等. 计算机断层摄影术在经皮肺动脉瓣植入术的应用及评价. 中国循环杂志, 2017, 32(5): 489-492.
16. Liu H, Zheng SQ, Li XY, et al. Derivation and validation of a nomogram to predict in-hospital complications in children with tetralogy of Fallot repaired at an older age. J Am Heart Assoc, 2019, 8(21): e013388.
17. Pexieder T. Conotruncus and its septation at the advent of the molecular biology era. Dev Mech Heart Dis, 1995: 227-247.
18. Hegde SV, Lensing SY, Greenberg SB. Determining the normal aorta size in children. Radiology, 2015, 274(3): 859-865.
19. Groh MA, Meliones JN, Bove EL, et al. Repair of tetralogy of Fallot in infancy. Effect of pulmonary artery size on outcome. Circulation, 1991, 84(5 Suppl): Ⅲ206-Ⅲ212.
20. Tan JL, Davlouros PA, McCarthy KP, et al. Intrinsic histological abnormalities of aortic root and ascending aorta in tetralogy of Fallot: Evidence of causative mechanism for aortic dilatation and aortopathy. Circulation, 2005, 112(7): 961-968.
21. Keskin M. Evaluation of short and long-term outcomes of children with tetralogy of Fallot. SDU J Health Sci Institut, 2020, 11(3).
22. Li S, Zhang Y, Li S, et al. Risk Factors Associated with prolonged mechanical ventilation after corrective surgery for tetralogy of Fallot. Congenit Heart Dis, May-Jun 2015, 10(3): 254-262.
23. Caputo M, Bays S, Rogers CA, et al. Randomized comparison between normothermic and hypothermic cardiopulmonary bypass in pediatric open-heart surgery. Ann Thorac Surg, 2005, 80(3): 982-988.
24. Liu Y, Xing J, Li Y, et al. Chronic hypoxia-induced Cirbp hypermethylation attenuates hypothermic cardioprotection via down-regulation of ubiquinone biosynthesis. Sci Transl Med, 2019, 11(489): eaat8406.
25. Filseth OM, How OJ, Kondratiev T, et al. Post-hypothermic cardiac left ventricular systolic dysfunction after rewarming in an intact pig model. Crit Care, 2010, 14(6): R211.
26. Goetzenich A, Schroth SC, Emmig U, et al. Hypothermia exerts negative inotropy in human atrial preparations: In vitro-comparison to rabbit myocardium. J Cardiovasc Surg (Torino), 2009, 50(2): 239-245.
27. Qing M, Wöltje M, Schumacher K, et al. The use of moderate hypothermia during cardiac surgery is associated with repression of tumour necrosis factor-alpha via inhibition of activating protein-1: An experimental study. Crit Care, 2006, 10(2): R57.
28. Vida VL, Angelini A, Guariento A, et al. Preserving the pulmonary valve during early repair of tetralogy of Fallot: Anatomic substrates and surgical strategies. J Thorac Cardiovasc Surg, 2015, 149(5): 1358-1363.
29. Chacko BR, Chiramel GK, Vimala LR, et al. Spectrum of pulmonary valve morphology and its relationship to pulmonary trunk in tetralogy of Fallot. Indian J Radiol Imaging, 2017, 27(1): 65-69.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Analysis and evaluation of risk factors associated with poor prognoses of children with tetralogy of Fallot during perioperative period

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