BACKGROUND
We aimed to examine the rationale and assess risk of additional cardiopulmonary bypass
(CPB) episodes, and specifically, re-institution of CPB for reintervention, in congenital
heart surgery.
METHODS AND RESULTS
We retrospectively reviewed all children undergoing cardiac surgery with CPB at one
institution (2014-2016). Tetralogy of Fallot was excluded as the annulus-sparing surgical
strategy involves planned intraoperative revision. The final cohort of 922 patients
was stratified: single CPB run (CPB=1, n=771); >1CPB without revisions (CPB>1NR, n=77)
for reperfusion, bleeding, or intractable arrhythmias; and >1CPB with revision (CPB>1R,
n=74). Successful revisions were defined as: those resulting in at most mild residual
lesions, did not induce new lesions, did not require postoperative revision, and did
not result in mortality prior to discharge. Forced revisions were defined as revisions
for unacceptable hemodynamics or failure to wean from CPB. Outcomes of interest were
in-hospital mortality, complications, need for postoperative revision, and a composite
(death, stroke, ECMO, arrest, and leaving OR with open chest). Predictors of the composite
outcome were assessed by logistic regression. Mean age was 2.9±4.5 years, 54% were
male and mean RACHS was 2.5±0.8. In CPB>1R, 18 (24%) required 2 or 3 revisions. Revisions
were valvular in 34 (46%) and forced in 51 (69%) patients. Success with a single revision
occurred in 22 (30%) and by the final attempt in 32 (43%) patients. One patient's
lesion worsened as a result of the revision. When comparing CPB=1 vs CPB>1NR vs CPB>1R,
outcomes with significant differences included: stroke, arrest, postoperative revision,
open chest upon leaving OR, and the composite outcome (Table 1). In-hospital death,
re-exploration, need for ECMO, and hospital stay were similar (Table 1). Among CPB>1R
patients, 12 (16%) required postoperative revision. Logistic regression identified
revision as a predictor of the composite outcome with greatest effect seen in 2 revisions:
1: OR=2.39 (95% CI: 1.35, 4.21) p=0.002, 2: OR=3.68 (95% CI: 1.26, 10.74) p=0.02,
3: OR=1.23 (95% CI: 0.25, 12.23) p=0.8. Additionally, CPB runs=3 was associated with
the composite outcome: OR=2.25 (95% CI: 1.00, 5.05) p=0.048. A trend towards CPB runs = 4
was seen while CPB runs=2 was not correlated with the composite outcome.
CONCLUSION
Revisions are uncommon, and most are forced. Revisions frequently do not eliminate
residual lesions, occasionally require additional postoperative revisions, but are
not associated with increased early mortality. Revisions and >2 CPB runs were associated
with greater risk of the composite outcome. Those for non-forced reasons should likely
be considered with caution.
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© 2021 Published by Elsevier Inc.