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Long-term studies reveal major improvements in outcomes after pediatric cardiac surgery
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Two new studies with follow-up spanning decades demonstrate substantial improvements in outcomes after pediatric cardiac surgery.
A 40-year prospective study of pediatric cardiac surgery patients in Norway and a 60-year retrospective study of pediatric cardiac surgeries in Finland since 1953 both found that long-term survival after pediatric cardiac surgery improved as time went on.
Norwegian study
The prospective study included 7,038 patients who underwent surgical treatment for congenital heart disease from 1971 to 2011 at Oslo University Hospital, Rikshospitalet.
Gunnar Erikssen, MD, from the department of cardiology at Rikshospitalet, and colleagues classified 53.2% of patients’ congenital heart diseases as simple, 41.5% as complex and 5.2% as miscellaneous.
Median age at first operation for complex defects declined from 1.6 years in 1971-1979 to 0.35 years in 1980-1989, 0.27 years in 1990-1999 and 0.19 years in 2000-2011 (P for 1990-1999 vs. 2000-2011=.0002). Concurrently, surgery for complex defects became more common over time (1971-1979, 37 per year; 2000-2011, 109 per year).
Among all patients, 1,033 had died before 2013. For patients with complex congenital heart disease, cumulative survival to 16 years was 62.4% in 1971-1989 vs. 86.9% in 1990-2011 (P<.0001).
When the researchers compared patients who were operated on from 2000 to 2004 vs. 2005 to 2011, 1-year survival improved from 90.7% to 96.5% (P=.003) and 5-year cumulative survival improved from 88.8% to 95% (P=.0003).
Among patients with simple defects, 11.6% required at least one reoperation before age 16 years, while that was the case for 33.8% of those with complex defects, according to the researchers. Among patients with complex defects, freedom from reoperation increased from 66% in 1990-1999 to 73% in 2000-2011 (P=.0001).
Finnish study
Alireza Raissadati, MD, and colleagues retrospectively obtained data from a pediatric cardiac surgery database in Finland and analyzed 13,786 cardiac operations performed on 10,964 pediatric patients from 1953 to 2009; follow-up information was obtained for 98% of patients.
The 60-year survival rate for all patients studied was 70% (72% excluding operative mortality) vs. 86% for an age- and sex-matched general population cohort, Raissadati, from the department of surgery and cardiology at the Hospital for Children and Adolescents, Helsinki University Central Hospital, and colleagues reported.
Mean age at operation was 8.9 years in the 1950s vs. 2.2 years in the 2000s (difference, 6.7 years; 95% CI, 6.2-7.1), and the decrease was consistent across all types of defects, according to the researchers.
Results indicated that long-term survival of patients with severe cardiac defects improved significantly over time. For example, the 22-year survival of patients with transposition of the great arteries improved from 71% in 1953-1989 to 93% in 1990-2009 (HR for death=0.29; 95% CI, 0.17-0.49).
Early mortality, defined as less than 30 days after an operation, decreased from 7% in the 1970s to 3% in the 2000s (95% CI, 0.05-0.08).
Chronic conditions
In a related editorial, Marshall L. Jacobs, MD, noted that these studies provide proof of several points long taken for granted, including:
- In developed countries with widespread access to tertiary health care services, the rate of pediatric heart surgeries is increasing and is not fully explained by changes in birth rates.
- Patients with complex forms of heart disease can now be managed early in life; some conditions once thought to be “uniformly lethal” can now be managed surgically.
- Short-term and long-term survival outcomes have improved substantially, and continue to improve for the more challenging conditions.
- Long-term survival of pediatric cardiac surgery patients may be tied to multiple surgical and interventional procedures.
“The emergence of an ever-larger population of patients surviving to adulthood with congenital heart disease reflects very positively on the community of individuals and organizations that have cared for these patients over the last many decades,” Jacobs, from the division of cardiac surgery, department of surgery, Johns Hopkins School of Medicine, wrote. “But it is a clarion call announcing the reality that, with the possible exception of the very simplest anomalies, the vast majority of forms of congenital heart diseases are actually chronic diseases, with lifelong implications for patients’ health and well-being, and for the societal platforms and health care systems that must adapt, in order to ensure that congenital heart disease patients of all ages have access to appropriate professional expertise and care.”
For more information:
Erikssen G. Circulation. 2014;doi:10.1161/CIRCULATIONAHA.114.012033.
Jacobs ML. Circulation. 2014;doi:10.1161/CIRCULATIONAHA.114.014318.
Raissadati A. Circulation. 2014;doi:10.1161/CIRCULATIONAHA.114.011190.
Disclosure: The researchers and Jacobs report no relevant financial disclosures.