Nurullah OKUMUŞ, Serdar BEKEN, Murat KOÇ, Ayşegül ZENCİROĞLU, Nuran ÜSTÜN, Senem ÖZGÜR

Main Risk Factors for Mortality After Cardiovascular Interventions in Newborns with Critical Congenital Heart Diseases

Amaç: Kritik konjenital kalp hastalıklı (KKH) yenidoğanlarda girişim sonrası mortaliteyi etkileyen risk faktörlerininbelirlenmesi amaçlandı.Gereç ve Yöntemler: Üçüncü düzey bir yenidoğan yoğun bakım ünitesinde (YYBÜ) Eylül 2010 Ocak 2012 tarihleriarasında izlenen ve girişim uygulanan kritik KKH tanılı 105 yenidoğan incelendi. Hastaların demografik verileri, girişimöncesi ve sonrası klinik bulguları, girişim tipi, Doğuştan Kalp Cerrahisi için Risk Ayarlanması sınıflamasına göre girişimselrisk skoru (Risk Adjustment in Congenital Heart Surgery; RACHS-1) ile ilgili veriler kaydedildi. Bulgular: Kardiyak girişim sırasında ortalama yaş 15.2±11.8 gündü. Transkateter girişim 29 (%27.6) hastada uygulandı.Toplam 76 hastaya (%72.4) kardiyak cerrahi girişim yapıldı. Girişim sonrası dönemde düşük kardiyak debi, pnömonive sepsis görülme sıklığı cerrahi girişim yapılan olgularda daha yüksekti. Bu hastalarda YYBÜ kalış süresi de dahauzundu. Mortalite oranı %35.2 (n=37) olarak bulundu. Transkateter girişim yapılan hastalarda mortalite daha düşüktü.Univaryant analizde ölen hastalarda gebelik haftasının daha düşük, prematürite oranının daha fazla, eşlik eden hastalıksıklığının daha yüksek, girişim öncesi mekanik ventilatörde kalma oranı, inotrop desteği, pulmoner hipertansiyon vesepsis oranının daha fazla, cerrahi girişim gereksiniminin daha çok, girişim sırasındaki yaş ve RACHS-1 skorunun dahayüksek olduğu saptandı. Çoklu regresyon analizinde RACHS-1 skorunun yüksek olmasının mortalite ile ilişkili olduğu(Odds oranı: 4.5, %95 GA (1.5-13.1), p=0.005), gebelik yaşının büyük olmasının ise koruyucu bir faktör olduğu dikkatiçekti (Odds oranı: 0.6, GA( %95) (0.5-0.9), p = 0.01).Sonuç: Bu çalışmada cerrahi girişim gereken kritik KKHlı yenidoğanlar arasında mortalitenin yüksek olduğu, özellikle gebelik haftasınındüşük, RACHS-1 skorunun ise yüksek olmasının mortalite riskini artırdığı sonucuna varıldı.

Kri̇ti̇k Konjeni̇tal Kalp Hastalıklı Yeni̇doğanlarda Kardi̇yak Gi̇ri̇şi̇m Sonrası Mortali̇teyi̇ Etki̇leyen Ana Ri̇sk Faktörleri

Objective: It was aimed to define the main risk factors that affect mortality in infants with critical congenital heartdisease (CHD). Material and Methods: We analyzed data from 105 infants with critical CHD underwent cardiovascular intervention ata tertiary neonatal intensive care unit (NICU) between September 2010 and January 2012. Demographicdata, clinicalfindings (before and after intervention), type of intervention, and intervention risk score according to Risk Adjustment inCongenital Heart Surgery (RACHS-1) classification were evaluated.Results: The mean age at cardiovascular intervention was 15.2±11.8 days. Transcatheter interventions were performedin 29 patients (27.6%). Seventy-six patients (72.4%) underwent cardiovascular surgery. At post-interventional period,the rates of low cardiac output, pneumonia, and sepsis were significantly higher among patients underwent surgicalintervention. Length of NICU stay was also longer among them. Overall mortality rate was 35.2% (n=37). Mortality wassignificantly lower in infants underwent transcatheter intervention. Univariate analyses showed that nonsurvivors differedfrom survivors in terms of gestational age, prematurity, the presence of associated disorder, pre-interventional need ofmechanical ventilation, need of inotropic support, the presence of pulmonary hypertension and sepsis, requirement ofcardiovascular surgery, age at intervention, and RACHS-1 score. Multivariate analysis showed that higher RACHS-1score was associated with mortality (OR: 4.5, 95% CI (1.5-13.1), p=0.005) while higher gestational age was a preventivefactor (OR: 0.6, 95% CI (0.5-0.9), p=0.01). Conclusion: Our study indicates that lower gestational age and severity of the disease seem to be most possible riskfactors for mortality among infants with critical CHD.

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1. Van der Linde D, Konings EE, Slager MA, Witsenburg M, Helbing WA, Takkenberg JJ, et al. Birth prevalence of congenital heart disease worldwide: A systematic review and meta-analysis. J Am Coll Cardiol 2011;58:2241-7.
2. Cho SY, Oh JH, Lee JH, Lee JY, Lee SJ, Han JW, et al. Recent incidence of congenital heart disease in neonatal care unit of secondary medical center: A single center study. Korean J Pediatr 2012;55:232-7.
3. Başpinar O, Karaaslan S, Oran B, Baysal T, Elmaci AM, Yorulmaz A. Prevalence and distribution of children with congenital heart diseases in the central Anatolian region, Turkey. Turk J Pediatr 2006;48:237-43.
4. Gilboa SM, Salemi JL, Nembhard WN, Fixler DE, Correa A. Mortality resulting from congenital heart disease among children and adults in the United States, 1999 to 2006. Circulation 2010;122:2254-63.
5. Tchervenkov CI, Jacobs JP, Bernier PL, Stellin G. The improvement of care for paediatric and congenital cardiac disease across the World: A challenge for the World Society for Pediatric and Congenital Heart Surgery. Cardiol Young 2008;Suppl 2: 63-9.
6. Saxena A, Sharma M, Kothari SS, Juneja R, Reddy SC, Sharma R, et al. Prostaglandin E1 in infants with congenital heart disease: Indian experience. Indian Pediatr 1998;35:1063-9.
8. Connor JA, Gauvreau K, Jerkins KJ. Factors associated with increased resource utilization for congenital heart disease. Pediatrics 2005;116:689-95.
9. Magliola R, Althabe M, Moreno G, Lenz AM, Pilan ML, Landry L, et al. Cardiac surgical repair in newborns: Five years experience in neonatal cardiovascular surgery. Arch Argent Pediatr 2009;107: 417-22.
10. Jenkins KJ, Gauvreau K, Newburger JW, Spray TL, Moller JH, Iezzoni LI. Consensus-based method for risk adjustment for surgery for congenital heart disease. J Thorac Cardiovasc Surg 2002;123:110-8.
11. Panni RZ, Ashfaq A, Amanullah MM. Earlier surgical intervention in congenital heart disease results in better outcome and resource utilization. BMC Health Serv Res 2011;11:353.
12. Kreutzer J. Transcatheter intervention in the neonate with congenital heart disease. Clin Perinatol 2001;28:137-57.
13. Tokel K, Ekici E, Kutsal A, İkizler C. Aort koarktasyonunda balon anjiyoplasti: İlk deneyimler. Türk Kardiyol Dern Arş 1997;25:287-92.
14. Ergül Y, Nişli K, Dindar A, Eker Ömeroğlu R, Aydoğan U. The comparison a 16-year follow-up results of balloon angioplasty for aortic coarctation in children of different age groups: A single-center experience]. Anadolu Kardiyol Derg 2011;11:336-42.
15. Beekman RH. Coarctation of the aorta. In: Allen HD, Gutgesell HP, Clark EB, Driscoll DJ (eds). Moss and Adams Heart Disease in Infants, Children, and Adolescents. 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2001:988-1010.
16. Guerchicoff M, Marantz P, Infante J, Villa A, Gutiérrez A, Montero G. Assessing the impact of early diagnosis of congenital heart disease. Arch Argent Pediatr 2004;102: 445.
17. Cheng HH, Almodovar MC, Laussen PC, Wypij D, Polito A, Brown DW, et al. Outcomes and risk factors for mortality in premature neonates with critical congenital heart disease. Pediatr Cardiol 2011;32:1139-46.
18. Lim JS, Mc Crindle BW, Smallhorn JF, Golding F, Caldarone CA, Taketazu M, et al. Clinical features, management, and outcome of children with fetal and postnatal diagnoses of isomerism syndromes. Circulation 2005;112:2454-61.
19. Pappas A, Shankaran S, Hansen NI, Bell EF, Stoll BJ, Laptook AR, et al. Outcome of extremely preterm infants (_____1,000 g) with congenital heart defects from the national institute of child health and human development neonatal research network. Pediatr Cardiol 2012;33:1415-26.
20. Costello JM, Polito A, Brown DW, McElrath TF, Graham DA, Thiagarajan RR, et al. Birth before 39 weeks gestation is associated with worse outcomes in neonates with heart disease. Pediatrics 2010;126:277-84.
21. Bakshi KD, Vaidyanathan B, Sundaram KR, Roth SJ, Shivaprakasha K, Rao SG, et al. Determinants of early outcome after neonatal cardiac surgery in a developing country. J Thorac Cardiovasc Surg 2007;134:765-71.
22. Sinzobahamvya N, Arenz C, Brecher AM, Urban AE. Atrial isomerism: A surgical experience. Cardiovasc Surg 1999;7:436-42.
23. Choudhary SK, Bhan A, Sharma R, Mathur A, Airan B, Saxena A, et al. Repair of total anomalous pulmonary venous connection in infancy: Experience from a developing country. Ann Thorac Surg 1999;68:155-9.
24. Sivakumar K, Shivaprakasha K, Rao SG, Kumar RK. Operative outcome and intermediate follow-up of neonatal Blalock-Taussig shunts. Indian Heart J 2001;53:66-70.
25. Jacobs JP, Mavroudis C, Jacobs ML, Lacour-Gayet FG, Tchervenkov CI, William Gaynor J, et al. Lessons learned from the data analysis of the second harvest (1998-2001) of the Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database. Eur J Cardiothorac Surg 2004;26:18-37.
26. Health Transformation Program in Turkey. Progress report. January 2009. Ministry of Health. [database on the Internet]. 2009. Available from:www.tusak.saglik.gov.tr/pdf/kitaplar/TurkeySPDEng.pdf.
27. T.C. Sağlık Bakanlığı. Temel Sağlık Hizmetleri Genel Müdürlüğü. Türkiye Kalp ve Damar Hastaliklarini Önleme ve Kontrol Programi Birincil, İkincil ve Üçüncül Korumaya Yönelik Stratejik Plan ve Eylem Planı (2010-2014), Ankara: 2010. Yayın no: 812. http://www. aydinhsm.gov.tr/upload/files/kronik/kdhokpeylemplani.pdf
28. T.C. Sağlık Bakanlığı Tedavi Hizmetleri Genel Müdürlüğü. Türkiyede özellikle planlama gerektiren sağlık hizmetleri. Ankara: 2011. Yayın no: 836. http://www.tkhk.gov.tr/Eklenti/351,turkiyede-ozellikli- planlama-gerektiren-saglik hizmetle-.pdf?