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. 2017 Jun 19;12(6):e0178963.
doi: 10.1371/journal.pone.0178963. eCollection 2017.

Outcome of cardiac surgery in patients with congenital heart disease in England between 1997 and 2015

Aleksander Kempny  1 , Konstantinos Dimopoulos  1 , Anselm Uebing  1 , Gerhard-Paul Diller  1   2 , Ulrich Rosendahl  3 , George Belitsis  3   4 , Michael A Gatzoulis  1 , Stephen J Wort  1
Affiliations

Outcome of cardiac surgery in patients with congenital heart disease in England between 1997 and 2015

Aleksander Kempny et al. PLoS One. .

Abstract

Background: The number of patients with congenital heart disease (CHD) is increasing worldwide and most of them will require cardiac surgery, once or more, during their lifetime. The total volume of cardiac surgery in CHD patients at a national level and the associated mortality and predictors of death associated with surgery are not known. We aimed to investigate the surgical volume and associated mortality in CHD patients in England.

Methods: Using a national hospital episode statistics database, we identified all CHD patients undergoing cardiac surgery in England between 1997 and 2015.

Results: We evaluated 57,293 patients (median age 11.9years, 46.7% being adult, 56.7% female). There was a linear increase in the number of operations performed per year from 1,717 in 1997 to 5,299 performed in 2014. The most common intervention at the last surgical event was an aortic valve procedure (9,276; 16.2%), followed by repair of atrial septal defect (9,154; 16.0%), ventricular septal defect (7,746; 13.5%), tetralogy of Fallot (3,523; 6.1%) and atrioventricular septal defect (3,330; 5.8%) repair. Associated mortality remained raised up to six months following cardiac surgery. Several parameters were predictive of post-operative mortality, including age, complexity of surgery, need for emergency surgery and socioeconomic status. The relationship of age with mortality was "U"-shaped, and mortality was highest amongst youngest children and adults above 60 years of age.

Conclusions: The number of cardiac operations performed in CHD patients in England has been increasing, particularly in adults. Mortality remains raised up to 6-months after surgery and was highest amongst young children and seniors.

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Conflict of interest statement

Competing Interests: Dr Kempny has received unrestricted educational grant support from Actelion Global. Prof Gatzoulis and the Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension have received support from the British Heart Foundation. Dr Wort and Dr Dimopoulos have acted as Consultants and received unrestricted educational grants from Actelion, GSK, Bayer and Pfizer. This project was supported by the NIHR Cardiovascular Biomedical Research Unit of Royal Brompton and Harefield NHS Foundation Trust and Imperial College London. This report is independent research by the National Institute for Health Research Biomedical Research Unit Funding Scheme. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1
Fig 1. Number of cardiac operations in patients with CHD by year and age.
There was an increase over time in the number of annually performed cardiac surgery in CHD patients, irrespective of age; the highest increase was observed in adults.
Fig 2
Fig 2. Length of hospital stay after cardiac surgery in CHD patients.
Length of hospital stay after surgery in CHD patients undergoing (A) elective or (B) non-elective cardiac surgery.
Fig 3
Fig 3. Survival after cardiac surgery in CHD patients.
This panel presents figures for all surgical procedures (A, B, C) and elective procedures only (D, E, F). These include Kaplan-Meier survival curves after cardiac surgery (A, D), mortality calculated for each month following surgery (B, E) and mortality six months after surgery (C, F). Expected mortality was calculated for age and gender-matched UK population. Mortality within the first six months after surgery is 33–42% higher than the mortality at 30 days from surgery or within the same hospital stay (i.e. the follow-up period that STS or EuroScore account for). The absolute excess mortality, above the one predicted by scores, is highest in patients in whom the risk predicted by mortality scores is high.
Fig 4
Fig 4. Leading cause of death in patients dying within 30 days from surgery or within the same hospital stay.
Causes of death for patients who died within 30-days from surgery or within the same hospital stay. CHD, congenital heart disease; Congenital other, non-cardiac congenital malformation; IHD, ischemic heart disease; Aortic event, aortic aneurysm or dissection; PHT, pulmonary hypertension; CVD, cerebrovascular disease; HTN, systemic hypertension. Infection, not including endocarditis. The most common 10 causes of death are colour coded.
Fig 5
Fig 5. Leading cause of death in patients who died beyond 30 days from surgery and after discharge from hospital.
CHD, congenital heart disease; Congenital other, non-cardiac congenital malformation; IHD, ischemic heart disease; Aortic event, aortic aneurysm or dissection; PHT, pulmonary hypertension; CVD, cerebrovascular disease; HTN, systemic hypertension. Infection, not including endocarditis. The most common 10 causes of death are colour coded.
Fig 6
Fig 6. Mortality at six months after cardiac surgery in CHD patients.
Mortality risk at 6 months after elective and non-elective cardiac surgery in CHD patients. There is a non-linear relation between age at operation and mortality, with a relatively sharp decline from birth to teenage years, with nadir at 15–18 years, slow increase in mortality until the age of 55–65 years, when mortality starts to rise sharply.
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Grants and funding

This project was supported by the NIHR Cardiovascular Biomedical Research Unit of Royal Brompton and Harefield NHS Foundation Trust and Imperial College London. This report is independent research by the National Institute for Health Research Biomedical Research Unit Funding Scheme. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health.