Complications And Related Risk Factors After Total Cavopulmonary Connection

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Risk factors for prolonged mechanical ventilation following total cavopulmonary connection surgeryObjective:We aims to identify the clinical risk factors for prolonged mechanical ventilation(PMV)after total cavopulmonary connection(TCPC)surgery.Methods:A total of 504 patients with TCPC surgery from 2010 to 2018 at Fuwai hospital were included in this retrospective study.The definition of PMV was derived from the Cox regression model for predicting postoperative length of hospital stay.Lasso regression,logistic regression and Cox regression were applied to identify predictors for PMV.Results:Patients with mechanical ventilation time>9 hours were identified as having PMV.Independent predictors of PMV included:age,intraoperative maximum vasoactive-inotropic score(VIS),minimal temperature during cardiopulmonary bypass(CPB),postoperative prothrombin time,alkaline phosphatase and total bilirubin levels,and postoperative fluid balance.These predictors were also achieved in the Cox regression for predicting the duration of mechanical ventilation.Patients with PMV were associated with increased blood transfusions,more consumption of vasopressin and anti-pulmonary hypertension medication,higher incidence of re-intubation,more renal replacement treatment,longer intensive care unit(ICU)and hospital stay,higher hospitalization costs and more specialist visits.Conclusions:Based on our experience bias,age at operation,maximal VIS and minimal temperature during CPB,postoperative prothrombin time,alkaline phosphatase and total bilirubin levels,and postoperative fluid balance were independent predictors of PMV.Adopting a comprehensive strategy of perioperative management that targets the identified risk factors might significantly lower the risk of PMV and improve in-hospital outcomes.Part ? Risk factors for prolonged pleural effusion following total cavopulmonary connection surgeryObjectives:We aimed to identify risk factors for prolonged pleural effusion(PPE)following total cavopulmonary connection(TCPC)surgery.Methods:We studied a retrospective cohort of 525 who undergoing TCPC surgery from 2010 to 2019.We defined PPE as the duration of pleural effusion exceeding 14 days.Logistic regression was applied to identify risk factors for PPE and Cox regression was used to identify risk factors for predicting the duration of pleural effusion.The impacts of PPE on the short-term outcomes were evaluated.Results:The rate of PPE was 27.4%in our study and independent risk factors for PPE included:young age,no fenestration,low postoperative total protein,prolonged mechanical ventilation and chylothorax.These predictors were also achieved in the Cox regression for predicting the duration of pleural effusion.The applicability of the model was acceptable in different subgroups,which derived from the total cohort.Patients with PPE were associated with more renal replacement treatment,longer length of ICU and hospital stay,more hospitalization costs and a higher rate of in-hospital mortality.Conclusions:PPE in our study occurs at a relatively lower rate than that reported in previous studies and patients with PPE was associated with higher rate of in-hospital mortality when compared to patients without PPE.Young age,no fenestration,low postoperative total protein,prolonged mechanical ventilation and chylothorax were identified as independent risk factors to predict PPE.A preventive strategy that targets the identified risk factors to reduce the incidence of PPE following TCPC surgery could be beneficial for in-hospital outcomesPart ? Identifying predictors for persistent acute kidney injury following total cavopulmonary connection surgeryObjectives:We aimed to assess the incidence and identify the predictors for persistent acute kidney injury(AKI)after total cavopulmonary connection(TCPC).Methods:We retrospectively analysed 465 children undergoing TCPC surgery from 2010 to 2019 in Fuwai Hospital.We defined persistent AKI as AKIs occurring between postoperative day one(POD1)and POD3 and sustaining at least on POD7.Univariate and multivariate logistic regressions were applied to analyze the predictors for persistent AKI.Results:A total of 35.3%patients developed AKI between POD1 to POD3 and 15.5%patents had persistent AKI after TCPC.Patients with persistent AKI had prolonged mechanical ventilation and ICU stay,and had higher rates of renal replacement treatment and reintubation,which was associated with higher hospitalization costs and in-hospital mortality.The independent predictors for persistent AKI were intraoperative fluid balance,PODO maximal lactic acid,renal perfusion pressure(RPP),peripheral oxygen saturation(SpO2)when admission,PODO estimated glomerular filtration rate and PODO total bilirubin.The areas under receiver operating characteristic curve(AUC)in the total cohort and the subgroup undergoing TCPC surgery after 2017 were 0.75(95%CI,0.66-0.82)and 0.87(95%CI,0.77-0.97),respectively.The acceptable AUCs(nearly 0.7)were achieved in other 5 subgroups and good calibration ability(p>0.05)were achieved in the total cohort and all six subgroups.Conclusions:Persistent AKI after TCPC was common and strongly associated with poorer in-hospital outcomes in Chinese pediatric patients.Six perioperative variables,including intraoperative fluid balance,PODO maximal lactic acid,RPP,SpO2,PODO estimated glomerular filtration rate and PODO total bilirubin,were identified as independent predictors for persistent AKI.Riview Progress in complications following total cavopulmonary connectionTotal cavopulmonary connection(TCPC)is a palliative procedure for patients with functionally single ventricle.With the development of operation skills and improving of management strategies,the outcomes after TCPC surgery are improved.However,complications after TCPC still bring great challenges to the postoperative management and dealing with those complications timely can reduce the mortality after TCPC.This review summarizes our current knowledge about complications after TCPC,which is expected to provide reference for clinical practice.