Pediatric Heart Surgeons: Best For Adult Heart Defect Surgery
Adults with congenital heart disease are more likely to have cardiac surgery done by a heart surgeon not specialized in pediatric heart surgery but patients may be better off if it’s done by a pediatric or congenital heart surgeon, according to a report in Circulation: Journal of the American Heart Association.
A congenital heart defect occurs when the heart or blood vessels near the heart develop abnormally before birth.
Researchers identified congenital heart surgeries performed from 1988 to 2003, using the Nationwide Inpatient Sample database. They analyzed the outcomes of cases performed by pediatric heart surgeons, defined as heart surgeons with a 75 percent yearly case volume spent on patients younger than 18 years. They compared those cases to outcomes of heart surgeons, without specialization in pediatric heart surgery.
The risk of in-hospital death for adult congenital heart disease patients operated on by congenital heart surgeons was 1.87 percent. For those whose operations were performed by surgeons without a focus in congenital heart surgery, the figure was 4.84 percent.
“We found that this survival advantage increased with increasing annual pediatric surgery volume,” said Tara Karamlou, M.D., M.Sc., lead author of the study and cardiothoracic surgery fellow at the University of Michigan in Ann Arbor. “We also found that patients had shorter hospital stays and lower hospital charges when they used surgeons who performed a greater percentage of pediatric heart cases.”
Of 30,250 operations, nearly three quarters of them were pediatric cases. Among the 27 percent of the cases identified as adults with congenital heart disease, researchers found important differences between those performed by pediatric heart surgeons and those done by non-pediatric heart surgeons.
“Whereas specialized pediatric heart surgeons performed 68 percent of the pediatric operations, more than 95 percent of adult congenital heart disease patients received their care from non-congenital heart surgeons,” Karamlou said. “There is a striking separation that occurs: patients with adult congenital heart disease undergo repair by surgeons whose primary focus is adult cardiac surgery, but pediatric patients within the same diagnostic subgroups undergo repair by surgeons whose primary focus is congenital heart surgery. The separation, therefore, appears primarily motivated by an arbitrary designation of ‘adulthood’ rather than a fundamental difference in the underlying disease process.”
The data show that initiatives to develop centers that include congenital heart surgeons for managing adult congenital heart disease are warranted, Karamlou said. Any financial burden created by initiating these centers of specialized care may be overcome by the lives saved and lower costs related to these surgeries, she said.
Researchers said there were limitations to the study. Information gathered from administrative databases, such as those used here, are not able to fully control for how ill patients were prior to surgery, nor for other confounding variables. A portion of the data on the specific surgeons operating on the patients was not available in the databases, as well as data that might suggest that the hospital environment, rather than or in addition to the surgeon, played an important role. Further investigation is warranted.
“We did this study to define national practice patterns for adult congenital heart disease patients and to determine whether these patients experience improved outcomes when treated by specialized pediatric heart surgeons,” Karamlou said. “This information is important, given the rapidly increasing numbers of adult patients with congenital heart disease.”
In other current studies, researchers are attempting to define the ideal clinical environment for these adult patients.
As of 2002, the prevalence of congenital cardiovascular defects in the United States was 650,000 to 1.3 million, according to the American Heart Association. Almost as many people with congenital cardiovascular defects are younger than 25 years as are over that age, but the proportions differ among disease types. In 2004, hospital costs for congenital cardiovascular defect conditions totaled $2.6 billion.