Authors: Amy Babb, MD AND Amanpreet Kalsi, MBBS, FRCA - Vanderbilt University Medical Center -
Monroe Carell Jr. Children's Hospital at Vanderbilt
After surgical repair of a complex cardiac defect, an infant requires an unplanned cardiac catheterization intervention. The parents ask about the risks associated with additional procedures after the initial surgery. Based on recent Pediatric Cardiac Critical Care Consortium (PC4) registry data, which of the following groups of patients is associated with the HIGHEST hospital mortality rate?
EXPLANATION
The Pediatric Cardiac Critical Care Consortium (PC4) consists of a multicentric collaborative that aims to improve the quality of care for patients with congenital heart disease (CHD). A study published in 2025 in the Journal of Thoracic and Cardiovascular Surgery used PC4 registry data to examine unplanned cardiac reinterventions (UCR) in 34,495 patients across 62 centers between February 2019 and January 2022 who underwent congenital cardiac surgery. The registry defined UCR as an unplanned reoperation and/or unplanned catheterization procedure during the same hospitalization as the index surgery. Analysis of the data found that UCRs occurred in 7.6% of patients – about 1 in 13 – with reoperation being the most common reintervention. The rate of UCRs across participating centers ranged from 3.6% (10th percentile) to 10.3% (90th percentile). Interestingly, additional evaluation of the data found no association between UCR rate and high, middle, and low volume surgical centers. The most frequent reoperations were permanent pacemaker implantation, followed by “other procedures”, pulmonary artery reconstruction, and PA band adjustments.1
UCRs are strongly associated with worse outcomes, increasing the hospital mortality rate significantly (16.1% in patients requiring any UCR compared to 1.3% in those that did not; adjusted odds ratio of 6.45). Patients requiring both reoperation and catheterization have the highest hospital mortality at 31.9%. Reoperation alone carries a 16.3% mortality, and catheterization alone carries a 9.8% mortality. Mortality with reoperations is also reported by other studies, including one based on the Society of Thoracic Surgeons – Complex Heart Surgery (STS_CHS) registry.2 Several patient-specific risk factors were found to independently predict a UCR. Younger age (especially preterm infants), lower weight for age, noncardiac and/or chromosomal anomalies, and black race were found to predict UCR. Prior cardiac surgery, higher surgical complexity, and multiple cardiopulmonary bypass runs during the index operation also increased the likelihood of UCR. Whilst many risk factors for important residual lesions remain unmodifiable, the authors did note significant variability in the rate of reoperation across centers, which may eventually be modifiable.
The clinical course associated with the highest mortality rate is one in which patients require both an unplanned reoperation and catheterization, according to recent data from the PC4 registry.
REFERENCES
1. Reddy RK, Schumacher KR, Ghanayem NS, et al. Unplanned reinterventions after congenital cardiac surgery and hospital mortality: A report from the Pediatric Cardiac Critical Care Consortium (PC4). J Thorac Cardiovasc Surg. 2025;170(5):1234-1241.e8. doi:10.1016/j.jtcvs.2025.03.005
2. Costello JM, Mongé MC, Hill KD, et al. Associations Between Unplanned Cardiac Reinterventions and Outcomes After Pediatric Cardiac Operations. Ann Thorac Surg. 2018;105(4):1255-1263. doi:10.1016/j.athoracsur.2017.10.050