Skip to main content

Advertisement

SpringerLink
Log in

The Risks of Being Tiny: The Added Risk of Low Weight for Neonates Undergoing Congenital Heart Surgery

  • Original Article
  • Published:
Pediatric Cardiology Aims and scope Submit manuscript

Abstract

The aims of this study were (1) to describe the additive risk of performing cardiac surgery in neonates born ≤ 2.0 kg, after accounting for the baseline risks of low birth weight, and (2) to describe the additive risk of being born ≤ 2.0 kg in neonates undergoing cardiac surgery. We used a risk difference analysis in a retrospective cohort, 2006–2016. Neonates born ≤ 2.0 kg undergoing congenital heart surgery during initial postnatal admission were included. Data were standardized alternatingly for birth weight and cardiac surgical risk using national population data to estimate the number of deaths expected had they not required cardiac surgery or were they of normal weight. Of 105 neonates ≤ 2 kg, median birth weight was 1.6 kg (IQR 1.3–1.8 kg). Median gestational age was 33 weeks (IQR 31–35 weeks). Observed operative mortality was 14.3%; 0% for neonates ≤ 1.0 kg (CI 0–33.6%), 20.6% for neonates > 1.0–1.5 kg (CI 8.7–37.9%), and 12.9% for neonates > 1.5–2.0 kg (CI 5.7–23.9%). Among neonates ≤ 2.0 kg not undergoing cardiac surgery, expected mortality was 4.8% (CI 1.6–10.8); cardiac surgery increased the risk of mortality 9.5% (CI 1.7–17.4%). Conversely, the expected risk for normal birth weight neonates undergoing cardiac surgery was 5.7% (CI 2.1–12.0%); low birth weight increased the risk of mortality 8.6% (CI 0.5–16.6%). To continue making advancements in cardiac surgery, we must understand that the rate of mortality observed in normal weight infants is not a realistic target and that, despite advances, the risk attributable to the surgery remains higher among low birth weight patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Ades AM, Dominguez TE, Nicolson SC, Gaynor JW, Spray TL, Wernovsky G, Tabbutt S (2010) Morbidity and mortality after surgery for congenital cardiac disease in the infant born with low weight. Cardiol Young 20:8–17

    Article  Google Scholar 

  2. Best KE, Tennant PWG, Rankin J (2017) Survival, by birth weight and gestational age, in individuals with congenital heart disease: a population-based study. J Am Heart Assoc 6:e005213

    Article  Google Scholar 

  3. Bove T, Francois K, De Groote K, Suys B, De Wolf D, Verhaaren H, Matthys D, Moerman A, Poelaert J, Vanhaesebroeck P, Van Nooten G (2004) Outcome analysis of major cardiac operations in low weight neonates. Ann Thorac Surg 78:181–187

    Article  Google Scholar 

  4. Curzon CL, Milford-Beland S, Li JS, O'Brien SM, Jacobs JP, Jacobs ML, Welke KF, Lodge AJ, Peterson ED, Jaggers J (2008) Cardiac surgery in infants with low birth weight is associated with increased mortality: analysis of the Society of Thoracic Surgeons Congenital Heart Database. J Thorac Cardiovasc Surg 135:546–551

    Article  Google Scholar 

  5. Kalfa D, Krishnamurthy G, Duchon J, Najjar M, Levasseur S, Chai P, Chen J, Quaegebeur J, Bacha E (2014) Outcomes of cardiac surgery in patients weighing < 2.5 kg: affect of patient-dependent and -independent variables. J Thorac Cardiovasc Surg 148:2499–2506

    Article  Google Scholar 

  6. Hickey EJ, Nosikova Y, Zhang H, Caldarone CA, Benson L, Redington A, Van Arsdell GS (2012) Very low-birth-weight infants with congenital cardiac lesions: is there merit in delaying intervention to permit growth and maturation? J Thorac Cardiovasc Surg 143:126–136

    Article  Google Scholar 

  7. Guillen U, DeMauro S, Ma L, Zupancic J, Wang E, Gafni A, Kirpalani H (2011) Survival rates in extremely low birthweight infants depend on the denominator: avoiding potential for bias by specifying denominators. Am J Obstet Gynecol 205(329):e321–327

    Google Scholar 

  8. Jacobs JP, Jacobs ML, Maruszewski B, Lacour-Gayet FG, Tchervenkov CI, Tobota Z, Stellin G, Kurosawa H, Murakami A, Gaynor JW, Pasquali SK, Clarke DR, Austin EH 3rd, Mavroudis C (2012) Initial application in the EACTS and STS Congenital Heart Surgery Databases of an empirically derived methodology of complexity adjustment to evaluate surgical case mix and results. Eur J Cardio-thorac Surg 42:775–779 (discussion 779–780)

    Article  Google Scholar 

  9. Archer JM, Yeager SB, Kenny MJ, Soll RF, Horbar JD (2011) Distribution of and mortality from serious congenital heart disease in very low birth weight infants. Pediatrics 127:293–299

    Article  Google Scholar 

  10. Adams-Chapman I, Hansen NI, Shankaran S, Bell EF, Boghossian NS, Murray JC, Laptook AR, Walsh MC, Carlo WA, Sanchez PJ, Van Meurs KP, Das A, Hale EC, Newman NS, Ball MB, Higgins RD, Stoll BJ, Eunice Kennedy Shriver National Institute of Child H, Human Development Neonatal Research N (2013) Ten-year review of major birth defects in VLBW infants. Pediatrics 132:49–61

    Article  Google Scholar 

  11. Mai CT, Riehle-Colarusso T, O'Halloran A, Cragan JD, Olney RS, Lin A, Feldkamp M, Botto LD, Rickard R, Anderka M, Ethen M, Stanton C, Ehrhardt J, Canfield M, National Birth Defects Prevention N (2012) Selected birth defects data from population-based birth defects surveillance programs in the United States, 2005–2009: Featuring critical congenital heart defects targeted for pulse oximetry screening. Birth Defects Res A 94:970–983

    Article  CAS  Google Scholar 

  12. O'Brien SM, Clarke DR, Jacobs JP, Jacobs ML, Lacour-Gayet FG, Pizarro C, Welke KF, Maruszewski B, Tobota Z, Miller WJ, Hamilton L, Peterson ED, Mavroudis C, Edwards FH (2009) An empirically based tool for analyzing mortality associated with congenital heart surgery. J Thorac Cardiovasc Surg 138:1139–1153

    Article  Google Scholar 

  13. Horbar JD, Edwards EM, Greenberg LT, Morrow KA, Soll RF, Buus-Frank ME, Buzas JS (2017) Variation in performance of neonatal intensive care units in the United States. JAMA Pediatr 171:e164396

    Article  Google Scholar 

  14. Horbar JD, Carpenter JH, Badger GJ, Kenny MJ, Soll RF, Morrow KA, Buzas JS (2012) Mortality and neonatal morbidity among infants 501 to 1500 grams from 2000 to 2009. Pediatrics 129:1019–1026

    Article  Google Scholar 

  15. Horbar JD, Badger GJ, Carpenter JH, Fanaroff AA, Kilpatrick S, LaCorte M, Phibbs R, Soll RF, Members of the Vermont Oxford N (2002) Trends in mortality and morbidity for very low birth weight infants, 1991–1999. Pediatrics 110:143–151

    Article  Google Scholar 

  16. Stoll BJ, Hansen NI, Bell EF, Shankaran S, Laptook AR, Walsh MC, Hale EC, Newman NS, Schibler K, Carlo WA, Kennedy KA, Poindexter BB, Finer NN, Ehrenkranz RA, Duara S, Sanchez PJ, O'Shea TM, Goldberg RN, Van Meurs KP, Faix RG, Phelps DL, Frantz ID 3rd, Watterberg KL, Saha S, Das A, Higgins RD, Eunice Kennedy Shriver National Institute of Child H, Human Development Neonatal Research N (2010) Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network. Pediatrics 126:443–456

    Article  Google Scholar 

  17. Stoll BJ, Hansen NI, Bell EF, Walsh MC, Carlo WA, Shankaran S, Laptook AR, Sanchez PJ, Van Meurs KP, Wyckoff M, Das A, Hale EC, Ball MB, Newman NS, Schibler K, Poindexter BB, Kennedy KA, Cotten CM, Watterberg KL, D'Angio CT, DeMauro SB, Truog WE, Devaskar U, Higgins RD, Eunice Kennedy Shriver National Institute of Child H, Human Development Neonatal Research N (2015) Trends in care practices, morbidity, and mortality of extremely preterm neonates, 1993–2012. JAMA 314:1039–1051

    Article  CAS  Google Scholar 

  18. Krishnamurthy G (2019) Cardiopulmonary bypass in premature and low birth weight neonates—implications for postoperative care from a neonatologist/intensivist perspective. Semin Thorac Cardiovasc Surg Pediatr Cardiac Surg Annu 22:2–9

    Article  Google Scholar 

  19. Rysavy MA, Li L, Bell EF, Das A, Hintz SR, Stoll BJ, Vohr BR, Carlo WA, Shankaran S, Walsh MC, Tyson JE, Cotten CM, Smith PB, Murray JC, Colaizy TT, Brumbaugh JE, Higgins RD, Eunice Kennedy Shriver National Institute of Child H, Human Development Neonatal Research N (2015) Between-hospital variation in treatment and outcomes in extremely preterm infants. N Engl J Med 372:1801–1811

    Article  Google Scholar 

  20. Newborn AAoPCoFa (2004) Levels of neonatal care. Policy statement: organizational principles to guide and define the child health care system and/or improve the health of all children. Pediatrics 114:1341–1347

    Article  Google Scholar 

  21. Phibbs CS, Baker LC, Caughey AB, Danielsen B, Schmitt SK, Phibbs RH (2007) Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants. N Engl J Med 356:2165–2175

    Article  CAS  Google Scholar 

  22. Lasswell SM, Barfield WD, Rochat RW, Blackmon L (2010) Perinatal regionalization for very low-birth-weight and very preterm infants: a meta-analysis. JAMA 304:992–1000

    Article  Google Scholar 

  23. Gabler E (2019) Doctors were alarmed: ‘would I have my children have surgery here?’. New York Times, New York

    Google Scholar 

  24. McGrory K, Bedi N (2018) Johns Hopkins promised to elevate All Children’s Heart Institute. Then patients started to die at an alarming rate. Tampa Bay Times, Tampa Bay

    Google Scholar 

  25. Cohen E, Bonifeld J (2015) Secret deaths: CNN finds high surgical death rate for children at a Florida hospital. CNN, Atlanta

    Google Scholar 

  26. Sakai-Bizmark R, Mena LA, Kumamaru H, Kawachi I, Marr EH, Webber EJ, Seo HH, Friedlander SIM, Chang RR (2019) Impact of pediatric cardiac surgery regionalization on health care utilization and mortality. Health Serv Res 54:890–901

    PubMed  PubMed Central  Google Scholar 

  27. Burki S, Fraser CD Jr (2016) Larger centers may produce better outcomes: is regionalization in congenital heart surgery a superior model? Semin Thorac Cardiovasc Surg Pediatr Cardiac Surg Annu 19:10–13

    Article  Google Scholar 

  28. Jenkins KJ, Newburger JW, Lock JE, Davis RB, Coffman GA, Iezzoni LI (1995) In-hospital mortality for surgical repair of congenital heart defects: preliminary observations of variation by hospital caseload. Pediatrics 95:323–330

    CAS  PubMed  Google Scholar 

  29. Welke KF, O'Brien SM, Peterson ED, Ungerleider RM, Jacobs ML, Jacobs JP (2009) The complex relationship between pediatric cardiac surgical case volumes and mortality rates in a national clinical database. J Thorac Cardiovascu Surg 137:1133–1140

    Article  Google Scholar 

  30. Chang RK, Klitzner TS (2002) Can regionalization decrease the number of deaths for children who undergo cardiac surgery? A theoretical analysis. Pediatrics 109:173–181

    Article  Google Scholar 

  31. Hannan EL, Racz M, Kavey RE, Quaegebeur JM, Williams R (1998) Pediatric cardiac surgery: the effect of hospital and surgeon volume on in-hospital mortality. Pediatrics 101:963–969

    Article  CAS  Google Scholar 

  32. Pasquali SK, Li JS, Burstein DS, Sheng S, O'Brien SM, Jacobs ML, Jaquiss RD, Peterson ED, Gaynor JW, Jacobs JP (2012) Association of center volume with mortality and complications in pediatric heart surgery. Pediatrics 129:e370–376

    Article  Google Scholar 

  33. Welke KF, Diggs BS, Karamlou T, Ungerleider RM (2008) The relationship between hospital surgical case volumes and mortality rates in pediatric cardiac surgery: a national sample, 1988–2005. Ann Thorac Surg 86:889–896 (discussion 889–896)

    Article  Google Scholar 

  34. Vinocur JM, Menk JS, Connett J, Moller JH, Kochilas LK (2013) Surgical volume and center effects on early mortality after pediatric cardiac surgery: 25-year North American experience from a multi-institutional registry. Pediatr Cardiol 34:1226–1236

    Article  Google Scholar 

  35. Costello JM, Pasquali SK, Jacobs JP, He X, Hill KD, Cooper DS, Backer CL, Jacobs ML (2014) Gestational age at birth and outcomes after neonatal cardiac surgery: an analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database. Circulation 129:2511–2517

    Article  Google Scholar 

  36. Tita AT, Landon MB, Spong CY, Lai Y, Leveno KJ, Varner MW, Moawad AH, Caritis SN, Meis PJ, Wapner RJ, Sorokin Y, Miodovnik M, Carpenter M, Peaceman AM, O'Sullivan MJ, Sibai BM, Langer O, Thorp JM, Ramin SM, Mercer BM, Eunice Kennedy Shriver NM-FMUN (2009) Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med 360:111–120

    Article  CAS  Google Scholar 

Download references

Acknowledgements

The Vermont Oxford Network and the Society of Thoracic Surgeons played no role in the design, conduct, analysis, interpretations, or reporting. The views, conclusions, and opinions expressed here are solely those of the authors and do not represent those of the Vermont Oxford Network or the Society of Thoracic Surgeons.

Funding

Dr. Anderson and Dr. Crook receive salary support from the National Institutes of Health/National Heart Lung and Blood Institute (K23 HL133454).

Author information

Author notes

  1. Brett R. Anderson and Victoria L. Blancha Eckels contributed equally to the conduct of this study.

Authors and Affiliations

  1. Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children’s Hospital, Columbia University Irving Medical Center, 3959 Broadway, CH-2N, New York, NY, 10032, USA

    Brett R. Anderson & Sarah Crook

  2. Columbia University College of Physicians and Surgeons, New York, NY, USA

    Victoria L. Blancha Eckels

  3. Division of Neonatology, NewYork-Presbyterian/Morgan Stanley Children’s Hospital, Columbia University Irving Medical Center, New York, NY, USA

    Jennifer M. Duchon & Ganga Krishnamurthy

  4. Division of Cardiothoracic Surgery, NewYork-Presbyterian/Morgan Stanley Children’s Hospital, Columbia University Irving Medical Center, New York, NY, USA

    David Kalfa & Emile A. Bacha

Authors
  1. Brett R. Anderson
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Victoria L. Blancha Eckels
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sarah Crook
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jennifer M. Duchon
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. David Kalfa
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Emile A. Bacha
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Ganga Krishnamurthy
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

This work was conceived of and performed under close supervision and guidance by BA, in the Division of Pediatric Cardiology, and by GK, in the Division of Neonatology at Columbia University Irving Medical Center. BA, designed the study and wrote the first draft of the manuscript. VBE, collected the data, participated in the initial study design, and assisted in the first draft of the manuscript. All members of the research team participated in study design and conduction, analysis, data interpretation, and manuscript revisions. All authors read and approved the final version of this manuscript.

Corresponding author

Correspondence to Brett R. Anderson.

Ethics declarations

Conflict of interest

The authors declare that they have no competing interests.

Ethical Approval

This study received Institutional Review Board approval (AAAR9989, approved 08/09/2018).

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Anderson, B.R., Blancha Eckels, V.L., Crook, S. et al. The Risks of Being Tiny: The Added Risk of Low Weight for Neonates Undergoing Congenital Heart Surgery. Pediatr Cardiol 41, 1623–1631 (2020). https://doi.org/10.1007/s00246-020-02420-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00246-020-02420-0

Keywords

Search

Navigation