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J Thorac Cardiovasc Surg 2010;139:569-577
© 2010 The American Association for Thoracic Surgery

Congenital Heart Disease

Lesion-specific outcomes in neonates undergoing congenital heart surgery are related predominantly to patient and management factors rather than institution or surgeon experience: A Congenital Heart Surgeons Society Study

^a Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
^b Division of Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada
^c Division of Cardiothoracic Surgery and Biostatistics and Epidemiology, Cleveland Clinic Foundation, Cleveland, Ohio
^d Division of Cardiovascular Surgery, Children's Hospital National Medical Center, Washington, DC
^e Department of Surgery, Medical University of South Carolina, Charleston, SC
^f Division of Cardiothoracic Surgery, University of Michigan, Ann Arbor, Mich

Presented at the American Heart Association Scientific Sessions, November 2005, Dallas, Tex.

Received for publication February 7, 2008; revisions received September 25, 2008; accepted for publication November 23, 2008.

^_* Address for reprints: William G. Williams, MD, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada M5 G 1X8. (Email: bill.williams{at}sickkids.ca).

Objective: To identify the role of institution and surgeon factors, including case volume and experience, on survival of neonates with complex congenital heart disease.

Methods: A total of 2421 neonates from 4 groups—transposition of the great arteries (n = 829), pulmonary atresia with intact ventricular septum (n = 408), Norwood (n = 710), and interrupted aortic arch (n = 474)—were prospectively enrolled from Congenital Heart Surgeons Society institutions. Multivariable analysis of risk-adjusted survival was performed for each group, entering each institution or surgeon into the multivariable analysis separately. Institutional performance was defined as [predicted survival – actual survival]. Neutralization of risk factors within each institution was evaluated using complex interaction terms. Institution and surgeon experience, defined by 5 domains (total case volume, total time each operation was performed, cases per year, rank-order of cases, case velocity), were also investigated.

Results: Institutional performance varied among all groups. Improved outcomes in Norwood and pulmonary atresia with intact ventricular septum were unrelated to any "experience" domains, whereas improved outcomes in transposition of the great arteries were significantly related to increased experience in most domains. No institution enrolling in all 4 studies ranked number 1 in performance for all groups. Neutralization of low birth weight as a risk factor contributed to decreased mortality after Norwood in one institution.

Conclusion: Survival of neonates with complex congenital heart disease is influenced more by patient and management factors than by institution or surgeon experience. Institutional excellence in managing some diagnostic groups does not indicate similar performance for all diagnostic groups. Weighted risk-adjusted comparisons could provide a mechanism to improve results in institutions with less than optimal outcomes.

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