[Downloaded free from http://www.annalspc.com on Monday, April 6, 2020, IP: 115.178.251.

232]

ORIGINAL ARTICLE

Outcome of pediatric cardiac surgery and predictors of major

complication in a developing country
Indah K Murni, Mulyadi M Djer1, Piprim B Yanuarso1, Sukman T Putra1, Najib Advani1, Jusuf Rachmat2, Aries Perdana3,
Rubiana Sukardi4
Department of Pediatrics, Faculty of Medicine, Dr. Sardjito Hospital, Universitas Gadjah Mada, Yogyakarta, Departments of 1Child Health, 2Cardio‑Thoracic Surgery
and 3Anesthesiology, Dr. Cipto Mangunkusumo Hospital, University of Indonesia, 4Integrated Cardiac Centre, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia

ABSTRACT
Background : Evaluating outcome and identifying predictors of major complications among children
undergoing cardiac surgery are essential to improve care. We evaluated short‑term
outcomes of postcardiac surgery and predictors of major complications in a national
referral hospital in Indonesia.
Methods : A prospective cohort study was conducted from April 2014 to March 2015 on all
children undergoing cardiac surgery. Participants were followed up from the time of
surgery until hospital discharge and 30‑day mortality. We performed univariate and
multivariate logistic regression using STATA 12.1 to identify predictors of postsurgical
major complications.
Results : A total of 257 patients (median age: 36 months) were recruited; 217 (84.1%) had complications,
including low cardiac output syndrome (19.8%), arrhythmia (18.6%), sepsis (17.4%), and
pleural effusion (14.8%). Forty‑nine (19%) patients had major complications, including
cardiac arrest (5%), need for emergency chest opening (3.9%), and multiple organ
failure (7.4%). 12.8% died during hospital stay, and 30‑day mortality was 13.6%. Predictors
of major complications were cyanotic congenital heart disease (odds ratio [OR]: 4.6, 95%
confidence interval [CI]: 1.5–14.2), longer duration of cardiopulmonary bypass (CPB, OR:
4.4, 95% CI: 1.5–13.4), high inotropes (OR: 13.1, 95% CI: 3.2–54.2), and increase in lactate >0.75
mmol/L/h or more in the first 24 h (OR: 37.1, 95% CI: 10.1–136.3).
Conclusion : One‑fifth of children undergoing cardiac surgery experienced major complications with
around 13% mortality. Cyanotic congenital heart disease, longer duration of CPB, high
inotropes on leaving operating theater, and increase in blood lactate are associated with
major complications in children after cardiac surgery.
Keywords : Cardiac surgery, children, complication, mortality, outcome, predictor

well described in high‑income countries; however, data

INTRODUCTION
from low‑to‑middle‑income countries have been limited.
The performance of pediatric cardiac surgery programs Mortality has been used as a robust indicator to evaluate
should be continually evaluated to improve the quality of
patient care.[1] Outcomes of pediatric cardiac surgery are This is an open access journal, and articles are distributed under the
terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike
4.0 License, which allows others to remix, tweak, and build upon the
Access this article online work non‑commercially, as long as appropriate credit is given and the
Quick Response Code: new creations are licensed under the identical terms.
Website:
www.annalspc.com For reprints contact: [email protected]

How to cite this article: Murni IK, Djer MM, Yanuarso PB, Putra ST,
DOI: Advani N, Rachmat J, et al. Outcome of pediatric cardiac surgery and
10.4103/apc.APC_146_17 predictors of major complication in a developing country. Ann Pediatr
Card 2019;12:38-44.

Address for correspondence: Dr. Indah K Murni, Department of Pediatrics, Faculty of Medicine, Dr. Sardjito Hospital, Universitas Gadjah Mada,
Yogyakarta, Indonesia. E‑mail: [email protected]

38 © 2019 Annals of Pediatric Cardiology | Published by Wolters Kluwer ‑ Medknow

[Downloaded free from http://www.annalspc.com on Monday, April 6, 2020, IP: 115.178.251.232]

Murni, et al.: Outcome of cardiac surgery and predictors of major complication

the quality of pediatric cardiac surgery care.[2] However, chest opening. We also recorded baseline characteristics
morbidities or complications after cardiac surgery may of patients, clinical signs or symptoms, the outcomes
serve an additional indicator to determine the quality of cardiac surgery, and potential predictors of major
of cardiac surgical services.[2] complications after surgery. Risk Adjustment for
Congenital Heart Surgery‑1 (RACHS‑1) category was
In low‑to‑middle‑income countries, limitations of
used to compare outcome data for children undergoing
human resources and facilities for cardiac surgery
cardiac surgery.
and postoperative management may adversely affect
the outcomes of the pediatric cardiac surgery. Major Five potential predictors were included as follow:
complications are often preceded by a period of preoperative congestive heart failure, cyanotic congenital
inadequate oxygen balance, and identifying the oxygen heart disease, longer duration of cardiopulmonary
imbalance is challenging in children after cardiac bypass (CPB) (>120 min), high inotropic drug requirement
surgery.[3,4] Therefore, knowing the predictors for major on discharge from operating room, and increase in blood
complication is important to formulate a preventive lactate level (>0.75 mmol/L/h or more in the first 24 h
strategy for major complications after cardiac surgery after cardiac surgery).[3,6] High inotropic drug requirement
and to improve care. Given limited data, studies are was defined as the use of at least two types of drugs with
needed to identify predictors for adverse outcomes of high doses (≥10 mcg/kg/min of dopamine or dobutamine,
pediatric cardiac surgery performed. This study aimed or epinephrine or norepinephrine at least 0.1 mcg/kg/min,
to evaluate the outcomes and predictors for major or milrinone at least 0.5 mcg/kg/min).
complications in children undergoing cardiac surgery as
initial problems at a national referral hospital of cardiac
Outcome measures
service in Indonesia. We set inhospital mortality, 30‑day mortality, and the
incidence of complications including major complications
METHODS after cardiac surgery as the primary outcomes. A 30‑day
mortality was defined when death occurred outside of
Study design and population the hospital but within 30 days after cardiac surgery
A prospective cohort study was conducted in cardiac performed. Complication was defined as a deviation
intensive care unit (CICU), Dr. Cipto Mangunkusumo from the expected outcome of cardiac surgery.[7] In
Hospital, Jakarta, Indonesia, between April 2014 and addition, we secondarily looked at factors to predict
March 2015. Dr. Cipto Mangunkusumo National General the development of major complications after pediatric
Hospital is the national referral hospital in Indonesia. cardiac surgery in children in Indonesia.
The CICU is an 8‑bed unit providing postoperative care Data analysis
for both adult and pediatric patients and is managed by
intensivist and pediatric cardiac intensivist. There are two We first described baseline data and outcomes using
pediatric cardiac surgeons in this hospital. The hospital mean, median, or proportions as appropriate. We first
started working on pediatric cardiac care in 2002. This performed univariate analysis using the Chi‑square test
study had been approved by the Ethics Committee of the to determine the association between each predictor
University of Indonesia, Jakarta, Indonesia. The ethics and the occurrence of major complications. We further
committees did not require individual patient consent, conducted a multivariate logistic regression to determine
but all parents of children in the ward were informed predictors which were independently associated with
of the study. major complications after cardiac surgery. All potential
predictors, including all variables found to be statistically
We consecutively enrolled pediatric patients admitted
significant on the univariable analysis, were included in
to CICU after cardiac surgery for both congenital and
the multivariable model. Findings are presented as odds
acquired heart diseases. All participating children were
ratios with corresponding 95% confidence intervals (CIs)
monitored daily from the time of surgery performed until
and P values. The Hosmer–Lemeshow test was used to
they were discharged or died to identify the presence
check for goodness of fit for logistic regression model.
of complication after cardiac surgery. Complications
were defined based on the multisocietal database Data analysis was performed using STATA version 12.1,
committee for pediatric and congenital heart disease StataCorp LP, College Station, Texas, USA. P <0.05 or a CI
criteria.[5] Factors associated with the development of not including 1 was considered as statistically significant.
major complications were identified.

Data collection RESULTS

We collected data using a standardized form to record Two hundred and fifty‑seven patients were enrolled.
major complications, which included death, multiorgan Their baseline characteristics are described in Table 1.
dysfunction, cardiac arrest, and need for emergency Most patients were undernourished and about half had

Annals of Pediatric Cardiology / Volume 12 / Issue 1 / January-April 2019 39

[Downloaded free from http://www.annalspc.com on Monday, April 6, 2020, IP: 115.178.251.232]

Murni, et al.: Outcome of cardiac surgery and predictors of major complication

failure to thrive. The most common congenital heart Table 1: Baseline characteristics
operation performed was ventricular septal defect (VSD) Characteristics n=257
repair (28.7%), and the most common cyanotic congenital Sex, n (%)
heart disease surgery was for tetralogy of Fallot (TOF) Female 134 (52.1)
Age, median in months (minimal‑maximal) 36 (0.5‑211)
repair, which comprised 24.4% of the total procedures. Nutritional state, n (%)
The majority of patients who underwent definitive Undernourished 149 (58)
cardiac surgery were included in the RACHS‑1 category Normal 98 (38.1)
Overweight 10 (3.9)
2 (84.4%). Approximately more than 10% of children Failure to thrive, n (%) 68 (26.5)
had long duration of mechanical ventilation (>7 days) Syndrome, n (%) 20 (7.8)
and hospital stay (>14 days) [Table 2]. Diagnosis, n (%)
Ventricular septal defect 74 (28.7)
Most patients (84.1%) experienced some postoperative Tetralogy of Fallot 63 (24.5)
Atrial septal defect 23 (8.9)
complications. The most common complication was
Mitral stenosis or regurgitation 17 (6.6)
hypocalcemia (63%), hyperglycemia (61.5%), low cardiac DORV 16 (6.2)
output syndrome (LCOS) (19.8%), arrhythmia (18.6%), Single ventricle 12 (4.7)
Atrioventricular septal defect 9 (3.5)
nosocomial bloodstream infections or sepsis (17.4%),
PA‑VSD 8 (3.1)
and pleural effusion (14.8%) [Table 3]. Around 13% PA‑IVS 6 (2.3)
of all blood cultures obtained were positive and the Patent ductus arteriosus 5 (1.9)
TGA‑VSD 4 (1.6)
causes of nosocomial bloodstream infections were
TGA‑IVS 4 (1.6)
mostly Gram‑negative bacteria including Acinetobacter TAPVD or PAPVD 4 (1.6)
baumannii, Escherichia coli, and Klebsiella pneumoniae. Tricuspid atresia 3 (1.2)
Ebstein’s anomaly 3 (1.2)
The incidences of postoperative arrhythmia and total
Mitral atresia 2 (0.8)
atrioventricular (AV) block in our cohort were 18.6 and Truncus arteriosus 1 (0.4)
5.8%, respectively. Others 3 (1.2)
Definitive operation, n (%) 200 (77.5)
About one‑fifth  (19%) developed at least one major RACHS‑1, n (%)
complication after cardiac surgery during the follow‑up. Category 1 24 (9.4)
Category 2 217 (84.4)
In-hospital mortality occurred in 33 (12.8%) and a Category 3 5 (1.9)
30‑day mortality in 35 (13.6%) children after cardiac Category 4 9 (3.5)
Category 5 2 (0.8)
surgery [Table 4]. Two patients died within 30 days after
SD: Standard deviation, CI: Confidence interval, PA‑VSD: Pulmonary
cardiac surgery outside the hospital, including a patient
atresia with ventricular septal defect, PA‑IVS: Pulmonary atresia
with congenitally corrected transposition of the great with intact ventricular septum, DORV: Double outlet right ventricular,
arteries (TGAs) undergoing bidirectional cavopulmonary TGA‑VSD: Transposition of the great arteries with ventricular septal defect,
TGA‑IVS: Transposition of the great arteries with intact ventricular septum,
shunt (BCPS), and one patient following repair of TAPVD: Total anamolous pulmonary venous drainage, PAPVD: Partial
complete atrio ventricular septal defect (CAVSD). The anamolous pulmonary venous drainage, RACHS‑1: Risk Adjustment for
possible causes of death were recurrent massive pleural Congenital Heart Surgery‑1

effusion in the patient after BCPS procedure and total

AV block in the patient with CAVSD repair. Table 2: Outcomes of pediatric cardiac surgery
Outcomes n=257
We evaluated five potential predictors to predict Use of CPB, n (%) 204 (79.4)
major complications after cardiac surgery among CPB time, median (min), minimal‑maximal 75 (17‑313)
these children. The univariate analysis identified that Aortic clamp time, median (min), minimal‑maximal 35 (6‑239)
ICU stay, median (h), minimal‑maximal 24 (5‑960)
all predictors were significantly associated with the Duration of mechanical ventilation, median (h), 18 (2‑912)
development of major complications. In the multivariate minimal‑maximal
logistic regression analysis, cyanotic congenital heart Use of ventilator >7 days, n (%) 27 (10.5)
Hospital stay, median (days), minimal‑maximal 6 (1‑120)
disease, longer duration of CPB, high inotropic drugs on Hospital stay ≥14 days, n (%) 40 (15.5)
leaving operating room, and increased blood lactate level CPB: Cardiopulmonary bypass, ICU: Intensive care unit
were independently associated with the development
of major complications after cardiac surgery. Cyanotic
congenital heart disease and longer duration of CPB
DISCUSSIONS
were associated with around 4‑fold higher risk in the As far as we are aware, this study was the first study
probability of developing major complications, while in Indonesia evaluating the outcomes of children after
high inotropic drugs on discharge from operating theater cardiac surgery, demonstrating an inhospital mortality
and increased blood lactate level were independently of 12.8%. Mortality rates after surgery differ markedly
associated with around 13‑ and 30‑fold increased risk, depending on the complexity and severity of cases
respectively [Table 5]. attempted, comorbidities (such as malnutrition and

40 Annals of Pediatric Cardiology / Volume 12 / Issue 1 / January-April 2019

[Downloaded free from http://www.annalspc.com on Monday, April 6, 2020, IP: 115.178.251.232]

Murni, et al.: Outcome of cardiac surgery and predictors of major complication

Table 3: Proportion of complications after recognize a learning curve when undertaking new
pediatric cardiac surgery surgical procedure. Introduction of a new procedure
Type of complications n=257 using training courses and expert assistance might
Readmission, n (%) 9 (3.5) reduce the learning curve.[15]
Multiple organ dysfunctions, n (%) 19 (7.4)
Shock, n (%) 4 (1.6) The 30‑day mortality rate in our study was 13.6%. The
Cardiac complications, n (%) 85 (33.1) highest mortality among our patients occurred in those
Low cardiac output syndrome 51 (19.8) undergoing an arterial switch operation for TGA with VSD
Metabolic acidosis 65 (25.3)
Pericardial effusion 2 (0.8) and TGA with intact ventricular septum. In our study,
Pulmonary hypertension 19 (7.4) the most common cause for mortality was pulmonary
Pulmonary hypertension crisis 8 (3.1) hypertension, which often resulted from delayed timing
Cardiac tamponade 2 (0.8)
Procedure complications, n (%) 36 (14) of surgery associated with late presentations of children
Bleeding 28 (10.9) with congenital heart diseases. Most patients who died
Need for emergency chest reopening 10 (3.9) after arterial switch operation mostly suffered from
Arrhythmia, n (%) 48 (18.6)
Lung complications, n (%) 78 (30.4)
pulmonary hypertensive crisis, which is challenging to
Acute respiratory distress syndrome 11 (4.3) deal with in setting with limited resources.
Atelectasis 16 (6.2)
Chylothorax 5 (1.9) The incidence of complications in our patients was
Diaphragm paralysis 4 (1.6) as high as 81%, which was relatively high compared
Pleural effusion 38 (14.8) to previously published studies. This may be caused
Pneumonia 15 (5.8)
Pneumothorax 2 (0.8) by different definitions of complications, in which
Reintubation 7 (2.7) we included endocrine complications after cardiac
Pulmonary edema 2 (0.8) surgery, such as hypocalcemia, hyperglycemia, and
Vocal cord dysfunction 8 (3.1)
Renal complications, n (%) 68 (26.4) hypoglycemia, which were rarely accounted in previous
Renal dysfunction 36 (14) studies as such complications could physiologically
Acute renal failure 32 (12.4) occur after cardiac surgery using CPB. Hyperglycemia
Infections, n (%) 45 (17.5)
Sepsis 45 (17.5)
and hypocalcemia occurred in >60% patients after
Wound infection 6 (2.3) cardiac surgery in our study. This was similar to findings
Systemic inflammatory response syndrome, n (%) 50 (19.5) reported by other studies in developing countries.[16,17]
Neurological complications, n (%) 20 (7.8)
When we excluded the endocrine complication, the
Encephalopathy 7 (2.7)
Neurological deficit 9 (3.5) incidence of complication after cardiac surgery in our
Seizure 10 (3.9) patients decreased to 44%. The most complications
Gastrointestinal complications, n (%) 9 (3.5) occurring after cardiac surgery were LCOS, arrhythmia,
Ascites 1 (0.4)
Gastrointestinal bleeding 7 (2.7) nosocomial sepsis, and pleural effusion.
Necrotic enterocolitis 1 (0.4)
Endocrine complications, n (%) 205 (79.8) Finding from this study shows that the incidence of
Hypocalcemia 162 (63) LCOS was similar to other studies, which was 25%–32%
Hypoglycemia 35 (13.6) in patients after cardiac surgery.[18] The management of
Hyperglycemia 158 (61.5)
Vascular complications, n (%) 2 (0.8)
children after cardiac surgery includes avoiding factors
Superior vena cava syndrome 2 (0.8) contributed to the development of LCOS. These include
maintaining adequate preload, using vasoactive drugs
to improve contractility, and maintaining systemic
chronic infections), as well as the quality of surgery and
and pulmonary vascular resistance.[7,18] In our hospital,
postoperative care.[8]
when managing LCOS, we used inotropic and inodilator
A study in other developing countries found mortality of drugs simultaneously including dopamine, epinephrine,
similar or lower levels to us: Iran (12.4%),[9] Guatemala norepinephrine, and milrinone.
(10.7%), [10] India (7.9%), [11] and China (5.5%). [12]
Total AV block occurred in 5.8% patients after TOF
In large pediatric cardiac services in high‑income
correction, CAVSD repair, and VSD closure. This is in
countries, mortality after cardiac surgery in children
accordance with a previous study that total AV block
has been reported to be <5%.[13] There is an inverse
commonly occurred in patients with TOF, CAVSD, and
relationship between volume of cardiac surgery
VSD as the conduction system located along those
performed and mortality. Compared with units that
defects, which had injured.[19]
perform more than 300 operations annually, units with
around 101 cases/year were associated with increased Another frequent postoperative complication is
mortality of 3‑fold, whereas those with <10 cardiac nosocomial bloodstream infections or sepsis, which
surgery cases per year were associated with an 8‑fold occurred in 17.4% children after cardiac surgery. This
increased mortality.[14] In addition, the surgeons should incidence is much higher compared to a previous

Annals of Pediatric Cardiology / Volume 12 / Issue 1 / January-April 2019 41

[Downloaded free from http://www.annalspc.com on Monday, April 6, 2020, IP: 115.178.251.232]

Murni, et al.: Outcome of cardiac surgery and predictors of major complication

study, which only found 8.6% patients suffered from usually need longer surgery and CPB time because of
nosocomial sepsis.[20] Gram‑negative sepsis is prevalent higher surgical complexity. They might suffer from
in children with postoperative bloodstream infections in severe metabolic acidosis and tissue hypoxemia, which
low‑to‑middle‑income countries and is associated with is likely to predispose them for mortality.[9] The presence
significant morbidity, higher mortality, and development of cyanotic congenital heart disease is an intrinsic
of antibiotic resistance. Practical steps can be taken to factor that cannot be controlled in increasing the risk
make surgery safer since good nutrition, early corrective of developing major complications after cardiac surgery,
surgery, and measures to reduce nosocomial infection but it can raise awareness to mitigate harmful outcomes.
are likely to play a role.[21]
The use of high inotropes on leaving operating room was
We identified factors predicting the development of associated with mortality and cardiac arrest in children
major complications after cardiac surgery to guide after cardiac surgery. The more severe the hemodynamic
further preventative strategies. Predictors for developing state, the lower the cardiac index, and therefore, higher
major complications in our study were cyanotic inotropic support was needed.[22]
congenital heart disease, longer duration of CPB, high
Increase in blood lactate could reflect the presence of
inotropic drugs on leaving operating theater, and
anaerobic metabolism, which is caused by inadequate
increase in blood lactate.
oxygenation, reduced oxygen delivery, or cellular
In patients with cyanotic congenital heart disease, hypoxia. Increase in blood lactate >0.75 mmol/L can
especially those suffering from complex heart lesions predict early outcome of neonates after cardiac surgery
with high specificity[6] but low sensitivity since this might
Table 4: Proportion of major complications after physiologically reflect hyperlactatemia after CPB and
pediatric cardiac surgery impaired lactate clearance.[4]
Major complication n=257
This finding highlights the need for comprehensive
Major complications, n (%) 49 (19)
Death 35 (13.6) interventions to improve the quality of pediatric cardiac
Cardiac arrest 13 (5) surgery services and reduce mortality and other major
Re‑operation 10 (3.9) complications among children after cardiac surgery by
Multiple organ dysfunction 19 (7.4)
Mortality based on diagnosis, n (%)
preventing the occurrence of clinical conditions that
TGA‑VSD 2/4 (50) required longer CPB, high inotropes, and caused increase
TGA‑IVS 2/4 (50) in blood lactate after cardiac surgery.
Mitral atresia 1/2 (50)
Single ventricular 5/12 (41.7) Some facts in developing world related to cardiac surgery
Ebstein’s anomaly 1/3 (33.3) program include competing priorities, poor structural
Tricuspid atresia 1/3 (33.3)
Atrioventricular septal defect 3/9 (33.3) organizations, lack of financial resources, lack of trained
PA‑VSD 2/8 (25) human resources, and absence of stable training and
TAPVD 1/4 (25) education
infrastructure.[13] These require an effective
Double outlet right ventricular 3/16 (18.8)
PA‑IVS 1/6 (16.7) policy response to make efforts for improving quality of
Tetralogy of Fallot 8/63 (11) cardiac surgery program in such low‑to‑middle‑income
Mitral stenosis or regurgitation 2/18 (11) countries. Attempts should be conducted earlier before
Truncus arteriosus 0/1 (0)
Ventricular septal defect 0/74 (0) the actual implementation of the cardiac surgery
Atrial septal defect/patent ductus arteriosus 0/28 (0) and critical care program. These include training
PA‑VSD: Pulmonary atresia with ventricular septal defect, PA‑IVS: Pulmonary in pediatric cardiac surgery and critical care in
atresia with intact ventricular septum, DORV: Double outlet right ventricular, low‑and‑middle‑income countries from well‑established
TGA‑VSD: Transposition of the great arteries with ventricular septal defect,
TGA‑IVS: Transposition of the great arteries with intact ventricular septum, pediatric cardiac center program in high‑income
TAPVD: Total anomaly pulmonary venous drainage countries. In addition, a model of mentoring physicians

Table 5: Predictors of major complications after pediatric cardiac surgery

Predictors Major complication Without major Unadjusted OR P Adjusted OR P
(n=49) complication (n=208) (95% CI) (95% CI)
Preoperative, n (%)
Congestive heart failure 6 (12.2) 16 (7.6) 1.6 (0.6‑4.5) 0.31
Cyanotic CHD 40 (81.6) 81 (31.5) 7 (3.2‑15.1) <0.0001 4.6 (1.5‑14.2) 0.007
Intra‑operative, n (%)
Duration of CPB >120 min 24 (50) 28 (13.5) 6.2 (3.1‑12.3) <0.0001 4.4 (1.5‑13.4) 0.008
High inotropic support 25 (51) 4 (2) 53.1 (17.1‑165.6) <0.0001 13.1 (3.2‑54.2) <0.001
Postoperative, n (%)
Increase in lactate in 1 h 46 (93.9) 32 (15.3) 84.3 (24.7‑287.7) <0.0001 37.1 (10.1‑136.3) <0.0001
CHD: Congenital heart disease, CPB: Cardiopulmonary bypass, OR: Odds ratio, CI: Confidence interval

42 Annals of Pediatric Cardiology / Volume 12 / Issue 1 / January-April 2019

[Downloaded free from http://www.annalspc.com on Monday, April 6, 2020, IP: 115.178.251.232]

Murni, et al.: Outcome of cardiac surgery and predictors of major complication

and other staff from well-established centers to establish cardiac surgery: A minimalist approach might be
high-quality referral and cardiac training centers in low- maximally effective. Crit Care Resusc 2004;6:306‑10.
to-middle-income countries is needed. Furthermore, a 4. Duke T, Butt W, South M, Karl TR. Early markers of major
member of subspecialties from low‑and‑middle‑income adverse events in children after cardiac operations.
countries should visit a well‑established cardiac center J Thorac Cardiovasc Surg 1997;114:1042‑52.
to observe the unit or participate in overseas training 5. Part IV. The dictionary of definitions of complications
or education programs.[23‑26] associated with the treatment of patients with congenital
cardiac disease. Cardiol Young 2008;18 Suppl 2:282‑530.
Limitation of this study is that this study was performed
6. Charpie JR, Dekeon MK, Goldberg CS, Mosca RS, Bove EL,
in a single national referral hospital and therefore may
Kulik TJ, et al. Serial blood lactate measurements predict
not represent the status of other hospitals in Indonesia. early outcome after neonatal repair or palliation for
Howeverare it is likely that practices in Jakarta are not complex congenital heart disease. J Thorac Cardiovasc
so different from other referral hospitals which provide Surg 2000;120:73‑80.
pediatric cardiac surgery services. To be generalizable, 7. Gazit AZ, Huddleston CB, Checchia PA, Fehr J, Pezzella AT.
this study should be reproduced in other tertiary referral Care of the pediatric cardiac surgery patient‑Part 1. Curr
hospitals in Indonesia and other low‑to‑middle‑income Probl Surg 2010;47:185‑250.
countries. Other limitations are lactate clearance time, 8. Tefuarani N, Vince J, Hawker R, Sleigh A, Williams G. The
and venous oxygen saturation (SvO2) was not measured medium‑to‑long‑term outcome of Papua New Guinean
routinely in conjunction with blood lactate examination children after cardiac surgery. Ann Trop Paediatr
after cardiac surgery. A SvO2 may suggest different 2004;24:65‑74.
pathophysiology of tissue hypoxia compared to lactate.[4] 9. Roodpeyma  S, Hekmat  M, Dordkhar  M, Rafieyian  S,
An abnormality in SvO2 could be present without an Hashemi A. A prospective observational study of
abnormality in blood lactate and therefore might explain paediatric cardiac surgery outcomes in a postoperative
intensive care unit in Iran. J Pak Med Assoc 2013;63:55‑9.
small changes in lactate and improve the accuracy of
blood lactate in predicting major complications after 10. Leon‑Wyss JR, Veshti A, Veras O, Gaitán GA, O’Connell M,
cardiac surgery.[4] Mack RA, et al. Pediatric cardiac surgery: A challenge and
outcome analysis of the Guatemala effort. Semin Thorac
Cardiovasc Surg Pediatr Card Surg Annu 2009;12:8‑11.
CONCLUSION
11. Joshi SS, Anthony G, Manasa D, Ashwini T, Jagadeesh AM,
Approximately one‑fifth of children undergoing cardiac Borde DP, et al. Predicting mortality after congenital
heart surgeries: Evaluation of the aristotle and risk
surgery at a national referral hospital in Indonesia had
adjustement in congenital heart surgery‑1 risk prediction
major adverse events and around 13% died. Cyanotic scoring systems: A retrospective single center analysis
congenital heart disease, longer duration of CPB, high of 1150 patients. Ann Card Anaesth 2014;17:266‑70.
inotropes on leaving operating room, and increase in 12. Ho TC, Ouyang H, Lu Y, Young AH, Chintala K,
blood lactate were associated with increased risk of Detrano RC, et al. Postprocedural outcomes of rural
mortality and developing other major complications in children undergoing correction of congenital heart
children after cardiac surgery. lesions in Yunnan Province, China. Pediatr Cardiol
2011;32:811‑4.
Acknowledgment
13. Tchervenkov CI, Jacobs JP, Bernier PL, Stellin G,
We gratefully acknowledge Prof. Trevor Duke and Kurosawa H, Mavroudis C, et al. The improvement
Dr. Nikmah S Idris for providing the editorial assistance. of care for paediatric and congenital cardiac disease
across the world: A challenge for the world society for
Financial support and sponsorship pediatric and congenital heart surgery. Cardiol Young
2008;18 Suppl 2:63‑9.
Nil.
14. Gauvreau K. Reevaluation of the volume‑outcome
Conflicts of interest relationship for pediatric cardiac surgery. Circulation
2007;115:2599‑601.
There are no conflicts of interest.
15. Hasan A, Pozzi M, Hamilton JR. New surgical procedures:
Can we minimise the learning curve? BMJ 2000;320:171‑3.
REFERENCES
16. Robertie PG, Butterworth JF 4th, Prielipp RC, Tucker WY,
Zaloga GP. Parathyroid hormone responses to marked
1. Eghtesady P, Brar AK, Hall M. Prioritizing quality
hypocalcemia in infants and young children undergoing
improvement in pediatric cardiac surgery. J Thorac
repair of congenital heart disease. J Am Coll Cardiol
Cardiovasc Surg 2013;145:631‑9.
1992;20:672‑7.
2. Welke KF, Ungerleider RM. Mortality as an outcome
17. Lou S, Ding F, Long C, Liu J, Zhao J, Feng Z, et al. Effects
parameter for pediatric heart surgery. ASAIO J
of peri‑operative glucose levels on adverse outcomes
2006;52:552‑5.
in infants receiving open‑heart surgery for congenital
3. Duke T, Stocker C, Butt W. Monitoring children after heart disease with cardiopulmonary bypass. Perfusion

Annals of Pediatric Cardiology / Volume 12 / Issue 1 / January-April 2019 43

[Downloaded free from http://www.annalspc.com on Monday, April 6, 2020, IP: 115.178.251.232]

Murni, et al.: Outcome of cardiac surgery and predictors of major complication

2011;26:133‑9. Donohue JE, Yu S, et al. Vasoactive‑inotropic score is

associated with outcome after infant cardiac surgery:
18. Ascenzi JA, Kane PL. Update on complications of
An analysis from the pediatric cardiac critical care
pediatric cardiac surgery. Crit Care Nurs Clin North Am consortium and virtual PICU system registries. Pediatr
2007;19:361‑9, v. Crit Care Med 2014;15:529‑37.
19. Anderson JB, Czosek RJ, Knilans TK, Meganathan K, 23. Nguyen N, Pezzella AT. Pediatric cardiac surgery
Heaton P. Postoperative heart block in children with in low‑and middle‑income countries or emerging
common forms of congenital heart disease: Results economies: A continuing challenge. World J Pediatr
from the KID database. J Cardiovasc Electrophysiol Congenit Heart Surg 2015;6:274‑83.
2012;23:1349‑54.
24. Nguyen N, Leon‑Wyss J, Iyer KS, Pezzella AT. Paediatric
20. Elella RA, Najm HK, Balkhy H, Bullard L, Kabbani MS. cardiac surgery in low‑income and middle‑income
Impact of bloodstream infection on the outcome of countries: A continuing challenge. Arch Dis Child
children undergoing cardiac surgery. Pediatr Cardiol 2015;100:1156‑9.
2010;31:483‑9.
25. Rao SG. Pediatric cardiac surgery in developing
21. Murni IK, MacLaren G, Morrow D, Iyer P, Duke T. countries. Pediatr Cardiol 2007;28:144‑8.
Perioperative infections in congenital heart disease.
26. Murni IK, Musa NL. The need for specialized pediatric
Cardiol Young 2017;27:S14‑S21.
cardiac critical care training program in limited resource
22. Gaies MG, Jeffries HE, Niebler RA, Pasquali SK, settings. Front Pediatr 2018;6:59.

44 Annals of Pediatric Cardiology / Volume 12 / Issue 1 / January-April 2019