Tracheal surgery for airway anomalies associated with increased mortality in pediatric patients undergoing heart surgery: Society of Thoracic Surgeons Database analysis

Published:November 26, 2020DOI:



      Airway anomalies are common in children with cardiac disease but with an unquantified impact on outcomes. We sought to define the association between airway anomalies and tracheal surgery with cardiac surgery outcomes using the Society of Thoracic Surgery Congenital Heart Surgery Database.


      Index cardiac operations in children aged less than 18 years (January 2010 to September 2018) were identified from the Society of Thoracic Surgery Congenital Heart Surgery Database. Patients were divided on the basis of reported diagnosis of an airway anomaly and subdivided on the basis of tracheal lesion and tracheal surgery. Multivariable analysis evaluated associations between airway disease and outcomes controlling for covariates from the Society of Thoracic Surgery Congenital Heart Surgery Database Mortality Risk Model.


      Of 198,674 index cardiovascular operations, 6861 (3.4%) were performed in patients with airway anomalies, including 428 patients (0.2%) who also underwent tracheal operations during the same hospitalization. Patients with airway anomalies underwent more complex cardiac operations (45% vs 36% Society of Thoracic Surgeons/European Association for Cardiothoracic Surgery Congenital Heart Surgery Mortality category ≥3 procedures) and had a higher prevalence of preoperative risk factors (73% vs 39%; both P < .001). In multivariable analysis, patients with airway anomalies had increased odds of major morbidity and tracheostomy (P < .001). Operative mortality was also increased in patients with airway anomalies, except those with malacia. Tracheal surgery within the same hospitalization increased the odds of operative mortality (adjusted odds ratio, 3.9; P < .0001), major morbidity (adjusted odds ratio, 3.7; P < .0001), and tracheostomy (adjusted odds ratio, 16.7; P < .0001).


      Patients undergoing cardiac surgery and tracheal surgery are at significantly higher risk of morbidity and mortality than patients receiving cardiac surgery alone. Most of those with unoperated airway anomalies have higher morbidity and mortality, which makes it an important preoperative consideration.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      aOR (adjusted odds ratio), CHD (congenital heart disease), CI (confidence interval), STAT (Society of Thoracic/European Association for Congenital Heart Surgery Mortality), STS-CHSD (Society of Thoracic Surgeons Congenital Heart Surgery Database)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Thoracic and Cardiovascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Lee Y.S.
        • Jeng M.J.
        • Tsao P.C.
        • Soong W.J.
        • Chou P.
        Prognosis and risk factors for congenital airway anomalies in children with congenital heart disease: a nationwide population-based study in Taiwan.
        PLoS One. 2015; 9: e0137437
        • Guillemaud J.P.
        • El-Hakim H.
        • Richards S.
        • Chauhan N.
        Airway pathologic abnormalities in symptomatic children with congenital cardiac and vascular disease.
        Arch Otolaryngol Head Neck Surg. 2007; 133: 672-676
        • Sulkowski J.P.
        • Deans K.J.
        • Asti L.
        • Mattei P.
        • Minneci P.C.
        Using the Pediatric Health Information System to study rare congenital pediatric surgical diseases: development of a cohort of esophageal atresia patients.
        J Pediatr Surg. 2013; 48: 1850-1855
        • Herrera P.
        • Caldarone C.
        • Forte V.
        • Campisi P.
        • Holtby H.
        • Chait P.
        • et al.
        The current state of congenital tracheal stenosis.
        Pediatr Surg Int. 2007; 23: 1033-1044
        • Hofferberth S.C.
        • Watters K.
        • Rahbar R.
        • Fynn-Thompson F.
        Management of congenital tracheal stenosis.
        Pediatrics. 2015; 136: 660-669
        • Backer C.L.
        • Mavroudis C.
        • Gerber M.E.
        • Holinger L.D.
        Tracheal surgery in children: an 18-year review of four techniques.
        Eur J Cardiothorac Surg. 2001; 19: 777-784
        • Mainwaring R.D.
        • Shillingford M.
        • Davies R.
        • Koltai P.
        • Navaratnam M.
        • Reddy V.M.
        • et al.
        Surgical reconstruction of tracheal stenosis in conjunction with congenital heart defects.
        Ann Thorac Surg. 2012; 93: 1266-1273
        • Arcieri L.
        • Pak V.
        • Poli V.
        • Baggi R.
        • Serio P.
        • Assanta N.
        • et al.
        Tracheal surgery in children: outcome of a 12-year survey.
        Interact Cardiovasc Thorac Surg. 2018; 26: 660-666
        • Roodpeyma S.
        • Kamali Z.
        • Afshar F.
        • Naraghi S.
        Risk factors in congenital heart disease.
        Clin Pediatr. 2002; 41: 653-658
        • Pfammatter J.
        • Casaulta C.
        • Pavlovic M.
        • Berdat P.A.
        • Frey U.
        • Carrel T.
        Important excess morbidity due to upper airway anomalies in the perioperative course in infant cardiac surgery.
        Ann Thorac Surg. 2006; 83: 1008-1012
        • Jacobs J.P.
        • O'Brien S.M.
        • Pasquali S.K.
        • Gaynor J.W.
        • Mayer J.E.
        • Karamlou T.
        • et al.
        The Society of Thoracic Surgeons congenital heart surgery database mortality risk model: part 2—clinical application.
        Ann Thorac Surg. 2015; 100: 1063-1070
      1. STS-CHS Database Data Specification, version 3.0 [Internet].
        (Available at:) (Accessed April 22, 2020)
        • Overman D.M.
        • Jacobs M.L.
        • O'Brien J.E.
        • Kumar S.R.
        • Mayer J.E.
        • et al.
        Ten years of data verification: the Society of Thoracic Surgeons congenital heart surgery database audits.
        World J Pediatr Congenit Heart Surg. 2019; 10: 454-463
        • Jacobs J.P.
        • Shahian D.M.
        • D'Agostino R.S.
        • Jacobs M.L.
        • Kozower B.D.
        • Badhwar V.
        • et al.
        The Society of Thoracic Surgeons national database 2017 annual report.
        Ann Thorac Surg. 2017; 104: 1774-1781
        • Jacobs J.P.
        • Mayer J.E.
        • Pasquali S.K.
        • Hill K.D.
        • Overman D.M.
        • St Louis J.D.
        • et al.
        The Society of Thoracic Surgeons congenital heart surgery database: 2018 update on outcomes and quality.
        Ann Thorac Surg. 2018; 105: 680-689
        • O'Brien S.M.
        • Clarke D.R.
        • Jacobs J.P.
        • Jacobs M.L.
        • Lacour-Gayet F.G.
        • Pizarro C.
        • et al.
        An empirically based tool for analyzing mortality associated with congenital heart surgery.
        J Thorac Cardiovasc Surg. 2009; 138: 1139-1153
        • Jacobs J.P.
        • O'Brien S.
        • Hill K.
        • Kumar R.
        • Austin E.
        • Gaynor W.
        • et al.
        Refining the STS CHSD mortality risk model with enhanced risk adjustment.
        Ann Thorac Surg. 2019; 108: 558-566
        • Benneyworth B.D.
        • Shao J.M.
        • Cristea A.I.
        • Ackerman V.
        • Rodefield M.D.
        • Turrentine M.W.
        • et al.
        Tracheostomy following surgery for congenital heart disease: a 14-year institutional experience.
        World J Pediatr Congenit Heart Surg. 2016; 7: 360-366
        • Cotts T.
        • Hirsch J.
        • Thorne M.
        • Gajarski R.
        Tracheostomy after pediatric cardiac surgery: frequency, indications, and outcomes.
        J Thorac Cardiovasc Surg. 2011; 141: 413-418
        • Tabib A.
        • Abrishami S.E.
        • Mahdavi M.
        • Mortezaeian H.
        • Totonchi Z.
        Predictors of prolonged mechanical ventilation in pediatric patients after cardiac surgery for congenital heart disease.
        Res Cardiovasc Med. 2016; 5: e30391

      Linked Article

      • Commentary: God is in the details!
        The Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 3
        • Preview
          The negative relationship of congenital heart disease with airway anomalies has long been appreciated by health care providers. Recent studies have shown that both morbidity and mortality in children undergoing repair of congenital heart disease are significantly greater in those with airway anomalies.1,2 However, the wide spectrum of pathology within each group does not permit a simple generalization of this relationship. In this study, Riggs and colleagues3 have sought to define this association in a more refined way using the Society of Thoracic Surgeons Congenital Heart Surgery Database.
        • Full-Text
        • PDF
      • Commentary: Airway anomalies and congenital heart defects, a dangerous combination
        The Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 3
        • Preview
          Congenital heart defects (CHDs) and airway anomalies often occur as comorbid conditions. Although intuitively one would assume the presence of an airway anomaly would result in increased mortality, the precise impact has not been defined. In addition, when both anomalies require surgical correction, some advocate for a simultaneous approach, whereas others favor a staged approach.1,2 Lastly, the natural remaining follow-up question remains: which should be repaired first?
        • Full-Text
        • PDF
      • Commentary: Congenital heart disease patients with airway anomalies do worse: We knew that, or so we thought
        The Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 3
        • Preview
          In their article in this issue of the Journal, Riggs and colleagues1 use data from the Society of Thoracic Surgery Congenital Heart Surgery Database (STS-CHD) to investigate the impact of airway anomalies and tracheal surgery on the outcomes of children undergoing congenital heart surgery. Although the presence of concomitant airway anomalies in children with congenital heart disease is well known,2 there are little available data to quantify the associated risks. The authors should be congratulated, as this manuscript will be an important resource for preoperative counseling and provides a necessary framework for future studies.
        • Full-Text
        • PDF