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Congenital: Truncus Arteriosus| Volume 163, ISSUE 1, P224-236.e6, January 2022

Long-term outcomes of truncus arteriosus repair: A modulated renewal competing risks analysis

Published:February 11, 2021DOI:https://doi.org/10.1016/j.jtcvs.2021.01.136
Long-term outcomes of truncus arteriosus repair: A modulated renewal competing risks analysis
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      Abstract

      Objective

      In this study, we sought to identify independent risk factors for mortality and reintervention after early surgical correction of truncus arteriosus using a novel statistical method.

      Methods

      Patients undergoing neonatal/infant truncus arteriosus repair between January 1984 and December 2018 were reviewed retrospectively. An innovative statistical strategy was applied integrating competing risks analysis with modulated renewal for time-to-event modeling.

      Results

      A total of 204 patients were included in the study. Mortality occurred in 32 patients (15%). Smaller right ventricle to pulmonary artery conduit size and truncal valve insufficiency at birth were significantly associated with overall mortality (right ventricle to pulmonary artery conduit size: hazard ratio, 1.34; 95% confidence interval, 1.08-1.66, P = .008; truncal valve insufficiency: hazard ratio, 2.5; 95% confidence interval, 1.13-5.53, P = .024). truncal valve insufficiency at birth, truncal valve intervention at index repair, and number of cusps (4 vs 3) were associated with truncal valve reoperations (truncal valve insufficiency: hazard ratio, 2.38; 95%, confidence interval, 1.13-5.01, P = .02; cusp number: hazard ratio, 6.62; 95% confidence interval, 2.54-17.3, P < .001). Right ventricle to pulmonary artery conduit size 11 mm or less was associated with a higher risk of early catheter-based reintervention (hazard ratio, 1.54; 95% confidence interval, 1.04-2.28, P = .03) and reoperation (hazard ratio, 1.96; 95% confidence interval, 1.33-2.89, P = .001) on the right ventricle to pulmonary artery conduit.

      Conclusions

      Smaller right ventricle to pulmonary artery conduit size and truncal valve insufficiency at birth were associated with overall mortality after truncus arteriosus repair. Quadricuspid truncal valve, the presence of truncal valve insufficiency at the time of diagnosis, and truncal valve intervention at index repair were associated with an increased risk of reoperation. The size of the right ventricle to pulmonary artery conduit at index surgery is the single most important factor for early reoperation and catheter-based reintervention on the conduit.

      Graphical abstract

      Figure thumbnail fx1
      Graphical Abstract

      Key Words

      Abbreviations and Acronyms:

      AIC (Akaike's Information Criterion), CAA (coronary artery anomaly), CI (confidence interval), HR (hazard ratio), PA (pulmonary artery), P25-P75 (25th-75th percentiles), RV-PA (right ventricle to pulmonary artery), TA (truncus arteriosus), TV (truncal valve), VSD (ventricular septal defect)
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      Article info

      Publication history

      Published online: February 11, 2021
      Accepted: January 27, 2021
      Received in revised form: January 27, 2021
      Received: May 30, 2020

      Footnotes

      A.G. and I.P.D. contributed equally.

      Identification

      DOI: https://doi.org/10.1016/j.jtcvs.2021.01.136

      Copyright

      © 2021 by The American Association for Thoracic Surgery

      ScienceDirect

      Access this article on ScienceDirect

      Linked Article

      • Rethinking traditional survival analysis: Modulated renewal analysis with competing risks regression
        JTCVS OpenVol. 8
        • Preview
          We read with interest the article by Guariento and colleagues1 regarding long-term outcomes of truncus arteriosus repair. In their study, the authors applied an innovative statistical methodology that they call “modulated renewal analysis with competing risks regression.” In contrast to traditional survival analysis, this methodology allows one to perform time-to-event analysis of repeated events within the same patient while accounting for mortality as a competing outcome via informative censoring.
        • Full-Text
        • PDF
        Open Access
      • Commentary: As good as new: Using modulated renewal to analyze reintervention after truncus arteriosus repair
        The Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 1
        • Preview
          As survival for patients with congenital heart disease (CHD) continues to improve, it is important to continuously evaluate our measures of success for these patients. In the current era, the goals of care have expanded beyond simply improving survival. As such, management strategies aimed at optimizing functional performance and overall quality of life should be carefully considered. Such aims are particularly relevant for patients with truncus arteriosus (TA). Although complete repair in early infancy is the established standard of care, with a reported survival rate of 76.8% at 20 years,1 the morbidity for patients with TA is incurred in the form of multiple reinterventions.
        • Full-Text
        • PDF
      • Commentary: When complicated statistics may be the best way to answer questions on complicated hearts
        The Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 1
        • Preview
          In this issue of the Journal, Guariento et al1 report on a large single-center series of patients with truncus arteriosus treated at Boston Children's Hospital over a 34-year period. The real contributions of this article are not only the relatively unsurprising clinical conclusions regarding the impact of truncal valve insufficiency and original right-sided conduit size on mortality and the risk factors for reintervention, but also the reintroduction to the congenital heart surgical community of the statistical methods used to arrive at those conclusions.
        • Full-Text
        • PDF
      • Commentary: Let's push on medical device innovation
        The Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 1
        • Preview
          Guariento and colleagues1 from Boston aim to identify independent risk factors for mortality and reintervention after repair of truncus arteriosus using a new, modulated renewal competing risk method, which means, for nonstatisticians, a method that allows researchers to include repeated events into the model while avoiding censoring of information due to early mortality.
        • Full-Text
        • PDF
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