133. When to do the Arterial Switch Operation to Optimize Outcomes and Resource Utilization: A National Database Analysis

7 Minutes 

Metro Toronto Convention Center 

Objective:The optimal timing of Arterial Switch Operation(ASO) has been a matter of debate in patients with d-TGA(d-Transposition of Great Arteries). We sought to examine characteristics, outcomes, & costs of early versus late ASO for d-TGA + IVS(Intact Ventricular Septum) from a large national database.
Methods:The Pediatric Health Informational System was queried from 2004-2022 to identify patients with d-TGA undergoing ASO. Patients were excluded if they had a VSD, arch reconstruction, concomitant defects or if ASO was performed >30 day of life. Patients were divided according to age at ASO:very early(0-3 d), early(4-7 d), late(8-14 d) & very late(15-30 d) groups. Baseline characteristics, demographics, use of balloon atrial septostomy(BAS), prostaglandin(PGE) & Nitric oxide(iNO) were analyzed. In-hospital outcomes including post-op mortality, need for ECMO, dialysis, delayed sternum closure, ICU length of stay, total costs of hospitalization were compared.
Results:A total of 3,556 patients/ASO cases were identified of which 21.7%(n=773) were very early, 51.0%(n=1,815) early, 21.1%(n=752) late & 6.1%(n=216) were very late. The median age at ASO was 6 days(IQR 4-8). Patients were similar in gender & race/ethnicity & presence of ASD. Patients in the late & very late groups were more likely to be preterm, have lower birthweight & have government insurance vs very early & early ASO groups. They were also more likely to have pre-op stroke, iNO use, BAS, & pre-op ECMO use(all P<0.05). Overall, in-hospital mortality was 1.4% & was similar between groups (p=0.15). Late & very late groups had higher rates of non-home discharge, post-op ECMO use, delayed sternum closure & longer ICU LOS. There was an incremental increase in the composite outcome of in-hospital death/non-home discharge/post-op ECMO/delayed sternum closure by timing of ASO( in order, v early to v late,): 8% vs 9.6% vs 16.2% vs 25.0%. On multivariate analysis, patients in [late & v late groups] vs [v early & early groups] had almost double the odds of developing composite outcome(aOR 1.97, 95%CI: 1.57-2.43, p<0.001).Median total adjusted costs of hospitalization were significantly higher in late & very late ASO groups (Very Early: $115,060; Early: $129,297; Late: $162,746; Very Late: $213,707)(Table)
Conclusions:This is the largest study examining timing of ASO in a cohort exclusively of d-TGA + IVS. ASO performed late (>7 days) resulted in worse outcomes & higher healthcare resource utilization.

Authors
Muhammad Faateh (1), Hosam Ahmed (1), Muhammad Aanish Raees (1), David Lehenbauer (1), James F. Cnota (1), David Morales, Sr. (1), Awais Ashfaq (1)
Institutions
(1) The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH

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