A Rare But Effective Strategy: Birth In The Operating Room For Immediate Cardiac Surgery
Spencer J. Hogue, BS, Kevin Kulshrestha, MD, MBE, James F. Cnota, MD, Allison Divanovic, MD, Awais Ashfaq, MD, David G. Lehenbauer, MD, David S. Cooper, MD, MPH, David L. S. Morales, MD.
Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
Objectives: With advancements in fetal cardiac imaging, certain rare lesions that carry high risk for postnatal demise are increasingly diagnosed. Planned delivery with a cardiac operating room ready for immediate surgery is an emerging strategy.
Methods: Between 2012-2023, patients prenatally-diagnosed with physiologies at risk for severe cardiogenic shock after birth were planned for delivery with an OR team ready. This program has evolved into delivery in a cardiac OR adjacent to where surgery is planned.
Results: Eight patients operated on by the senior author were identified. Six (75%) patients were operated on day-of-life zero, all with obstructed TAPVR and four requiring simultaneous Norwood. Two patients with hydrops fetalis stabilized postnatally but went into shock at 12hrs and 72hrs, requiring a novel Norwood with left-ventricular exclusion for severe/moderate aortic and mitral insufficiency. Ventilator duration and hospital length of stay were 18.5 [IQR:10.8-26.0] and 41.0 [IQR:31.8-127.5] days. Three (38%) patients required re-operations in-hospital. Post-discharge procedures included Glenn-(n=5), Fontan-(n=2), bi-ventricular repair-(n=1), and heart transplant-(n=1). One (13%) mortality occurred at 31 days; no other patients required ECMO. Median follow-up was 5.0 [IQR:0.3-7.4] years. Overall, the in-hospital, one-, and five-year survivals were 88% (n=7/8). (Table)
Conclusions: These congenital heart lesions have historically had poor survival. The strategy of OR delivery and immediate operation for certain rare conditions appears to be a promising strategy for these high-risk patients.
| Patient No. | Cardiac Diagnoses | Index Procedures Performed | Age at Procedure (days) | Post-operative ECMO? | Hospital Length of Stay (days) | In-Hospital Re-interventions? | Current Age (years) | Subsequent Cardiac Procedures (age) | Alive at Last Encounter? |
| 1 | HLHS variant, Obstructed TAPVR | Norwood (4mm R-mBTS), TAPVR repair | 0 | N | 138 | Y (TV Repair, PVS Repair) | 1.1 | BDG (3.1 m) | Y |
| 2 | R Isomerism, Dextrocardia, Discontinuous PAs, DORV w/ malposed GA, Obstructed TAPVR | Creation of 3.5mm R-mBTS, Centralization of PAs, TAPVR repair | 0 | N | 38 | Y (Chest Exploration) | 0.1 | - | Y |
| 3 | "Swiss-Cheese" Ventricular Septum, Obstructed TAPVR | TAPVR repair, Multiple VSD Closure | 0 | N | 23 | Y (Redo TAPVR Repair) | 8 | - | Y |
| 4 | R Isomerism, DORV, Unbalanced CAVC, d-malposed GA, RVOTO, Obstructed TAPVR | Mixed TAPVR repair | 0 | Y (18 d) | 31 | N | 5.5 | Desaturated > Cath; Post-cath ECMO & OR for mBTS | N (31 d) |
| 5 | HLHS variant, Cervical Aorta, Obstructive TAPVR | Norwood (3.5mm R-mBTS), Aortic Shortening, TAPVR repair | 0 | N | 44 | N | 4.9 | BDG (4.9 m) | Y |
| 6 | R Isomerism, Dextrocardia, Pulmonary Atresia, diminutive PAs, Obstructive TAPVR | Creation of 3.5 mm L-mBTS, TAPVR repair, PA reconstruction | 0 | N | 34 | N | 10.5 | BDG (5.9 m); Bi-V Repair (4.4 y) | Y |
| 7 | HLHS, Severe AI/MR, Non-functional LV | Norwood (4mm R-mBTS) w/ LV exclusion | 3 | N | 108 | N | 6.3 | BDG (2.9 m); Fontan (3.6 y) | Y |
| 8 | HLHS, Severe AI/MR, Non-functional LV | Norwood (3.5mm R-mBTS) w/ LV exclusion, TV repair | 1 | N | 134 | N | 5.1 | BDG (2.8 m); Fontan (2.8 y); VAD (3.6 y); HTx (4.0 y) | Y |
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