Prediction of adverse events after catheter-based procedures in adolescents and adults with congenital heart disease in the IMPACT registry

Abstract

Aims: We sought to identify factors associated with major adverse events (MAE) after cardiac catheterization in adolescents and adults with congenital heart disease (CHD), and create the first model to individualize risk discussions in this growing population.

Methods and results: Improving Pediatric and Adult Congenital Treatment (IMPACT), a National Cardiovascular Data Registry, contains congenital catheterization data from over 87 hospitals in the United States. Demographics, pre-procedure, and procedural variables were collected for patients over age 10. Multivariable logistic regression was used to identify significant predictors of MAE, a composite of death, urgent surgery or procedure due to a catheterization complication, transfusion, embolic stroke, tamponade, extracorporeal membrane oxygenation or ventricular assist device placement, and device embolization, malposition or thrombosis requiring surgical intervention. A risk score was built based on the effect sizes of each predictor and validated in a split sample. A MAE occurred in 686 (2.5%) of the 27 293 index procedures meeting inclusion criteria. The independent multivariate predictors of MAE were older age, pre-procedural anticoagulation use, renal disease, lower haemoglobin, lower oxygen saturation, non-elective procedure, higher index procedure risk and having had no prior cardiac procedures. Being underweight or overweight had borderline significance and was added to the model. The C-statistic for the model was robust at 0.787 in the derivation and 0.773 in the validation cohort.

Conclusion: The factors predicting adverse events after cardiac catheterization in adolescents and adults with CHD are different than in the general population. Validation of this model in other national or multi-institutional datasets is the next step.

Keywords: Adult congenital heart disease; Adverse event; Bleeding; Cardiac catheterization; Risk model.

Figure 1

Significant predictors of the combined outcome in the final multivariable model. Odds ratio and 95% confidence interval for the risk factors included in the final model. Cardiac catheterization or cardiac surgeries performed prior to the index admission are considered prior procedures. Effect of haemoglobin presented as drop of 1 g/dL (0.62 mmol/L). BMI, body mass index.

Figure 2

Observed/Expected plot for final model. Mean observed major adverse event (MAE) rate and expected risk of each decile of patients is presented by one data point.

Figure 3

Components of risk score and incidence of MAE by risk group. Major adverse events are defined as a composite of intra-procedural death or cardiac arrest, death in the hospital, urgent surgery or procedure due to a complication of the catheterization, event requiring extracorporal membrane oxygenation (ECMO) or ventricular assist device (VAD) placement, device malposition or thrombosis requiring surgery, device embolization requiring retrieval, anaemia requiring transfusion after the catheterization, and embolic stroke within 72 h after the procedure.