Preoperative Malnutrition Increases Risk of In-Hospital Mortality, Major Infection, and Longer Intensive Care Unit Stay After Ventricular Septal Defect Closure

Abstract

Background: High energy requirements and poor feeding can lead to growth failure in patients with ventricular septal defect (VSD), but effects of preoperative malnutrition on surgical outcomes are poorly understood, especially in low-resource settings.

Methods and results: We analyzed a cohort of children <5 years of age undergoing VSD closure at 60 global centers participating in the International Quality Improvement Collaborative for Congenital Heart Disease, 2015 to 2020. We calculated adjusted odds ratios (ORs) for in-hospital death and major infection and adjusted coefficients for duration of intensive care unit stay for 4 measures of malnutrition: severe wasting (weight-for-height Z score, <-3), moderate wasting (-3<weight-for-height Z score≤-2), underweight (weight-for-age Z score, ≤-2), and stunting (height-for-age Z score, ≤-2) according to World Health Organization Child Growth Standards. Among 10 966 children undergoing VSD closure in the analyzed cohort, 8136 (74%) were membranous VSDs. Median age was 9.6 months (interquartile range, 3.6-12.0), and 4088 (37.3%) had wasting/severe wasting, 5029 (45.9%) had underweight, and 3515 (32.1%) had stunting. There were 4749 (43.3%) children who met the criteria for ≥2 malnutrition categories. Overall, 84 patients (0.8%) died in-hospital, and 199 (1.8%) had major infection. Severe wasting (OR, 3.38 [95% CI, 1.55-7.35]; P=0.002), underweight (OR, 6.46 [95% CI, 2.81-14.8]; P<0.001), and stunting (OR, 2.73 [95% CI, 1.40-5.34]; P=0.003) were independent predictors of mortality. Similar results were observed for infection and duration of intensive care unit stay. Underweight was the strongest predictor of adverse outcomes. Children meeting criteria for all 3 (stunting, wasting, and underweight) had 17.2 times higher odds of mortality (P<0.001) than nonmalnourished children.

Conclusions: Malnutrition was associated with mortality, infection, and longer intensive care unit stay in a global cohort of children undergoing VSD closure.

Keywords: congenital heart disease; global health; malnutrition; mortality; ventricular septal defect.

Figure 1. The number of patients meeting inclusion and exclusion criteria for the cohort.

ASD indicates atrial septal defect; DORV, double outlet right ventricle; IQIC, International Quality Improvement Collaborative; MR, mitral regurgitation; PA, pulmonary artery; PDA, patent ductus arteriosus; PFO, patent foramen ovale; TI, tricuspid insufficiency; and VSD, ventricular septal defect.

Figure 2. The distribution of weight‐for‐height Z scores (A), weight‐for‐age Z scores (B), and height‐for‐age Z scores (C) in the overall cohort.

Vertical lines indicate categorical categories of malnutrition. HAZ indicates height‐for‐age Z score; WAZ, weight‐for‐age Z score; and WHZ, weight‐for‐height Z score.

Figure 3. The distribution of WAZ, HAZ, and WHZ by each type of VSD. There was a significant difference in WHZ, WAZ, and HAZ by type of VSD (P<0.001 for all 3).

DORV indicates double outlet right ventricle; HAZ, height‐for‐age Z score; VSD, ventricular septal defect; WAZ, weight‐for‐age Z score; and WHZ, weight‐for‐height Z score.

Figure 4. The adjusted odds ratios of in‐hospital mortality (A), the adjusted odds ratios of major infection (B), and the adjusted coefficient of length of ICU stay (hours) (C) by malnutrition category.

Models were adjusted for age at time of surgery, sex, major medical illness, history of any preoperative management, and VSD type. ICU indicates intensive care unit; and VSD indicates ventricular septal defect.

Figure 5. The adjusted odds ratios of in‐hospital mortality (A), the adjusted odds ratios of major infection (B), and the adjusted coefficients of length of ICU stay (hours) (C) for children meeting criteria for 1, 2, or all 3 categories of malnutrition, compared with a reference group of children with no malnutrition.

Models were adjusted for age at time of surgery, sex, major medical illness, history of any preoperative management, and VSD type. ICU indicates intensive care unit; and VSD indicates ventricular septal defect.