Open Access

ARTICLE

Utilization of inhaled nitric oxide after surgical repair of truncus arteriosus: A multicenter analysis

Christine M. Riley¹, Christopher W. Mastropietro², Peter Sassalos³, Jason R. Buckley⁴, John M. Costello⁴, Ilias Iliopoulos⁵, Aimee Jennings⁶, Katherine Cashen⁷, Sukumar Suguna Narasimhulu⁸, Keshava M. N. Gowda⁹, Arthur J. Smerling¹⁰, Michael Wilhelm¹¹, Aditya Badheka¹², Adnan Bakar^13,14, Elizabeth A. S. Moser¹⁵, Venu Amula¹⁶

1 Department of Pediatrics, Division of Cardiac Critical Care, Children’s National Health System, Washington, District of Columbia
2 Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
3 Department of Cardiac Surgery, Section of Pediatric Cardiovascular Surgery, University of Michigan, C.S. Mott Children’s Hospital, Ann Arbor, Michigan
4 Department of Pediatrics, Division of Cardiology, Medical University of South Carolina Children’s Hospital, Charleston, South Carolina
5 Department of Pediatrics, Division of Cardiac Critical Care, The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
6 Department of Pediatrics, Division of Critical Care, Seattle Children’s Hospital, Seattle, Washington
7 Department of Pediatrics, Division of Critical Care, Wayne State University School of Medicine, Children’s Hospital of Michigan, Detroit, Michigan
8 Department of Pediatrics, Division of Cardiac Intensive Care, University of Central Florida College of Medicine, The Heart Center at Arnold Palmer Hospital for Children, Orlando, Florida
9 Department of Pediatrics, Division of Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio
10 Department of Pediatrics, Division of Critical Care, Columbia University College of Physicians & Surgeons, Morgan Stanley Children’s Hospital of New York, New York, New York
11 Department of Pediatrics, Division of Cardiac Intensive Care, University of Wisconsin, Madison, Wisconsin
12 Department of Pediatrics, Division of Critical Care Medicine, University of Iowa Stead Family Children’s Hospital, Iowa City, Iowa
13 Department of Pediatrics, Division of Cardiac Critical Care, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
14 Cohen Children’s Medical Center, New Hyde Park, New York
15 Department of Biostatistics, Indiana University School of Medicine & Richard M. Fairbanks School of Public Health, Indianapolis, Indiana
16 Department of Pediatrics, Division of Critical Care Medicine, University of Utah School of Medicine, Primary Children’s Hospital, Salt Lake City, Utah

* Corresponding Author: Christine M. Riley, Department of Pediatrics, Division of Cardiac Critical Care, Children’s National Health System, 111 Michigan Ave, Washington, DC 20010. Email:

Congenital Heart Disease 2019, 14(6), 1078-1086. https://doi.org/10.1111/chd.12849

Abstract

Background: Elevated pulmonary vascular resistance (PVR) is common following repair of truncus arteriosus. Inhaled nitric oxide (iNO) is an effective yet costly therapy that is frequently implemented postoperatively to manage elevated PVR.
Objectives: We aimed to describe practice patterns of iNO use in a multicenter cohort of patients who underwent repair of truncus arteriosus, a lesion in which recovery is often complicated by elevated PVR. We also sought to identify patient and center factors that were more commonly associated with the use of iNO in the postoperative period.
Design: Retrospective cohort study.
Setting: 15 tertiary care pediatric referral centers.
Patients: All infants who underwent definitive repair of truncus arteriosus without aortic arch obstruction between 2009 and 2016.
Interventions: Descriptive statistics were used to demonstrate practice patterns of iNO use. Bivariate comparisons of characteristics of patients who did and did not receive iNO were performed, followed by multivariable mixed logistic regression analysis using backward elimination to identify independent predictors of iNO use.
Main Results: We reviewed 216 patients who met inclusion criteria, of which 102 (46%) received iNO in the postoperative period: 69 (68%) had iNO started in the operating room and 33 (32%) had iNO initiated in the ICU. Median duration of iNO use was 4 days (range: 1‐21 days). In multivariable mixed logistic regression analysis, use of deep hypothermic circulatory arrest (odds ratio: 3.2; 95% confidence interval: 1.2, 8.4) and center (analyzed as a random effect, p = .02) were independently associated with iNO use.
Conclusions: In this contemporary multicenter study, nearly half of patients who underwent repair of truncus arteriosus received iNO postoperatively. Use of iNO was more dependent on individual center practice rather than patient characteristics. The study suggests a need for collaborative quality initiatives to determine optimal criteria for utilization of this important but expensive therapy.

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