The Harsh Reality of Tracheostomy in Congenital Cardiac Surgery

J. Briscoe¹, A. Venna², R. Mehta², Y. Domnina³, H. Greenlick-Michals³, M. Desai⁴, A. Tongut⁵, C. Yerebakan⁶, Y. d'Udekem^2
1Georgetown University, Washington, District of Columbia ²Children's National Hospital, Washington, District of Columbia ³Childrens National Hospital, Washington, District of Columbia ⁴Children’s National Hospital, Washington, District of Columbia ⁵Children’s National Hospital, Washington DC, District of Columbia ⁶Children’s National Medical Center, Washington, District of Columbia

Purpose: Early tracheostomy improves outcomes in the adult population, but there is little evidence of benefits in the pediatric population. We investigated the hospital and late survival, and the capacity to wean off the tracheostomy in patients who underwent congenital cardiac surgery. We intended to identify factors predicting worse outcomes.

Methods: A single center institution review of 65 patients who underwent tracheostomy placement and cardiac surgery in a pediatric hospital between 1990 to 2022 was performed. A total of 61 patients had tracheostomy placement after cardiac surgery. Multivariable logistic regression analysis was performed to assess predictors of mortality. Kaplan-Meier estimate was performed to evaluate mortality following tracheostomy placement.

Results: Median age at tracheostomy was 191 days (IQR [108,279.5]), median birth weight was 2.6 0.95 kgs (Table). A total of 35 patients had a genetic or chromosomal abnormality (54%). The indication for tracheostomy was primarily pulmonary in 41 patients, cardiac in 13, neurological in 4 and both pulmonary and cardiac in 2. Patients were reintubated a median of 3 times [0.75,4] before tracheostomy. Duration of ventilation time before tracheostomy was 85 days [45,117.75]. Six patients were lost to follow-up. A total of 39 patients were reported to have died. Overall mortality was 60% (Figure). The in-hospital mortality was 34% (22 pts). Forty-one patients were discharged from the hospital. Only 20 were reported to be alive after a median of 5 years (2-6.75). Ultimately, 10 patients were decannulated after a median time to decannulation of 1040 days [770,1182]. Patients undergoing tracheostomy for cardiac indication had a higher mortality (NS). By multivariable analysis the only independent predictors of mortality were a higher number of times a patient was reintubated (OR = 0.74 [0.55-0.99], p=0.0479) and the total length of hospital stay (OR = 1.015 [1.01-1.03], p=0.007).

Conclusion: With 60% mortality after tracheostomy in patients undergoing cardiac surgery in a pediatric hospital, one can wonder whether this practice improved the survival of this entire group of patients. Patients whose tracheostomy was indicated for respiratory failure had a higher chance of survival than those who underwent tracheostomy for a cardiac indication. Families should be warned that, in the sickest of these patients, tracheostomy may only offer increased survival for a limited time.

Identify the source of the funding for this research project: Internal department funds were used to fund this project.