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Background: Complications associated with suboptimal pain management after pediatric cardiac surgery have increased interest in regional anesthesia (RA). We sought to evaluate national trends and explore the association of RA with postoperative outcomes following pediatric cardiac surgery., Methods: Patients <18 years in the Society of Thoracic Surgeons Congenital Cardiac Anesthesia Society Database from 01/2016-05/2023 were analyzed. Non-OR operations and records with missing data on RA were excluded. Data on patients, centers, operations, year, and RA type and medication were collected, and trends over the 8-year study period were analyzed. The association of RA with outcomes was analyzed with multivariable modeling in a subpopulation of children without preoperative risk factors who underwent index atrial and ventricular septal defect (ASD/VSD) repairs and Fontan procedures., Results: The cohort included 95,514 operations from 62 U.S., Centers: RA was used in 8.4 % (N = 7997) and increased annually from 6.1 % in 2016 to 12.5 % in 2023. Prevalence was highest in cases performed in children 1-11 years, characterized as low risk, and conducted low volume centers. There were statistically significant increases (p < 0.001) in RA use across all age groups and surgical risk categories during the study period. While the number of neuraxial techniques remained constant year-to-year, the number of non-neuraxial techniques (i.e., fascial plane blocks) increased sixfold during the study period. In the sub-analysis cohort (N = 7931), patients with RA for septal defect repairs and Fontan procedures were more likely to be extubated in the OR compared to non-RA patients (p < 0.001). ASD and VSD patients with RA were also more likely to have a short length of stay compared to those without RA (p < 0.001)., Conclusions: RA use is increasing in pediatric cardiac surgery in the U.S. and may be associated with surgery-specific outcome improvements., Competing Interests: Declaration of competing interest The authors declare no competing interests., (Copyright © 2025 Elsevier Inc. All rights reserved.)

Background: Arterial switch operation (ASO) has supplanted physiologic repairs for transposition of the great arteries and related anomalies. As survival rates have increased, so has the potential need for cardiac reoperations to address ASO-related complications arising later in life., Methods: The Society of Thoracic Surgeons Congenital Heart Surgery Database (2010-2021) was reviewed to assess prevalence and types of cardiac reoperations for patients aged ≥10 years with prior ASO for transposition of the great arteries or double-outlet right ventricle/transposition of the great arteries type. A hierarchical stratification designating 13 procedure categories was established a priori by investigators. Each eligible surgical hospitalization was assigned to the single highest applicable hierarchical category. Outcomes were compared across procedure categories, excluding hospitalizations limited to pacemaker-only and mechanical circulatory support-only procedures. Variation during the study period in relative proportions of left heart vs non-left heart procedure category encounters was assessed., Results: There were 698 cardiac surgical hospitalizations for patients aged 10 to 35 years at 100 centers. The most common left heart procedure categories were aortic valve procedures (n = 146), aortic root procedures (n = 117), and coronary artery procedures (n = 40). Of 619 hospitalizations eligible for outcomes analysis, major complications occurred in 11% (67/619). Discharge mortality was 2.3% (14/619). Year-by-year analysis of surgical hospitalizations reveals substantial growth in numbers for the aggregate of all procedure categories. Growth in relative proportions of left heart vs non-left heart procedures was significant (P = .0029; Cochran-Armitage trend test)., Conclusions: This large multicenter study of post-ASO reoperations beyond early childhood documents year-over-year growth in total reoperations. Left-sided heart procedures recently had the highest rate of rise. These observations have implications for counseling, surveillance, and management., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The increasing number of congenital heart disease patients undergoing reoperative cardiac surgery presents critical and growing challenges. Our objective was to evaluate the association between the number of prior cardiopulmonary bypass operations and operative mortality and morbidity in a national cohort., Methods: The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) was reviewed for index cardiac operations on cardiopulmonary bypass during 2016 to 2021. Infants and patients with functionally univentricular physiology were excluded. Multivariable logistic regression adjusted for covariates in the STS-CHSD Mortality Risk Model, the STS-European Association for Cardio-Thoracic Surgery (STAT) Mortality Category, and institutional volume., Results: Of 50,625 eligible operations, 22,100 (44%) were performed on patients with ≥1 prior cardiopulmonary bypass operations. Most common diagnoses were tetralogy of Fallot (4340 of 22,100 [19.6%]), pulmonary atresia/ventricular septal defect (1334 of 22,100 [6.0%]), and aortic stenosis (966 of 22,100 [4.4%]). Operative mortality correlated with number of prior cardiopulmonary bypass operations: 157 of 28,525 (0.6%) for 0, 127 of 13,488 (0.9%) for 1, 81 of 5,664 (1.4%) for 2, 61 of 2039 (3.0%) for 3, 35 of 623 (5.6%) for 4, 10 of 207 (4.8%) for 5, and 5 of 79 (6.3%) for ≥6 operations (P < .001). On multivariable analysis, patients with ≥3 prior cardiopulmonary bypass operations had higher risk of operative mortality (odds ratio, 2.31; P < .001) and major morbidity (odds ratio, 1.60; P < .001). Annual institutional volume and age were not associated with either outcome., Conclusions: Three or more prior cardiopulmonary bypass operations was an independent risk factor for operative mortality/morbidity, even after controlling for risk factors and institutional volume. Future research is needed to identify modifiable factors to optimize outcomes, particularly for those with ≥3 prior cardiopulmonary bypass operations., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Children with congenital heart disease are at risk for growth failure due to inadequate nutrient intake and increased metabolic demands. We examined the relationship between anthropometric indices of nutrition (height-for-age z-score [HAZ], weight-for-age z-score [WAZ], weight-for-height z-score [WHZ]) and outcomes in a large sample of children undergoing surgery for congenital heart disease., Methods: Patients in the Society of Thoracic Surgeons Congenital Heart Surgery Database having index cardiac surgery at age 1 month to 10 years were included. Indices were calculated by comparing patients' weight and height to population norms from the World Health Organization and Centers for Disease Control and Prevention. Outcomes included operative mortality, composite mortality or major complication, major postoperative infection, and postoperative length of stay. For each outcome and index, the adjusted odds ratio (aOR) (for mortality, composite outcome, and infection) and adjusted relative change in median (for postoperative length of stay) for a 1-unit decrease in index were estimated using mixed-effects logistic and log-linear regression models., Results: Every unit decrease in HAZ was associated with 1.40 aOR of mortality (95% CI 1.32-1.48), and every unit decrease in WAZ was associated with 1.33 aOR for mortality (95% CI 1.25-1.41). The relationship between WHZ and outcome was nonlinear, with aOR of mortality of 0.84 (95% CI 0.76-0.93) for 1-unit decrease when WHZ ≥ 0 and a nonsignificant association for WHZ < 0. Trends for other outcomes were similar. Overall, the incidence of low nutritional indices was similar for 1-ventricle and 2-ventricle patients. Children between the age of 1 month and 1 year and those with lesions associated with pulmonary overcirculation had the highest incidence of low nutritional indices., Conclusions: Lower HAZ and WAZ, suggestive of malnutrition, are associated with increased mortality and other adverse outcomes after cardiac surgery in infants and young children. Higher WHZ over zero, suggestive of obesity, is also associated with adverse outcomes., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

As the largest congenital and pediatric cardiac surgical clinical data registry in the world, The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS CHSD) serves as a platform for reporting of outcomes and for quality improvement. In addition, it is an important source of data for clinical research and for innovations related to quality measurement. Each year, several teams of investigators undertake analyses of data in the STS CHSD pertaining to the surgical management of specific diagnostic and procedural groups, or to specific processes of care, and their associations with patient characteristics and outcomes across centers participating in the STS CHSD. Additional ongoing projects involve the development of new or refined metrics for quality measurement and reporting of outcomes and center-level performance. The STS, through its Workforce for National Databases and the STS Research Center and Workforce on Research Development provides multiple pathways through which investigators may propose and perform outcomes research projects based on STS CHSD data. This report reviews research published within the past year., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model adjusts not only for procedure and age group pairings but also for additional patient factors, including the binary presence or absence of a chromosomal abnormality (CA), syndrome (S), and/or a noncardiac congenital anatomic abnormality (NCAA). This analysis refines case-mix adjustment by adding more granular adjustment for individual conditions (CA, S, and NCAA), consistent with a hypothesis that associated risk of mortality differs between individual conditions., Methods: CA/S corresponding to the same condition were merged to a single condition code. Odds ratios were estimated for all CA/S. For CA/S associated with at least 10 deaths in neonates and infants and at least 10 deaths in children and adults, odds ratios were estimated for the effect of the CA/S separately in neonates/infants and in children/adults. In addition to these condition/age interactions, condition/age/procedure interactions were explored (eg, effect of Down syndrome was estimated based on age and procedure subgroups, including atrioventricular canal repair and single-ventricle palliation). Bayesian modeling was used to create 5 maximally homogeneous groups of CA/S from 81 candidate CA/S variables. A standard logistic regression model then incorporated indicator variables for the 5 categories of CAs/Ss, 7 unique NCAAs, and all other covariates in the previously published Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Model., Results: Analysis included 107,062 operations in 100 centers (2010 to 2015). Operative Mortality was 3,629 (3.4%). In the development sample, the C statistics of the original nonaugmented model and the augmented model were 0.872 and 0.875, respectively., Conclusions: The Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model has been augmented by addition of covariates representing individual CAs, Ss, and NCAAs., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The completeness and accuracy of data contained within clinical databases and registries is critical to the reliability of reports emanating from these platforms. Therefore, vigorous data verification processes are a core competency of any mature database or registry. The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS CHSD) has conducted audits of participant data for just over ten years. This report documents the validity of data elements within the STS CHSD., Methods: We review the various elements of a robust audit process, detail the STS CHSD audit methodology, and report completeness and agreement rates for all adjudicated fields in the most recently completed audit., Results: The rate of completeness for general data elements was 97.6% and the rate of agreement was 97.4%. The rate of completeness for variables in the mortality review was 100% and the rate of agreement was 99.3%., Conclusions: The STS CHSD audit is a highly structured and reproducible process. The most recently completed audit documents a very high level of completeness and accuracy of data variables, particularly those most germane to outcomes measurement.

The Society of Thoracic Surgeons Congenital Heart Surgery Database is a comprehensive clinical outcomes registry that captures almost all pediatric cardiac surgical operations in the United States. It is the platform for all activities of The Society of Thoracic Surgeons related to the analysis of outcomes and the improvement of quality in this subspecialty. This report summarizes current aggregate national outcomes in congenital and pediatric cardiac surgery and reviews related activities in the areas of quality measurement, performance improvement, and transparency. The reported data about aggregate national outcomes are exemplified by an analysis of 10 benchmark operation groups performed from January 2014 to December 2017. This analysis documents the overall aggregate Operative Mortality for operations performed at North American participants in The Society of Thoracic Surgeons Congenital Heart Surgery Database and the interquartile range (IQR) for participant-specific rates of Operative Mortality for the following procedural groups: off-bypass coarctation repair, 1.5% (IQR, 0.0% to 1.4%); ventricular septal defect repair, 0.5% (IQR, 0.0% to 0.5%); tetralogy of Fallot repair, 1.3% (IQR, 0.0% to 2.0%); complete atrioventricular canal repair, 2.5% (IQR, 0.0% to 4.1%); arterial switch operation, 2.2% (IQR, 0.0% to 3.0%); arterial switch operation and ventricular septal defect repair, 4.6% (IQR, 0.0% to 7.1%); Glenn/hemiFontan, 1.8% (IQR, 0.0% to 2.7%); Fontan operation, 1.0% (IQR, 0.0% to 0.4%); truncus arteriosus repair, 9.5% (IQR, 0.0% to 15.4%); and Norwood (stage 1) operation, 15.0% (IQR, 8.3% to 25.0%)., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We describe the statistical methods and results related to development of the first congenital heart surgery composite quality measure., Methods: The composite measure was developed using The Society of Thoracic Surgeons Congenital Heart Surgery Database (2012 to 2015), Bayesian hierarchical modeling, and the current Society of Thoracic Surgeons risk model for case-mix adjustment. It consists of a mortality domain (operative mortality) and morbidity domain (major complications and postoperative length of stay). We evaluated several potential weighting schemes and properties of the final composite measure, including reliability (signal-to-noise ratio) and hospital classification in various performance categories., Results: Overall, 100 hospitals (78,425 operations) were included. Each adjusted metric included in the composite varied across hospitals: operative mortality (median, 3.1%; 10th to 90th percentile, 2.1% to 4.4%) major complications (median 11.7%, 10th to 90th percentile, 6.4% to 17.4%), and length of stay (median, 7.0 days; 10th to 90th percentile, 5.9 to 8.2 days). In the final composite weighting scheme selected, mortality had the greatest influence, followed by major complications and length of stay (correlation with overall composite score of 0.87, 0.69, and 0.47, respectively). Reliability of the composite measure was 0.73 compared with 0.59 for mortality alone. The distribution of hospitals across composite measure performance categories (defined by whether the 95% credible interval overlapped The Society of Thoracic Surgeons average) was 75% (same as expected), 9% (worse than expected), and 16% (better than expected)., Conclusions: This congenital heart surgery composite measure incorporates aspects of both morbidity and mortality, has clinical face validity, and greater ability to discriminate hospital performance compared with mortality alone. Ongoing efforts will support the use of the composite measure in benchmarking and quality improvement activities., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Current pediatric and congenital heart surgery quality measures focus on operative mortality, and numerous stakeholders are interested in more comprehensive measures. This report describes the background, rationale, and conceptual framework related to the development of the first composite quality metric in the field., Methods: A multidisciplinary panel reviewed methodology and framework related to quality measurement and several composite quality measures across adult cardiac surgery and other fields. The panel subsequently developed methodology and selected measures for a congenital heart surgery composite measure and reviewed potential advantages and limitations. Individual measures considered for potential inclusion in the composite were reviewed within the context of Donabedian's triad and the Institute of Medicine quality domains. Decisions were made through group consensus., Results: The final composite measure selected is comprised of two domains: (1) a mortality domain (operative mortality) and (2) a morbidity domain (the 6 major complications endorsed by The Society of Thoracic Surgeons and Congenital Heart Surgeons Society plus cardiac arrest, and postoperative length of stay). Potential advantages include the more comprehensive view of quality compared with mortality alone and improvements in discrimination of hospital performance through increasing the number of end points. Potential limitations include the lack of longer term outcomes and challenges related to case-mix adjustment., Conclusions: We have applied and adapted conceptual framework and methodology related to composite quality measures across other fields to congenital heart surgery. The composite quality metric created is inclusive of both morbidity and mortality, and expands our view of quality in this patient population., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The Society of Thoracic Surgeons (STS) National Database was established in 1989 as an initiative for quality improvement and patient safety among cardiothoracic surgeons. As of January 1, 2018, the STS National Database has four components, each focusing on a different area of cardiothoracic surgery-adult cardiac surgery, general thoracic surgery, and congenital heart surgery, as well as mechanical circulatory support through the STS Intermacs Database. In December 2015, The Annals of Thoracic Surgery began publishing a monthly series of scholarly articles on outcomes analysis, quality improvement, and patient safety. As part of that series, this article provides an annual summary of the status of the STS National Database as of October 2018 and provides a synopsis of related articles that appeared in The Annals of Thoracic Surgery 2018 series entitled: "Outcomes Analysis, Quality Improvement, and Patient Safety"., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The Society of Thoracic Surgeons Congenital Heart Surgery Database is a comprehensive registry of clinical outcomes that captures almost all pediatric cardiac surgical operations in the United States. It is the platform for all activities of The Society of Thoracic Surgeons related to the analysis of outcomes and the improvement of quality in this subspecialty. This article summarizes current aggregate national outcomes in congenital and pediatric cardiac surgery and reviews related activities in the areas of quality measurement, performance improvement, and transparency. The reported data about aggregate national outcomes are exemplified by an analysis of 10 benchmark operation groups performed from January 2013 through December 2016. This analysis documents the overall aggregate Operative Mortality (interquartile range among all participating programs) for the following procedural groups: off-bypass coarctation repair, 1.3% (0.0% to 1.4%%); ventricular septal defect repair, 0.6% (0.0% to 0.9%); tetralogy of Fallot repair, 1.1% (0.0% to 2.0%); complete atrioventricular canal repair, 2.7% (0.0% to 4.4%); arterial switch operation, 2.2% (0.0% to 2.9%); arterial switch operation and ventricular septal defect repair, 5.1% (0.0% to 8.3%); Glenn/HemiFontan, 2.1% (0.0% to 3.1%); Fontan operation, 1.1% (0.0% to 0.0%); truncus arteriosus repair, 10.1% (0.0% to 15.4%); and Norwood procedure, 15.8% (9.0% to 25.0%)., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

An internationally approved and globally used classification scheme for the diagnosis of CHD has long been sought. The International Paediatric and Congenital Cardiac Code (IPCCC), which was produced and has been maintained by the International Society for Nomenclature of Paediatric and Congenital Heart Disease (the International Nomenclature Society), is used widely, but has spawned many "short list" versions that differ in content depending on the user. Thus, efforts to have a uniform identification of patients with CHD using a single up-to-date and coordinated nomenclature system continue to be thwarted, even if a common nomenclature has been used as a basis for composing various "short lists". In an attempt to solve this problem, the International Nomenclature Society has linked its efforts with those of the World Health Organization to obtain a globally accepted nomenclature tree for CHD within the 11th iteration of the International Classification of Diseases (ICD-11). The International Nomenclature Society has submitted a hierarchical nomenclature tree for CHD to the World Health Organization that is expected to serve increasingly as the "short list" for all communities interested in coding for congenital cardiology. This article reviews the history of the International Classification of Diseases and of the IPCCC, and outlines the process used in developing the ICD-11 congenital cardiac disease diagnostic list and the definitions for each term on the list. An overview of the content of the congenital heart anomaly section of the Foundation Component of ICD-11, published herein in its entirety, is also included. Future plans for the International Nomenclature Society include linking again with the World Health Organization to tackle procedural nomenclature as it relates to cardiac malformations. By doing so, the Society will continue its role in standardising nomenclature for CHD across the globe, thereby promoting research and better outcomes for fetuses, children, and adults with congenital heart anomalies.

The Society of Thoracic Surgeons (STS) National Database has three major component databases: the STS Adult Cardiac Surgery Database (ACSD), the STS Congenital Heart Surgery Database (CHSD), and the STS General Thoracic Surgery Database (GTSD). Beginning in January 2016, The Annals of Thoracic Surgery began publishing a monthly series of scholarly articles on outcomes analysis, quality improvement, and patient safety. This article summarizes the status of the STS National Database as of October 2017 and summarizes the articles about the STS National Database that appeared in The Annals of Thoracic Surgery 2017 series "Outcomes Analysis, Quality Improvement, and Patient Safety.", (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS CHSD) is the largest congenital and pediatric cardiac surgical clinical data registry in the world. It contains data pertaining to more than 435,000 total operations. The most recent biannual feedback report to participants (Spring 2017, Report of the Twenty-Sixth Harvest) included analysis of data submitted from 127 hospitals in North America. That represents nearly all centers performing pediatric and congenital heart operations in the United States and Canada. As an unparalleled platform for assessment of outcomes and for quality improvement activities in the subspecialty of surgery for pediatric and congenital heart disease, the STS CHSD continues to be a primary data source for clinical investigations and for research and innovations related to quality measurement. In 2016, several major original publications reported analyses of data in the CHSD pertaining to various processes of care, including assessment of variation across centers and associations between specific practices, patient characteristics, and outcomes. Additional publications reported the most recent development, evaluation, and application of metrics for quality measurement and reporting of pediatric and congenital heart operation outcomes and center level performance. Use of the STS CHSD for outcomes research and for quality measurement continues to expand as database participation has grown to include nearly all centers in North America, and the available wealth of data in the database continues to grow. This article reviews outcomes research and quality improvement articles published in 2016 that are based on STS CHSD data., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Data routinely captured in clinical registries may be leveraged to enhance efficiency of prospective research. The quality of registry data for this purpose has not been studied, however. We evaluated the completeness and accuracy of perioperative data within congenital heart centers' local surgical registries., Methods: Within 12 Pediatric Heart Network (PHN) sites, we evaluated 31 perioperative variables (and their subcategories, totaling 113 unique fields) collected via sites' local clinical registries for submission to The Society of Thoracic Surgeons Database, compared with chart review by PHN research coordinators. Both used standard STS definitions. Data were collected on 10 subjects for 2 to 5 procedures/site and adjudicated by the study team. Completeness and accuracy (agreement of registry data with medical record review by PHN coordinator, adjudicated by the study team) were evaluated., Results: A total of 56,500 data elements were collected on 500 subjects. With regard to data completeness, 3.1% of data elements were missing from the registry, 0.6% from coordinator-collected data, and 0.4% from both. Overall, registry data accuracy was 98%. In total, 94.7% of data elements were both complete/non-missing and accurate within the registry, although there was variation across data fields and sites. Mean total time for coordinator chart review per site was 49.1 hours versus 7.0 hours for registry query., Conclusions: This study suggests that existing surgical registry data constitute a complete, accurate, and efficient information source for prospective research. Variability across data fields and sites also suggest areas for improvement in some areas of data quality., Competing Interests: Mr. White discloses a financial relationship with CardioAccess., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The Society of Thoracic Surgeons Workforce on Congenital Heart Surgery (CHS) undertook a third subspecialty Practice Survey (2005, 2010, 2015) to obtain contemporary data., Methods: A search for potential participants was conducted using multiple directories and websites. The survey instrument was widely distributed electronically. All surgeons listing congenital or pediatric cardiac surgery among interests were targeted., Results: There were a total of 213 respondents: 177 (83%) were practicing congenital heart surgeons (median age 50 years; range, 34 to 80 years; 93% men), 9 (4%) were CHS trainees, 17 (8%) were retired congenital heart surgeons, and 10 (5%) were others. For practicing surgeons, mean duration of postgraduate training was 10 ± 2 years and 151 (85%) were CHS-board certified. Median practice duration for congenital heart surgeons was 15 years (less than 1 to 42 years). Work hours per week were greater than 70 for 74 (42%) surgeons, 103 (58%) work at a freestanding children's hospital, and 113 (64%) have full academic appointments. Caseload for 47 (27%) surgeons was less than 100 cases/year and 42 (24%) performed greater than 200 cases/year. For practicing surgeons, anticipated median retirement age was 66 years (range, 55 to 83 years), 31 (18%) estimated ≤5 years to retirement, and 163 (92%) were extremely or very satisfied in their career., Conclusions: These data provide contemporary insights regarding the CHS workforce in North America and should help facilitate rational plans to address the needs of an expanding patient population., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Among patients with congenital heart disease (CHD), the coexistence of noncardiac congenital anatomic abnormalities (NC), genetic abnormalities (GA), and syndromes (S) may influence therapeutic strategies and outcomes. The appreciated prevalence of these abnormalities has risen because increased screening and improved diagnostic precision enable identification of these comorbidities in a larger fraction of neonates with CHD. We examined the contemporary prevalence and distribution of NC/GA/S across diagnostic groups among neonates undergoing cardiac operations using a large nationally representative clinical registry., Methods: The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) was queried to identify neonates (≤30 days) who underwent index cardiac operations from 2010 to 2013. The fundamental cardiac diagnosis was used to identify 10 diagnostic groups. The prevalence of NC/GA/S was reported across each group., Results: The cohort included 15,376 index neonatal operations from 112 centers. Overall, 18.8% (2,894 of 15,376) of operations were performed in neonates with NC/GA/S. Patients with atrioventricular septal defect (212 of 357 [59.4%]), interrupted aortic arch (248 of 567 [43.7%]), truncus arteriosus (204 of 554 [36.8%]), and tetralogy of Fallot (417 of 1,383 [30.2%]) had the highest prevalence of NC/GA/S abnormalities, whereas those with transposition of the great arteries (111 of 2,778 [4.0%]) had the lowest prevalence. The most commonly identified NC/GA/S included heterotaxy (597 of 15,376 [3.9%]), DiGeorge syndrome or 22q11 deletion (550 of 15,376 [3.6%]), Down syndrome or trisomy 21 (318 of 15, 376 [2.1%]), intestinal malrotation (220 of 15,376 [1.4%]), and Turner syndrome or 45XO (189 of 15,376 [1.2%])., Conclusions: The prevalence of NC/GA/S varies widely across CHD diagnostic groups. This information may be useful for patient counseling, recommendations for screening for anomalies and genetic disorders, and perioperative management., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The Society of Thoracic Surgeons Congenital Heart Surgery Database is the largest congenital and pediatric cardiac surgical clinical data registry in the world. It is the platform for all activities of The Society of Thoracic Surgeons related to the analysis of outcomes and the improvement of quality in this subspecialty. This article summarizes current aggregate national outcomes in congenital and pediatric cardiac surgery and reviews related activities in the areas of quality measurement, performance improvement, and transparency. The reported data about aggregate national outcomes are exemplified by an analysis of 10 benchmark operations performed from January 2011 to December 2014 and documenting overall discharge mortality (interquartile range among programs with more than 9 cases): off-bypass coarctation, 1.0% (0.0% to 0.9%); ventricular septal defect repair, 0.7% (0.0% to 1.1%); tetralogy of Fallot repair, 1.0% (0.0% to 1.7%); complete atrioventricular canal repair, 3.2% (0.0% to 6.5%); arterial switch operation, 2.7% (0.0% to 5.6%); arterial switch operation plus ventricular septal defect, 5.3% (0.0% to 6.7%); Glenn/hemiFontan, 2.1% (0.0% to 3.8%); Fontan operation, 1.4% (0.0% to 2.4%); truncus arteriosus repair, 9.6% (0.0 % to 11.8%); and Norwood procedure, 15.6% (10.0% to 21.4%)., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The Society of Thoracic Surgeons (STS) National Database is the foundation for most of the Society's quality, research, and patient safety activities. Beginning in January 2016 and repeating each year, The Annals of Thoracic Surgery will publish a monthly Database series of scholarly articles on outcomes analysis, quality improvement, and patient safety. Six articles will be directly derived from the STS National Database and will be published every other month: three articles on outcomes and quality (one each from the STS Adult Cardiac Surgery Database, the STS Congenital Heart Surgery Database, and the STS General Thoracic Surgery Database), and three articles on research (one from each of these three specialty databases). These six articles will alternate with five additional articles on topics related to patient safety. The final article, to be published in December, will provide a summary of the prior 11 manuscripts. This series will allow STS and its Workforces on National Databases, Research Development, and Patient Safety to convey timely information aimed at improving the quality and safety of cardiothoracic surgery., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Adjustment for case mix is critical to accurate outcomes analysis in congenital heart surgery. Established tools encompass all age groups and are not specific to the growing population of adults undergoing congenital heart operations. We derived an empirically based adult congenital heart surgery (ACHS) mortality score., Methods: In-hospital mortality was analyzed for the 152 most common procedures/procedural groups in adults 18 years of age and older in The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) (2000-2013). Procedure-specific adult mortality rate estimates were calculated using Bayesian methods adjusting for small denominators for procedures with 30 cases or more (N = 52). Each procedural group was assigned an ACHS mortality score ranging from 0.1 to 3.0 based on the estimated mortality rate. Discrimination was assessed using the c-index in a separate validation sample., Results: A total of 12,513 procedures (116 centers) were analyzed. Overall unadjusted mortality was 1.8%. Significant differences in mortality rates in adults compared with all ages were seen for several procedures, including Ebstein's repair (0.7% versus 4.9%; p = 0.003) and Fontan operations (6.8% versus 1.4%; p < 0.01). The procedure with the lowest model-based estimate of mortality and accompanying ACHS mortality score was atrial septal defect repair (0.2%, 0.1), and the highest was Fontan revision (9.7%, 3.0). The c-index for the ACHS mortality score was 0.809 versus 0.777 for the "non-age-specific" Society of Thoracic Surgeons-European Association for Cardio-thoracic Surgery (STAT) mortality score applied to adults., Conclusions: Risk estimation based on the aggregate of all age groups is suboptimal when analyzing outcomes specifically among adults. An empirically based ACHS mortality score can facilitate case-mix adjustment by providing accurate estimation of mortality risk for adults., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The most common forms of risk adjustment for pediatric and congenital heart surgery used today are based mainly on the estimated risk of mortality of the primary procedure of the operation. The goals of this analysis were to assess the association of patient-specific preoperative factors with mortality and to determine which of these preoperative factors to include in future pediatric and congenital cardiac surgical risk models., Methods: All index cardiac operations in The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) during 2010 through 2012 were eligible for inclusion. Patients weighing less than 2.5 kg undergoing patent ductus arteriosus closure were excluded. Centers with more than 10% missing data and patients with missing data for discharge mortality or other key variables were excluded. Rates of discharge mortality for patients with or without specific preoperative factors were assessed across age groups and were compared using Fisher's exact test., Results: In all, 25,476 operations were included (overall discharge mortality 3.7%, n=943). The prevalence of common preoperative factors and their associations with discharge mortality were determined. Associations of the following preoperative factors with discharge mortality were all highly significant (p<0.0001) for neonates, infants, and children: mechanical circulatory support, renal dysfunction, shock, and mechanical ventilation., Conclusions: Current STS-CHSD risk adjustment is based on estimated risk of mortality of the primary procedure of the operation as well as age, weight, and prematurity. The inclusion of additional patient-specific preoperative factors in risk models for pediatric and congenital cardiac surgery could lead to increased precision in predicting risk of operative mortality and comparison of observed to expected outcomes., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Previous studies on the impact of race and sex on outcome in children undergoing cardiac operations were based on analyses of administrative claims data. This study uses clinical registry data to examine potential associations of sex and race with outcomes in congenital cardiac operations, including in-hospital mortality, postoperative length of stay (LOS), and complications., Methods: The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) was queried for patients younger than 18 years undergoing cardiac operations from 2007 to 2009. Preoperative, operative, and outcome data were collected on 20,399 patients from 49 centers. In multivariable analysis, the association of race and sex with outcome was examined, adjusting for patient characteristics, operative risk (Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery [STAT] mortality category), and operating center., Results: Median age at operation was 0.4 years (interquartile range 0.1-3.4 years), and 54.4% of patients were boys. Race/ethnicity included 54.9% white, 17.1% black, 16.4% Hispanic, and 11.7% "other." In adjusted analysis, black patients had significantly higher in-hospital mortality (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.37-2.04; p<0.001) and complication rate (OR, 1.15; 95% CI, 1.04-1.26; p<0.01) in comparison with white patients. There was no significant difference in mortality or complications by sex. Girls had a shorter LOS than boys (-0.8 days; p<0.001), whereas black (+2.4 days; p<0.001) and Hispanic patients (0.9 days; p<0.01) had longer a LOS compared with white patients., Conclusions: These data suggest that black children have higher mortality, a longer LOS, and an increased complication rate. Girls had outcomes similar to those of boys but with a shorter LOS of almost a day. Further study of potential causes underlying these race and sex differences is warranted., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Previous studies have suggested truncal valve insufficiency may adversely affect outcome after common arterial trunk (CAT) repair. It is unknown if truncal insufficiency requiring truncal valve surgery (TVS) at the time of primary CAT repair impacts outcome., Methods: Patients in The Society of Thoracic Surgeons Congenital Heart Surgery Database undergoing CAT repair from 2000 to 2009 were included. Outcomes were compared for patients with and without TVS at the time of CAT repair and were further stratified by interrupted aortic arch (IAA) repair., Results: Of 572 patients (63 centers), median age at surgery was 12 days (interquartile range, 6 to 34). Twenty-three patients underwent concomitant TVS (n=22 repair, n=1 replacement) during CAT repair, and 4 patients underwent TVS later during the same hospitalization (n=1 repair, n=3 replacement). Thirty-nine patients underwent IAA repair at the time of CAT repair, 5 of whom had concomitant TVS. Mortality for CAT repair with TVS versus isolated CAT repair was 30% versus 10% (p=0.0002). All 4 patients who required TVS later during the admission died. Truncal valve surgery was associated with increased mortality among CAT patients both with and without IAA repair, with the highest mortality (60%) among CAT patients undergoing IAA repair and TVS (n=5). Common arterial trunk plus TVS had an increased risk of mechanical support and a longer hospital stay., Conclusions: Truncal valve surgery in patients undergoing CAT repair is associated with significant mortality. Repair of IAA and TVS at the time of CAT repair carries particularly high risk. Failure to address significant truncal insufficiency, necessitating early reoperation with TVS, had uniformly poor outcomes., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Outcomes data for adults undergoing congenital heart surgery are limited. Previous analyses used administrative data or focused on single-center outcomes. We describe the most common operations, patient characteristics, and postoperative outcomes using a multicenter clinical database., Methods: The study included adults (aged ≥ 18 years) listed in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2000-2009). We describe patient characteristics and morbidity and mortality, and examine congenital procedures in the Society of Thoracic Surgeons Adult Cardiac Surgery Database to permit consideration of the primary dataset within a broader context., Results: A total of 5265 patients (68 centers) from the Society of Thoracic Surgeons Congenital Heart Surgery Database were included. Patients' median age was 25 years (interquartile range, 20-35). Common preoperative risk factors included noncardiac abnormalities (17%) and arrhythmia (14%). Overall, in-hospital mortality was 2.1%, 27% had 1 or more complication, and median length of stay was 5 days. Common operations included right ventricular outflow tract procedures (21%) and pacemaker/arrhythmia procedures (20%). We further evaluated cardiopulmonary bypass procedures in more than 100 patients. Mortality ranged from 0% (atrial septal defect repair) to 11% (Fontan revision/conversion). Separate evaluation of the Society of Thoracic Surgeons Adult Cardiac Surgery Database revealed 39,872 adults undergoing congenital heart operations., Conclusions: Most adult congenital heart operations listed in the Society of Thoracic Surgeons Congenital Heart Surgery Database are performed in the third to fourth decades of life; approximately half are for right heart pathology or arrhythmia. Many patients have complications, but mortality is low with the exception of those undergoing Fontan revision/conversion. Many more adults undergoing congenital heart surgery are entered into the Society of Thoracic Surgeons Adult Cardiac Surgery Database., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: The Society of Thoracic Surgeons (STS) Workforce on Congenital Heart Surgery undertook a second subspecialty Practice and Manpower Survey (2005, 2010) to obtain contemporary data., Methods: Preliminary research suggested a potential target group of 273 congenital heart surgeons, including 258 at 125 US centers and 15 at 8 Canadian centers. The web-based survey was sent to these surgeons, plus all individuals listing pediatric cardiac surgery on CTSNet., Results: Two hundred forty-six responders included 213 active congenital heart surgeons, 16 retired congenital heart surgeons, and 17 surgeons in training. Retirement age was 63.5±7.5 years. Two hundred thirteen active congenital heart surgeon responders represent 78% of the original estimate. Their responses generated the following data: The mean age was 49.2±8.5 (range, 35 to 75 years). American medical school graduates included 159 of 201 respondents (79%). Years of postgraduate training was 9.7±1.7. One hundred ninety-seven (92%) respondents were certified in thoracic surgery by the American Board of Thoracic Surgery (ABTS). Twenty-eight of 200 (14%) received their congenital heart surgery training outside the United States or Canada. One hundred forty-three of 190 respondents (75%) perform exclusively congenital heart operations; 31 (16%) perform exclusively pediatric heart operations. Of 186 respondents, 54 (29%) perform fewer than 100 major congenital heart operations per year, 78 (42%) perform 100 to 199 procedures, and 54 (29%) perform 200 procedures or more. Active congenital heart surgeons have been in their current positions for 9.3±8.6 years. Eight respondents are in their first year of practice. For 203 respondents, mean anticipated years to retirement is 16.1±7.6. Twenty-eight anticipate retirement within 5 years; 31 in 6 to 10 years., Conclusions: These data should help facilitate rational plans to meet workforce needs for an expanding patient population., (Copyright © 2011. Published by Elsevier Inc. All rights reserved.)

Background: Long-term evaluation of cardiothoracic surgical outcomes is a major goal of The Society of Thoracic Surgeons (STS). Linking the STS Database to the Social Security Death Master File (SSDMF) allows for the verification of "life status." This study demonstrates the feasibility of linking the STS Database to the SSDMF and examines longitudinal survival after cardiac operations., Methods: For all operations in the STS Adult Cardiac Surgery Database performed in 2008 in patients with an available Social Security Number, the SSDMF was searched for a matching Social Security Number. Survival probabilities at 30 days and 1 year were estimated for nine common operations., Results: A Social Security Number was available for 101,188 patients undergoing isolated coronary artery bypass grafting, 12,336 patients undergoing isolated aortic valve replacement, and 6,085 patients undergoing isolated mitral valve operations. One-year survival for isolated coronary artery bypass grafting was 88.9% (6,529 of 7,344) with all vein grafts, 95.2% (84,696 of 88,966) with a single mammary artery graft, 97.4% (4,422 of 4,540) with bilateral mammary artery grafts, and 95.6% (7,543 of 7,890) with all arterial grafts. One-year survival was 92.4% (11,398 of 12,336) for isolated aortic valve replacement (95.6% [2,109 of 2,206] with mechanical prosthesis and 91.7% [9,289 of 10,130] with biologic prosthesis), 86.5% (2,312 of 2,674) for isolated mitral valve replacement (91.7% [923 of 1,006] with mechanical prosthesis and 83.3% [1,389 of 1,668] with biologic prosthesis), and 96.0% (3,275 of 3,411) for isolated mitral valve repair., Conclusions: Successful linkage to the SSDMF has substantially increased the power of the STS Database. These longitudinal survival data from this large multi-institutional study provide reassurance about the durability and long-term benefits of cardiac operations and constitute a contemporary benchmark for survival after cardiac operations., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

A large body of literature devoted to "patient safety" and error prevention exists and utilizes a nomenclature that can be applied specifically to the field of congenital cardiac disease and aid in the goals of increasing the safety of patients, decreasing medical error, minimizing mortality and morbidity, and evaluating quality of care. The purpose of this manuscript is to suggest and document a quality of health care taxonomy and the appropriate application of this nomenclature of "patient safety" to the specialty of congenital cardiac disease, with special emphasis on the following ten terms: morbidity, complication, medical error, adverse event, harm, near miss, iatrogenesis, iatrogenic complication, medical injury, and sentinel event. Each of these terms is commonly utilized in the medical literature without universal agreement on their meaning and relationship. It is our hope that the standardization of the definitions of these terms, as they are applied to the analysis of outcomes of the treatments applied to patients with congenital and paediatric cardiac disease, will facilitate improved methodologies to assess and improve quality of care in our profession.