Congenital

On Saturday, Jan. 31 at 2:45 p.m., during the “Adult Congenital Heart Disease” session, Jennifer Nelson, MD, of Nemours Children’s Hospital will present Indications and Timing of Pulmonary Valve Replacement in Repaired Tetralogy of Fallot. Her talk will highlight a new, comprehensive body of work designed to bring greater clarity and consistency to decision-making around pulmonary valve replacement (PVR) for one of the largest populations of patients living with repaired congenital heart disease.

Image

PVR is a common and critical intervention for patients with repaired tetralogy of Fallot (TOF) and clinically significant pulmonary regurgitation; however, indications and timing have varied widely across practice settings. To reduce this variability, The Society of Thoracic Surgeons (STS), in collaboration with the World Society of Pediatric and Congenital Heart Surgery (WSPCHS) and the European Congenital Heart Surgeons Association (ECHSA), developed a three-part series of complementary clinical practice documents: Clinical Practice Guidelines, a pediatric-focused Expert Consensus Document, and an Expert Opinion paper on the role of exercise testing.

Developed through a rigorous literature review, adherence to PRISMA methodology, and a modified Delphi consensus process, these documents synthesize available evidence and expert judgment to establish practical, consensus-based recommendations.

Key considerations include symptoms, MRI-based ventricular assessment, arrhythmia risk, and procedural factors, emphasizing individualized, data-driven decisions over single thresholds. “Routine, standardized measurement during long-term follow-up is essential,” says Dr. Nelson, who also highlights the role of multidisciplinary review and exercise testing in revealing unrecognized functional limitations.

The new guidance incorporates emerging MRI-based evidence linking ventricular changes to mortality and supports earlier consideration of pulmonary valve replacement in select asymptomatic adults. It also emphasizes that arrhythmia risk persists after intervention, reinforcing the need for continued surveillance.

Together, this three-part series provides an updated framework to guide clinicians caring for children and adults with repaired TOF, balancing evolving evidence with real-world clinical complexity. “These recommendations matter because they should change practice,” Dr. Nelson adds. “They help clinicians better identify the right patient and the right time for pulmonary valve replacement, with the goal of improving long-term outcomes while minimizing unnecessary risk.”

During the Airway Issues session on Friday, Jan. 30 at 1:30 p.m., Joseph Nellis, MD, of Duke University Medical Center, will present the Richard E. Clark Memorial Paper, Impact of Preoperative Tracheostomy on Outcomes Following Congenital Cardiac Surgery: A Study of the STS Congenital Heart Surgery Database, at STS 2026. In this presentation, Dr. Nellis will examine how preoperative tracheostomy affects outcomes following congenital cardiac surgery, an area with limited prior data despite longstanding concerns about risk in this population.

Image

Congenital cardiac surgery patients with preoperative tracheostomy represent a small but increasingly recognized group with complex medical needs. To better understand how tracheostomy status influences surgical outcomes, Dr. Nellis and colleagues analyzed national registry data spanning a decade of congenital cardiac operations, comparing patients with preoperative tracheostomy to those without this airway history.

Overall, patients with preoperative tracheostomy experienced higher rates of postoperative complications, readmissions, and mortality compared with those without tracheostomy. Even after accounting for differences in baseline risk, preoperative tracheostomy remained associated with an increased likelihood of infection-related complications and early mortality, though it was not linked to longer hospital stays or higher overall morbidity.

In his presentation, Dr. Nellis will outline the implications these findings inform risk stratification and surgical planning for children with complex airway and cardiac disease. He emphasizes that while preoperative tracheostomy identifies a higher-risk patient population, it should not, by itself, exclude patients from consideration for definitive congenital cardiac surgery.
 

During the Saturday, Jan. 31, 7:50 a.m. presentation of the James S. Tweddell Memorial Paper for Congenital Heart Surgery, Elaine Griffeth, MD, of Mayo Clinic, will present new research as part of the “Research in Focus: Distinguished Abstracts” session at the 2026 Society of Thoracic Surgeons (STS) Annual Meeting. Her talk, Extended Validation of an Institutional Machine Learning Model for Postoperative Morbidity and Mortality Risk in Adult Congenital Heart Disease Patients Undergoing Cardiac Reoperation, will explore how advanced risk modeling can better inform surgical decision-making for adults with congenital heart disease (CHD).

Image

Adults with CHD represent a growing and medically complex population. Most were born with structural heart defects and underwent surgery early in life, yet many require additional cardiac operations as adults. Prior surgeries, evolving anatomy, and long-term health challenges make it difficult to accurately estimate operative risk using existing tools designed for the broader adult cardiac surgery population, highlighting the need for a CHD-specific national risk assessment model.

The study analyzed cases from the STS Adult Cardiac Surgery Database spanning several years, building on prior Mayo Clinic work using machine learning and logistic regression. Seven factors were strongly associated with postoperative morbidity and mortality: sex, age, single-ventricle physiology, surgical urgency, kidney function, ejection fraction, and prior heart operations.  

“This is a work in progress,” says Dr. Griffeth. “We want to have high reliability in the surgeries we are offering, and we are trying to tailor this model with data from past patients. The more informed patients are about their risks for surgery, the better.”
 

A new study sheds light on the challenges of pediatric mitral valve replacement (MVR) and evaluates the potential of the balloon-expandable Melody valve as an alternative to traditional mechanical prostheses. The findings offer important insights for treating young children with small mitral annuli, a population for whom MVR carries significant risks of morbidity and mortality.

A team of researchers, led by Morgan Moroi, MD, New York-Presbyterian/Columbia University Medical Center, conducted a retrospective review of 36 children under 2 years of age who underwent MVR at a single center between 2005 and 2023. Using propensity score matching to minimize baseline differences, the study compared outcomes between 12 patients receiving the Melody valve and 12 patients treated with mechanical prostheses.

The primary outcome was a composite measure of death, transplant, or surgical reintervention on the mitral valve prosthesis. Median follow-up was 1.6 years.

Key Findings

Both groups had similar baseline characteristics, with a median age of 5.2 months and median weight of 6.5 kg at the time of surgery. The study revealed several important differences and similarities in outcomes:

• Hospital Stay: Melody valve patients had shorter hospital stays (median: 20.5 days) compared to mechanical valve patients (median: 59.0 days), though the difference was not statistically significant (P=0.11).
• Mitral Valve Gradients: The Melody valve group had significantly lower mitral valve gradients at discharge (5.5 mmHg vs. 8.7 mmHg, P=0.046).
• Permanent Pacemakers: No patients in the Melody group required a permanent pacemaker, while 41.7% of the mechanical group did (P=0.04).
• Reintervention Rates: Both groups experienced early surgical reinterventions at similar rates (33.3% vs. 25%, P=1.00).
• Survival Outcomes: At 1 and 3 years, transplant-free survival was comparable between the groups, with no significant difference (P=0.92).
   

Implications 

The findings suggest that the Melody valve offers several advantages over mechanical prostheses in young children with small mitral annuli, including lower rates of permanent pacemaker insertion and no need for lifelong anticoagulation. While early reintervention rates were high across both groups, the Melody valve demonstrated equivalent survival outcomes and may provide a safer and more effective option for this vulnerable patient population. However, the study authors emphasize the need for further research with larger cohorts and longer follow-up to confirm these promising results.
 

Evaluating the performance of congenital heart surgery centers is essential for improving patient outcomes. However, traditional methods of assessing performance have their limitations. At yesterday’s STS 2025 session, Sharon-Lise Normand, PhD, a professor of health care policy at Harvard Medical School, presented Improving Risk Adjustment in the Assessment of Congenital Heart Center Surgical Quality, which explored the use of modern causal inference techniques. These techniques aimed to better account for differences in case mix across centers, enhance risk adjustment, and provide a more accurate evaluation of center performance.

Utilizing data from the STS Congenital Database over a five-year period, the study examined 115 heart surgery centers across the United States. It compared two approaches for predicting postoperative mortality rates:

1. Traditional Method: This approach employed a statistical model that included data from all types of heart surgeries, even those that differed significantly from the procedures performed at the specific center.
2. Causal Inference Method: In contrast, this method focused on identifying other centers that performed similar surgeries and compared the outcomes of patients at those centers to those at the center under study.

Key findings

Dr. Normand discussed how the study revealed that causal inference methods yielded significantly higher and more variable estimates of expected mortality compared to traditional regression models. This suggests that traditional methods may underestimate the complexity of risk adjustment and the variability in performance across different centers. Additionally, causal inference methods were more effective in aligning the distribution of risk factors between comparison and target centers, leading to more accurate estimates of expected mortality.

Implications

These findings emphasize the potential of causal inference methods to provide a more tailored approach to risk adjustment, enhancing the accuracy of performance assessments across various centers. “Further research is needed to explore the implications of these methods for quality improvement and reporting,” said Dr. Normand. “By refining risk adjustment techniques, we can more effectively identify high-performing centers, pinpoint areas for improvement, and ultimately contribute to better outcomes for patients with congenital heart disease.”
 

The Congenital Heart Surgery Clark Paper, Understanding Mortality Following Congenital Heart Surgery: What Do Procedure-Specific Factors (PSF) Add? will assess the contribution of PSFs beyond standard risk factors in estimating mortality in this population.

Meena Nathan, MD, a pediatric cardiac surgeon at Children’s Hospital Boston, will present this paper on Friday, Jan. 24, from 2:16 to 2:24 p.m. as part of the "The Tribulations of Trials: Challenges in CHD Clinical Studies" session. During her talk, she will discuss data from The Society of Thoracic Surgeons Congenital Heart Surgery Database, a crucial resource for enhancing the quality of congenital heart surgery. In 2013, the Database expanded to include 82 Patient Safety Factors (PSFs) for benchmark operations (BMOs), though the impact of these PSFs on mortality prediction has yet to be fully explored.

To address this knowledge gap, Dr. Nathan and her team analyzed the contribution of PSFs to mortality estimation beyond standard STS risk factors. The study included a large cohort of BMOs from 115 U.S. centers between 2017 and 2022.

Dr. Nathan will present study findings, which emphasize the complexity of mortality prediction in congenital heart surgery and highlight the need for continued research to identify the most relevant risk factors and PSFs for each procedure, with the goal of developing more accurate prediction models that enhance patient care and support informed decision-making.

During the Saturday, Jan. 25 presentation of the James S. Tweddell Memorial Paper for Congenital Heart Surgery, Reilly Hobbs, MD, from the University of Utah Medical Center will explore the relationship between the volume of Norwood procedures performed at a center and patient outcomes based on findings from the National Pediatric Cardiology – Quality Improvement Collaborative Database study.

Image

The Norwood procedure, a critical surgery for infants with single ventricle defects, has been extensively studied, but findings on how case volume affects outcomes have been inconsistent. This study examines data that clarifies the relationship between center case volume and survival and morbidity in patients undergoing this complex surgery.

In presenting the findings of the study, Congenital Heart Surgery, Volume-Outcome Relationship of Norwood Procedures: Insights from the National Pediatric Cardiology – Quality Improvement Collaborative Database, Dr. Hobbs will explain how centers were grouped based on their annual case volume—low, medium, and high—and how preoperative risk factors, complications, and survival outcomes were compared. He will also highlight how patients at high-volume centers had better outcomes than those at low-volume centers, including higher survival rates and lower mortality, particularly among patients with additional high-risk features. 

“The findings indicate that the number of Norwood procedures performed at a center significantly impacts patient outcomes with high-volume centers consistently achieving better results than low-volume centers,” says Dr. Hobbs. “It’s essential to emphasize the role of case volume in complex congenital heart surgeries and explore the potential benefits of directing high-risk patients to more experienced centers. Further research is needed to identify the key factors that contribute to improved outcomes at high-volume centers, ultimately enhancing care for single ventricle patients.”