Impact of Major Residual Lesions on Outcomes After Surgery for Congenital Heart Disease

Pediatric Heart Network Investigators, Meena Nathan, Jami C. Levine, Maria I. Van Rompay, Linda M. Lambert, Felicia L. Trachtenberg, Steven D. Colan, Iki Adachi, Brett R. Anderson, Emile A. Bacha, Aaron Eckhauser, J. William Gaynor, Eric M. Graham, Benjamin Goot, Jeffrey P. Jacobs, Rija John, Jonathan R. Kaltman, Kirk R. Kanter, Carlos M. Mery, L. LuAnn MinichRichard Ohye, David Overman, Christian Pizarro, Geetha Raghuveer, Marcus S. Schamberger, Steven M. Schwartz, Shanthi L. Narasimhan, Michael D. Taylor, Ke Wang, Jane W. Newburger

Research output: Contribution to journalArticlepeer-review

27 Scopus citations


Background: Many factors affect outcomes after congenital cardiac surgery. Objectives: The RLS (Residual Lesion Score) study explored the impact of severity of residual lesions on post-operative outcomes across operations of varying complexity. Methods: In a prospective, multicenter, observational study, 17 sites enrolled 1,149 infants undergoing 5 common operations: tetralogy of Fallot repair (n = 250), complete atrioventricular septal defect repair (n = 249), arterial switch operation (n = 251), coarctation or interrupted arch with ventricular septal defect (VSD) repair (n = 150), and Norwood operation (n = 249). The RLS was assigned based on post-operative echocardiography and clinical events: RLS 1 (trivial or no residual lesions), RLS 2 (minor residual lesions), or RLS 3 (reintervention for or major residual lesions before discharge). The primary outcome was days alive and out of hospital within 30 post-operative days (60 for Norwood). Secondary outcomes assessed post-operative course, including major medical events and days in hospital. Results: RLS 3 (vs. RLS 1) was an independent risk factor for fewer days alive and out of hospital (p ≤ 0.008) and longer post-operative hospital stay (p ≤ 0.02) for all 5 operations, and for all secondary outcomes after coarctation or interrupted arch with VSD repair and Norwood (p ≤ 0.03). Outcomes for RLS 1 versus 2 did not differ consistently. RLS alone explained 5% (tetralogy of Fallot repair) to 20% (Norwood) of variation in the primary outcome. Conclusions: Adjusting for pre-operative factors, residual lesions after congenital cardiac surgery impacted in-hospital outcomes across operative complexity with greatest impact following complex operations. Minor residual lesions had minimal impact. These findings may provide guidance for surgeons when considering short-term risks and benefits of returning to bypass to repair residual lesions.

Original languageEnglish (US)
Pages (from-to)2382-2394
Number of pages13
JournalJournal of the American College of Cardiology
Issue number19
StatePublished - May 18 2021

Bibliographical note

Funding Information:
This study was supported by grants (U24HL135691, U10HL068270, HL109818, HL109778, HL109816, HL109743, HL109741, HL109673, HL068270, HL109781, HL135665, HL135680) from the National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH). Drs. Nathan and Anderson were supported by K23 grants (NHLBI/NIH HL119600and HL133454, respectively). The views expressed in this paper are those of the authors and do not necessarily represent the views of the NHLBI, NIH, or U.S. Department of Health and Human Services. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Publisher Copyright:
© 2021 American College of Cardiology Foundation


  • days alive and out of the hospital
  • outcomes
  • Residual Lesion Score

PubMed: MeSH publication types

  • Journal Article
  • Multicenter Study
  • Observational Study
  • Research Support, N.I.H., Extramural


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