Publications by authors named "Ian A Nicholson"

10 Publications

  • Page 1 of 1

Complete atrioventricular septal defect repair in Australia: Results over 25 years.

J Thorac Cardiovasc Surg 2020 03 30;159(3):1014-1025.e8. Epub 2019 Aug 30.

Heart Centre for Children, Children's Hospital at Westmead, Sydney, Australia; The University of Sydney Children's Hospital Westmead Clinical, Children's Hospital at Westmead, Sydney, Australia.

Objectives: To evaluate whether the long-term outcomes of modified-single-patch (MSP) repair of complete atrioventricular septal defect are equivalent to double-patch (DP) repair with respect to survival and risk of reoperation for left atrioventricular valve regurgitation or left ventricular outflow tract obstruction.

Methods: All patients who underwent biventricular repair of complete atrioventricular septal defect in Australia from 1990 to 2015 using either a MSP or DP technique were identified. Demographic characteristic details, operative data, and outcomes were analyzed. A propensity score analysis was performed to balance the 2 treatment groups according to several baseline covariates. Survival and freedom from reintervention between the 2 groups were compared using Kaplan-Meier curves and log-rank tests.

Results: A total of 819 patients underwent repair of complete atrioventricular septal defect (252 MSP and 567 DP) during the study period. There was no significant difference in unmatched survival (P = .85) and event-free survival (P = .49) between MSP and DP repair. Propensity score matching resulted in a total of 223 matched pairs. Matched analysis found no difference in overall survival (P = .59) or event-free survival (P = .90) between repair techniques, with an estimated event-free survival at 5, 10, and 15 years of 83%, 83%, and 74% for DP and 83%, 80%, and 77% for the MSP group, respectively. There was no significant difference between repair techniques in reoperation for left atrioventricular valve regurgitation or left ventricular outflow tract obstruction or need for permanent pacemaker.

Conclusions: Overall and event free survival are similar following either MSP or DP repair of complete atrioventricular septal defect. There is no increased risk of reoperation for left ventricular outflow tract obstruction with the MSP technique.
View Article and Find Full Text PDF

Download full-text PDF

Source Listing
March 2020

Impact of High-Risk Characteristics in Hypoplastic Left Heart Syndrome.

World J Pediatr Congenit Heart Surg 2019 07;10(4):475-484

1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.

Background: Management of hypoplastic left heart syndrome (HLHS) presents many challenges. We describe our institutional outcomes for management of patients with HLHS over the past 12 years and highlight our strategy for those with highly restrictive/intact interatrial septum (R/I-IAS).

Methods: Eighty-eight neonates with HLHS underwent surgical treatment, divided equally into Era-I (n = 44, April 2006 to February 2013) and Era-II (n = 44, March 2013 to June 2018). Up to 2013, all patients with R/I-IAS were delivered at an adjacent adult hospital and then moved to our hospital for intensive care and management. From 2014, these patients were delivered at a co-located theatre in our hospital with immediate atrial septectomy. The hybrid approach was occasionally used with preference for the Norwood procedure for suitable candidates.

Results: One-year survival after Norwood procedure was 62.5% and 80% for Era-I and Era-II ( = not significant (ns)), respectively, and 41% of patients were categorized as high risk using conventional criteria. Survival at 1 year differed significantly between high-risk and standard-risk patients ( = 0.01). For high-risk patients, survival increased from 42% to 65% between eras ( = ns). In the R/I-IAS subgroup (n = 15), 11 underwent Norwood procedure after emergency atrial septectomy. Of these, seven born at the adjacent adult hospital had 40% survival to stage II versus 60% for the four born at the colocated theatre. Delivery in a colocated theatre reduced the birth-to-cardiopulmonary bypass median time from 445 (150-660) to 62 (52-71) minutes.

Conclusion: Reported surgical outcomes are comparable to multicenter reports and international databases. Proactive management for risk factors such as R/I-IAS may contribute to improved overall outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source Listing
July 2019

Congenitally corrected transposition: complex anatomic repair or Fontan pathway?

Asian Cardiovasc Thorac Ann 2017 Jul 13;25(6):432-439. Epub 2017 Jun 13.

1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, NSW, Australia.

Background Successful anatomic repair of congenitally corrected transposition of the great arteries achieves excellent outcomes. Several centers report excellent long-term survival with the Fontan pathway as well. We have selectively applied both approaches depending on individual patient morphology, with anatomic repair preferred but utilizing the Fontan pathway when high technical complexity or operative risk is anticipated. Methods Hospital records over an 18-year period (1998-2016) were reviewed to identify patients with congenitally corrected transposition of the great arteries who underwent surgical management. Physiological repairs and hypoplastic ventricles were excluded. Patient- and procedure-related variables were reviewed. Results We identified 19 patients. Group 1 consisted of 12 anatomic repairs, of which 10 (83.3%) required prior interim staging procedures. Mean age at anatomic repair was 2.6 ± 1.3 years, mean follow-up was 8.7 ± 5.3 years. Nine (75%) patients experienced important complications and 4 (33.3%) required reintervention during follow-up. There were no deaths; one patient required heart transplantation. Group 2 (7 patients) underwent Fontan palliation. Mean age at Fontan completion was 7.2 ± 3.8 years, mean follow-up was 6.3 ± 4 years. There was no reintervention, death, or transplant. Conclusion Patients with congenitally corrected transposition of the great arteries and two adequate-sized ventricles do well with both anatomic repair and the Fontan pathway in the medium term. Excellent outcomes with reduced early complication and reintervention rates can be achieved for this cohort of patients when a strategy of avoiding complex anatomic repair in favor of the Fontan pathway is used.
View Article and Find Full Text PDF

Download full-text PDF

Source Listing
July 2017

Early outcomes from a new regional programme for the surgical management of hypoplastic left heart syndrome.

ANZ J Surg 2015 Jun 19;85(6):466-71. Epub 2013 Feb 19.

Heart Centre for Children, The Children's Hospital at Westmead, Sydney Children's Hospitals Network, Sydney, New South Wales, Australia.

Background: Early survival and quality of outcome after surgery for hypoplastic left heart syndrome (HLHS) are influenced by patient-specific factors, the quality of surgery and perioperative care. Some skills are common to the care of other complex neonatal presentations but integrating this expertise is a key challenge for new programmes. We began offering surgery for HLHS from 2006 and provided a regional service from January 2009 and report early outcomes.

Methods: Prospectively collected data for neonates with HLHS undergoing surgical palliation from January 2006 until June 2011 were analysed. Standard definitions of high-risk and standard-risk presentations were utilized.

Results: Thirty neonates underwent surgical palliation of HLHS with a modified Norwood procedure with an overall survival to stage II palliation of 80%. A total of 46.7% of our patients were categorized as high-risk, mostly on the basis of low birth weight. Survival to stage II palliation was 100% in standard-risk patients and 57.1% in the high-risk group.

Conclusion: Outcomes for this new programme are comparable to reported outcomes demonstrating the feasibility of integrating a new complex procedure within an existing multidisciplinary unit handling large volumes of other complex neonatal work. Excellent outcomes can be achieved in standard-risk patients. Outcomes in the high-risk group may be improved by alternative approaches and rigorous case selection.
View Article and Find Full Text PDF

Download full-text PDF

Source Listing
June 2015

Five-year analysis of operative mortality and neonatal outcomes in congenital heart disease.

Heart Lung Circ 2011 Jul 21;20(7):460-7. Epub 2011 Apr 21.

The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia.

Background: We sought to compare overall mortality with neonatal outcomes over a five year period to define risk factors for mortality and service development priorities.

Methods: A retrospective cohort study of surgical outcomes following repair or palliation of structural congenital heart defects January 2005-2010. We defined mortality according to contemporary international guidelines and classified surgical procedures using the Risk Adjustment in Congenital Heart Surgery (RACHS-1) score. The effect of age and weight at operation on mortality and annual variation in case-complexity and surgeon case-mix were assessed. Subgroup analysis was performed in patients who were ≤30 days at operation (neonates).

Results: Overall mortality within 30 days of operation or prior to hospital discharge was 1.3 and 1.9%, respectively. Mortality was higher in neonates (6.8%) and low birth weight infants (≤2.5kg) (12.1%). Mortality was similar in bypass versus non-bypass procedures (odds ratio 0.74, p=0.425). Annual mortality rates were consistent despite a marked increase in case-complexity. Neonates overall required longer periods of intensive care support and were more likely to suffer serious complications compared to older children. Age, weight and RACHS-1 score were independent risk factors for mortality on multivariate analysis. In neonates undergoing bypass procedures, only RACHS-1 score was a significant risk factor.

Conclusions: This study provides an accurate and contemporary audit of mortality risk associated with congenital heart surgery. Outcomes compare favourably to international benchmarks but highlight the risks of morbidity and mortality associated with neonatal cardiac surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source Listing
July 2011

Evaluation of the extracardiac conduit modification of the Fontan operation for thrombus formation using magnetic resonance imaging.

Heart Lung Circ 2008 Oct 9;17(5):407-10. Epub 2008 Apr 9.

The Adolph Basser Cardiac Institute, The Children's Hospital at Westmead, Sydney, Australia.

Background: The prevalence of thrombosis after the Fontan procedure depends upon the surgical technique used and the method of detection employed. Current investigations for thrombosis lack sensitivity and specificity or, in the paediatric population, require a general anaesthetic. We undertook a study to examine the feasibility of using magnetic resonance imaging (MRI) to detect thrombosis within the conduit, cardiac chambers and pulmonary arteries after the extracardiac conduit modification of the Fontan procedure.

Methods: Of the 50 children who had undergone this procedure at our institution between 1997 and 2002, 26 were eligible for, and 13 underwent, MRI study. The mean age was 10.2 years (range 8.2-16.8 years, median 9.5 years) and the average time from operation was 63 months (range 29-79 months, median 68 months). The mean age at Fontan operation was 4.9 years (range 2.1-10.5 years). Ten were on low dose aspirin, two were on warfarin and one was not anti-coagulated. In all cases, satisfactory imaging of the venous pathways and pulmonary arteries was obtained and there were no thrombi detected.

Conclusions: We conclude that MRI is a potentially useful tool for the detection of thrombus in patients who have undergone the Fontan operation.
View Article and Find Full Text PDF

Download full-text PDF

Source Listing
October 2008

Outcomes following surgery for congenital heart disease in low-birthweight infants.

J Paediatr Child Health 2007 May;43(5):370-5

The Children's Hospital at Westmead, New South Wales, Australia.

Aim: To describe cardiac surgery, survival and outcomes for low-birthweight (< or = 2500 g) infants undergoing surgery for congenital heart disease.

Methods: Using data from a prospectively collected population-based database of admissions to neonatal intensive care units in New South Wales and the Australian Capital Territory, we identified all low-birthweight infants undergoing cardiac surgery between 1992 and 2001. Infants with only a persistent ductus arteriosus were excluded. Two-year cardiac and neurodevelopmental outcome data were sought from hospital medical records.

Results: A total of 121 low-birthweight infants underwent cardiac surgery, of whom 34% had a congenital syndrome or non-cardiac birth defect. Most (81%) underwent a palliative surgical procedure in the neonatal period. There were 19 early (15.7%) and 19 late deaths giving a 2-year mortality of 31%. Factors associated with mortality included birthweight below 1500 g (P = 0.006), low weight at surgery (P = 0.028) and Apgar score at 1 min (P = 0.019). No single factor predicted 30-day mortality. By 2 years of age, 27 (33% of survivors) were known to have neurodevelopmental delay. Although 22 children are known to be developing normally, the neurodevelopmental status of 34 children was not known.

Conclusions: These surgical data were comparable to previous single-institution studies. This group had a high risk of disability due to prematurity, low birthweight and associated conditions. There is a need to prospectively assess and manage neurodevelopmental outcomes in this group.
View Article and Find Full Text PDF

Download full-text PDF

Source Listing
May 2007

Mid-term results for double inlet left ventricle and similar morphologies: timing of Damus-Kaye-Stansel.

Ann Thorac Surg 2004 Aug;78(2):650-7; discussion 657

The Children's Hospital at Westmead, Adolph Basser Cardiac Institute, Westmead, NSW 2145, Australia.

Background: Patients with double inlet left ventricle/l-transposition and similar morphologies have their systemic outflow traverse a bulboventricular foramen (BVF), which has a propensity to narrow over time. A Norwood procedure may be performed as the initial palliation. We prefer aortic arch repair and pulmonary artery banding, delaying Damus-Kaye-Stansel (DKS) or BVF resection until the second palliation. The aims of this study were to compare our results with those reported for Norwood strategy and examine the development of systemic outflow obstruction.

Methods: Retrospective study of patients with double inlet left ventricle, L-TGA or similar morphology presenting between 1990 and 2000. Follow-up with clinical assessment, echocardiography and catheter studies.

Results: Twenty-five patients had initial palliation with pulmonary artery banding with repair of any associated arch obstruction. Twelve patients had DKS performed as part of their second stage procedure, and 3 had DKS performed later for recurrent stenosis after prior enlargement of BVF. Six patients had BVF resection without later restenosis and 4 patients did not develop BVF stenosis. There was one early death (4%) and two late (8%). Fontan completion was achieved in 20 of the 22 survivors. There were no cases of DKS obstruction, no pulmonary valve had more than mild regurgitation.

Conclusions: Our approach achieves low operative mortality and morbidity and compares favorably with reported results for Norwood palliation. The significant rate of systemic outflow obstruction in those who did not undergo DKS at the second stage confirms the utility of early DKS in children with this morphology.
View Article and Find Full Text PDF

Download full-text PDF

Source Listing
August 2004

Circulatory arrest for repair of postcoarctation site aneurysm.

Ann Thorac Surg 2004 Jun;77(6):2029-33

Department of Cardiothoracic Surgery, Westmead Hospital, The Children's Hospital at Westmead, Sydney, Australia.

Background: Aneurysm at previous coarctation repair may be seen more frequently as children operated for this condition survive into adulthood. We use deep hypothermic circulatory arrest to repair these aneurysms.

Methods: A case series was conducted using 12-year, single-institution, retrospective chart review.

Results: Twenty-one patients underwent left thoracotomy and repair of aneurysm at the site of previous coarctation repair. Three cases presented emergently as aortobronchial fistulas. The age range was 16 to 73 years (median, 26 years). The median circulatory arrest time was 33 minutes (range, 22 to 55 minutes). Repair involved interposition graft replacement. Six patients required additional tube graft replacement of the left subclavian artery. There was 1 operative mortality in a patient having a hypoxic brain injury secondary to an anaphylactic reaction to a plasma expander. There were no embolic strokes or paraplegia. One patient had a recurrent laryngeal nerve paresis. There was 1 case of Horner's syndrome after subclavian artery replacement.

Conclusions: Circulatory arrest allows for the accurate repair of this difficult pathologic process and avoids the risk of clamp-related injuries. Follow-up out to 16 years demonstrates this technique of repair to be durable, with no late deaths or reoperations for recurrent aneurysm.
View Article and Find Full Text PDF

Download full-text PDF

Source Listing
June 2004

Gordon Allport, character, and the "culture of personality," 1897-1937.

Hist Psychol 1998 Feb;1(1):52-68

U Prince Edward Island.

This article examines the cultural context of early American personality psychology through a consideration of the early career of Gordon Allport. Between 1921 and 1937, Allport was among the leading figures in the movement to establish personality as a research category in American psychology. Far from being a strictly scientific concern, Allport's project was deeply embedded in the cultural politics of the age. Of particular importance was the gradual erosion of the language of character and the self-sacrificing, morally grounded self that it supported. Allport's "psychology of personality" helped fuel this trend while simultaneously attempting to resist it. His experience illustrates the elasticity and moral ambiguity of the newly emerging category of personality.
View Article and Find Full Text PDF

Download full-text PDF

Source Listing
February 1998