Abstract
Background
Right atrial lines are routinely used postoperatively in pediatric cardiac patients, but data and guidelines on their optimal long-term use and removal remain limited.
Methods
This was an observational retrospective cohort study to characterize the safety and feasibility of right atrial line removal at hospital discharge in pediatric cardiac patients between 2011 and 2018 at a tertiary children’s hospital.
Results
A total of 686 children had 804 right atrial line placements during cardiac surgeries. Median age and weight were 22 (interquartile range [IQR], 7-134) days and 3.6 (IQR, 3.1-5.3) kg. In this cohort, single ventricle physiology constituted 35.3%, and 38% underwent palliative procedures. Median line duration was 11 (IQR, 7-19) days, with a median interval between line removal and hospital discharge of 0 (IQR, 0-4) days. Most right atrial lines (61.4%) were safely removed on the day of discharge without complications, discharge delays, or readmissions. Single-ventricle physiology, shunts, and palliative surgeries did not impact this practice.
Conclusions
The removal of right atrial lines at discharge seems to be feasible and safe in the postoperative care of pediatric cardiac patients, including those with single-ventricle physiology, shunts, and palliative surgeries. Prospective studies are warranted to further refine and optimize right atrial line removal practices.
Visual Abstract
In Short.
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The removal of right atrial lines at hospital discharge seems to be feasible and safe and was not associated with complications, discharge delays, or readmissions.
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This practice was not negatively impacted by single ventricle physiology, shunts, and/or palliative surgeries
The postoperative management of neonatal and pediatric patients undergoing cardiac surgery has advanced significantly, necessitating precise monitoring and reliable access for care.1 Right atrial lines (RALs) are routinely utilized in most institutions for limited periods of time as part of postoperative care.1 Previous studies have demonstrated that RALs provide a wide range of benefits and reduced rate of complications.1, 2, 3, 4, 5, 6, 7 Despite their prevalent utilization, there are limited data and a lack of standardized guidelines regarding the optimal duration and removal practices for RALs.1, 2, 3, 4, 5, 6, 7 Consequently, our study aimed to characterize the safety and feasibility of RAL removal at the time of hospital discharge and to identify factors influencing this practice.
Material and Methods
Study Design and Setting
This is a retrospective observational cohort study examining all neonatal and pediatric cardiac patients (<18 years old) who underwent RAL placement (January 2011-June 2018) in a tertiary-level cardiac intensive care unit (CICU). This secondary analysis utilizes data derived from a previous study focused on complications associated with RAL.7 Institutional review board approval was obtained prior to the initiation of the study. Patients admitted to the CICU were required to remain either in the CICU or in a step-down cardiology unit until their discharge, in alignment with institutional logistics. RALs were placed and removed by the cardiothoracic surgeon.7 Comprehensive information regarding the placement, maintenance practices, and removal of RALs at this institution has been previously reported.7
Cohort and Data Collection
All cardiac patients <18 years old who underwent RAL placement during the study period were included. Patients with incomplete or inaccurate data were excluded. Cardiac diagnoses were classified into single and nonsingle ventricle physiology. Cardiothoracic surgeries were further delineated into palliative (shunt, Glenn, Fontan, hybrid procedure, and pulmonary artery banding), and nonpalliative procedures. Outcomes included survival to hospital discharge, length of hospital stay (LOS), surgery-to-discharge duration, mechanical ventilation (MV) duration, and failed extubations.
Statistical Analysis
Data are summarized using medians with interquartile ranges (IQRs) for continuous variables and frequencies with percentages for categorical variables. Bivariate analyses used χ2 and Wilcoxon-Mann-Whitney tests to assess factors associated with RAL removal at discharge. Multivariable logistic regression with backward selection (alpha level for removal = 0.05) was used to analyze factors affecting RAL removal at discharge. Odds ratios (ORs) and 95% CIs were calculated. All P values were two2sided, with P < .05 deemed statistically significant. Statistical analyses were conducted using SAS software (version 9.4, SAS Institute Inc).
Results
Patient Population, RAL Characteristics, and Outcomes
During the study period, 692 children with congenital heart disease underwent 815 RAL placements. We excluded 6 patients discharged with a RAL in place and 5 RALs with incomplete removal dates, leaving 686 patients and 804 RAL placements for analysis. Median age and weight were 22 (IQR, 7-134) days and 3.6 (IQR, 3.1-5.3) kg, respectively. Neonates (<30 days old) constituted 53.5%, male patients 55.7%, and single-ventricle physiology 35.3%. Of the 804 cardiothoracic surgeries, 83.3% required cardiopulmonary bypass, and 38% were palliative procedures. Median RAL duration was 11 (IQR, 7-19) days, with median time from RAL removal to discharge of 0 (IQR 0-4) days. Survival to discharge was 95.6% (Supplemental Table 1).
RAL Removal at Discharge vs Prior to Discharge
Of the total RALs, 61.4% were removed on the day of discharge, with no complications, discharge delays, or readmissions related to their removal. RALs removed at discharge were more often linked to genetic diagnoses (21.9% vs 15.9%, P = .036), were double-lumen lines (91% vs 88.2%, P = .009), and had longer RAL duration (11 vs 10 days, P = .001). RALs removed before discharge had higher complication rates (9.4% vs 3%, P = .001), longer LOS (28 vs 18 days, P < .001), surgery-to-discharge duration (18 vs 11 days, P < .001), MV duration (5 vs 3 days, P < .001), and more failed extubations (107 vs 99, P = .001). More RALs were removed at discharge between 2014 and 2016 (P < .001) (Table 1).
Table 1.
RAL Removal at Discharge vs Prior to Discharge
| Characteristics | All RALs (N = 804) | RAL Removal at Discharge (n = 494, 61.4%) | RAL Removal Prior to Discharge (n = 310, 38.6%) | P Value |
|---|---|---|---|---|
| Demographic Characteristics | ||||
| Age, d | 44.5 (8-162) | 49.5 (8-167) | 38.5 (8-152) | .399 |
| Age group | .463 | |||
| Neonate | 368 (45.8) | 222 (44.9) | 146 (47.1) | |
| Infant | 329 (40.9) | 210 (42.5) | 119 (38.4) | |
| Child | 107 (13.3) | 62 (12.6) | 45 (14.5) | |
| Weight, kg | 3.9 (3.2-6.2) | 3.9 (3.2-6.3) | 3.8 (3.2-5.9) | .484 |
| Sexb | .136 | |||
| Female | 348 (43.3) | 224 (45.3) | 124 (40) | |
| Male | 456 (56.7) | 270 (54.7) | 186 (60) | |
| Prematurity | 128 (15.9) | 75 (15.2) | 53 (17.1) | .470 |
| Prenatal cardiac diagnosis | 457 (56.8) | 278 (56.3) | 179 (57.7) | .909 |
| Noncardiac abnormalities | 199 (24.8) | 120 (24.3) | 79 (25.5) | .703 |
| Clinical syndrome/association | 258 (32.1) | 152 (30.8) | 106 (34.2) | .311 |
| Genetic diagnosis | 157 (19.6) | 108 (21.9) | 49 (15.9) | .036 |
| Year of placement | <.001 | |||
| 2011 | 84 (10.4) | 23 (4.7) | 61 (19.7) | |
| 2012 | 106 (13.2) | 49 (9.9) | 57 (18.4) | |
| 2013 | 83 (10.3) | 52 (10.5) | 31 (10) | |
| 2014 | 143 (17.8) | 111 (22.5) | 32 (10.3) | |
| 2015 | 150 (18.7) | 113 (22.9) | 37 (11.9) | |
| 2016 | 136 (16.9) | 99 (20) | 37 (11.9) | |
| 2017a | 65 (8.1) | 31 (6.3) | 34 (11) | |
| 2018a | 37 (4.6) | 16 (3.2) | 21 (6.8) | |
| Cardiac and Surgical Characteristics | ||||
| Single ventricle physiology | 334 (41.5) | 202 (40.9) | 132 (42.6) | .636 |
| Surgical palliation (shunt, Glenn, Fontan) | 335 (41.7) | 205 (41.5) | 130 (41.9) | .902 |
| Shunt | 146 (18.2) | 84 (17) | 62 (20) | .283 |
| Preoperative ECMO | 26 (3.2) | 16 (3.2) | 10 (3.2) | .991 |
| Preoperative VAD | 5 (45.5) | 3 (37.5) | 2 (66.7) | .939 |
| Cardiopulmonary bypass surgery | 661 (82.2) | 410 (83) | 251 (81) | .658 |
| CPB time, min | 128 (91-171) | 130.5 (89-175) | 125 (93-163) | .561 |
| Cross-clamp time, min | 71 (44-118) | 73 (45-120) | 66.5 (42.5-115.5) | .326 |
| Circulatory arrest time, min | 9 (4-25) | 9 (4-25) | 10 (4-28) | .294 |
| Postoperative ECMO | 36 (4.5) | 21 (4.3) | 15 (4.8) | .694 |
| RAL Characteristics and Complications | ||||
| RAL type | .009 | |||
| Double lumen | 538 (90) | 344 (91) | 194 (88.2) | |
| Triple lumen | 13 (2.2) | 3 (0.8) | 10 (4.5) | |
| Single lumen | 47 (7. 9) | 31 (8.2) | 16 (7.3) | |
| Presence of RAL complicationb | 44 (5.5) | 15 (3) | 29 (9.4) | .001 |
| Complication typeb | .194 | |||
| Infection | 6 (13.6) | 4 (26.7) | 2 (6.9) | |
| Malfunction | 11 (25) | 4 (26.7) | 7 (24.1) | |
| Migration | 13 (29.5) | 2 (13.3) | 11 (37.9) | |
| Thrombosis | 14 (31.8) | 5 (33.3) | 9 (31) | |
| RAL duration, d | 11 (7-19) | 11 (8-18) | 10 (5-20) | .001 |
| Outcomes | ||||
| Survival to hospital discharge | 770 (95.8) | 478 (96.8) | 292 (94.2) | .078 |
| Length of hospital stay, d | 20 (13-40) | 18 (11-30) | 28 (16-56) | <.001 |
| Surgery to discharge, d | 13 (8-24) | 11 (8-18) | 18 (10-40) | <.001 |
| Mechanical ventilation duration, d | 3 (1-11) | 3 (1-7) | 5 (1-21) | <.001 |
| Failed extubation | 206 (25.6) | 99 (20) | 107 (34.5) | .001 |
Values are presented as median (interquartile range) or frequency (%).
CPB, cardiopulmonary bypass; ECMO, extracorporeal membrane oxygenation; PA, pulmonary artery; RAL, right atrial line; VAD, ventricular assist device.
After 2016, a transition occurred within the cardiothoracic surgery team.
These RAL complications occurred while the RAL was in place and were not caused by its removal.
Factors Associated With the Practice of Removing RALs at Discharge
Multivariable logistic regression showed that RAL removal at discharge was positively associated with year of placement (OR, 1.23, P < .001), RAL duration (OR, 1.05, P < .001), and genetic diagnoses (OR, 1.83, P = .004). Inversely associated factors included RAL complications (OR, 0.29, P = .001), LOS (OR, 0.97, P < .001), and MV duration (OR, 0.99, P = .014). Single-ventricle physiology, shunts, and palliative surgeries were not associated factors (Table 2).
Table 2.
Multivariable Logistic Regression Model After Backwards Variable Selection to Ascertain for Factors Associated With RAL Removal at Discharge
| Predictor | OR (95% CI) | P Value |
|---|---|---|
| Year of placement | 1.23 (1.13-1.34) | <.001 |
| Genetic diagnosis (Yes vs No) | 1.83 (1.2-2.78) | .004 |
| RAL duration (days) | 1.05 (1.03-1.07) | <.001 |
| Presence of RAL complication (Yes vs No) | 0.29 (0.14-0.61) | .001 |
| LOS stay (days) | 0.97 (0.97-0.98) | <.001 |
| MV duration (days) | 0.99 (0.98-1) | .014 |
LOS, length of hospital; MV, mechanical ventilation; OR, odds ratio; RAL, right atrial line.
Patients Discharged Home With RAL in Situ
Supplemental Table 2 describes 6 patients excluded from the main analysis who were discharged with a RAL in place for continuous infusions, parenteral nutrition, or frequent laboratory monitoring. The median postdischarge RAL duration was 183.5 (IQR, 48.5-275) days. Parents were educated in RAL management and complication recognition, with periodic assessments conducted by a dedicated provider familiar with RAL management. Notably, no complications or adverse events were reported in association with these RALs or their removal.
Comment
This study uniquely characterizes the safety and feasibility of RAL removal at discharge in postoperative pediatric cardiac patients. We identified 3 novel insights that contribute to the existing literature. First, the majority of RALs (61.4%) were safely removed on the day of discharge, with no associated complications, discharge delays, or readmissions. Second, factors influencing the practice of RAL removal at discharge were noted. Third, the presence of single-ventricle physiology, shunts, and palliative surgeries did not impact this practice.
During the study period, our standard practice involved utilizing RALs as the primary access point for most patients following cardiothoracic surgery. RALs were generally maintained until discharge, unless removed earlier due to complications or provider preference. This approach differs from other centers, where RALs are typically discontinued first or replaced with alternative long-term access, such as peripherally inserted central catheters.1, 2, 3, 4, 5, 6 We postulate that the success of this practice is inherently linked to our established protocol for RAL placement, maintenance, and removal, as well as to the learning curve of the personnel involved.7,8
Additionally, comorbidities, illness severity, and the presence of difficult access may confound the relationship between genetic diagnoses and RAL removal, as central access is typically maintained longer in these situations.9 Furthermore, LOS and MV duration may also function as confounding variables, given that patients who experience RAL complications often have these lines removed concurrently with the onset of the complication and frequently require extended ventilation and hospitalization.7 Importantly, the presence of single-ventricle physiology, shunts, and palliative surgeries did not influence the practice of removing lines at discharge. This is particularly noteworthy, as patients with these conditions often have tenuous cardiopulmonary hemodynamics, resulting in higher rates of morbidity, mortality, and complications.9,10
Our study has several limitations. This retrospective single-center review may limit the generalizability of the findings. We were unable to account for additional factors associated with RAL removal at discharge, such as physician preference or the influence of a learning curve related to institutional procedural refinement.
In conclusion, RAL removal at hospital discharge seems to be feasible and safe in the postoperative care of neonatal and pediatric cardiac patients. A prospective evaluation of RAL removal practices has the potential to enhance outcomes within this complex population.
Acknowledgments
The Supplemental Tables can be viewed in the online version of this article [https://doi.org/10.1016/j.atssr.2025.08.016] on https://www.annalsthoracicsurgeryshortrep.org.
Funding Sources
The authors have no funding sources to disclose.
Disclosures
The authors have no conflicts of interest to disclose.
Supplementary Data
References
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