Extubation Failure in Neonates After

Cardiac Surgery: Prevalence, Etiology,

and Risk Factors
Shinya Miura, MD, Nao Hamamoto, MD, Masaki Osaki, MD, Satoshi Nakano, MD, and
Chisato Miyakoshi, MD, MS
Departments of Cardiac Critical Care and Cardiology, Shizuoka Childrens Hospital, Shizuoka, Japan; and School of Mathematics and
Statistics, University of Shefeld, Shefeld, United Kingdom

Background. The purpose of this study was to explore

the prevalence, etiology, and risk factors of extubation
failure (EF) in postcardiac surgery neonates.
Methods. Neonates (30 days old or younger) who underwent cardiac surgery and were admitted to the cardiac
intensive care unit between September 2010 and
February 2016 were included. The prevalence and etiology of EF, dened as reintubation within 48 hours, were
reviewed. Demographic, operative, and perioperative
data were retrospectively collected. Multiple logistic
regression models were constructed to identify the risk
factors for EF.
Results. The median age at surgery was 10 days.
Extubation failure occurred in 25 of 156 cases (16.0%; 95%
condence interval: 10.6% to 22.7%), because of respiratory dysfunction (n [ 16), hemodynamic instability
(n [ 4), upper airway obstruction (n [ 4), or gastrointestinal bleeding (n [ 1). Subsequent extubations were
successful in 17 cases (68%) because of medical

optimization of the causes of reintubation. The remaining

8 cases needed surgical reintervention, including tracheostomy and cardiac surgery. The inhospital mortality rate
was 2.6%. In a bivariate analysis, younger age, airway
diseases, ventilation before surgery, prolonged mechanical
ventilation, and delayed sternal closure were associated
with EF. The multivariable analysis identied airway
diseases (adjusted odds ratio 18.2, 95% condence interval:
3.8 to 88.6, p [ 0.0003) and mechanical ventilation longer
than 7 days (adjusted odds ratio 8.2, 95% condence interval: 1.9 to 34.9, p [ 0.0046) as risk factors for EF.
Conclusions. The prevalence of EF is relatively high in
neonatal cardiac surgery. The etiologies can be diverse.
Extubation of neonates at high risk after cardiac surgery,
based on these possible risk factors, requires more diligent approaches.

however, younger age groups (less than 3 months) still

have relatively high EF rates (6% to 21%) [7, 10, 1618].
Especially in neonates, extubation is a challenge after
cardiac surgery owing to their immature respiratory
function, small-diameter airways, and risk of postanesthesia apnea [4, 13, 14, 19]. Recognition of extubation
readiness in these patients is extremely difcult, and very
few data have been published on EF in neonatal cardiac
surgeries.
The present study was performed to investigate EF
among neonates after cardiac surgery. The primary aim
of the study was to explore the incidence, etiology, and
risk factors of EF; and the secondary aim was to investigate outcomes of subsequent extubation, need for surgical reinterventions in EF cases, and mortality.

dvances in preoperative diagnosis, anesthesia, surgical techniques, and cardiopulmonary bypass have
enabled young children to benet from cardiac surgery,
even during the neonatal period [13]. Owing to the
progress in perioperative management, including fasttrack care, high rates of successful extubation [412],
short mechanical ventilation durations, and few complications [912] have been recently reported in select
pediatric cardiac patients, excluding those with complex
physiology and young infants. However, extubation failure (EF) in neonatal cardiac surgeries remains a signicant concern.
Extubation failure has been associated with longer
intensive care unit (ICU) stays, increased rates of complications, and greater mortality [1315]. Young age has
been reported as a risk factor for EF and prolonged mechanical ventilation [47, 15]. In recent studies [79, 12, 15],
EF in pediatric cardiac surgeries was rare (3% to 7%);

(Ann Thorac Surg 2016;-:--)

2016 by The Society of Thoracic Surgeons

Patients and Methods

Patients

Accepted for publication Aug 1, 2016.

Address correspondence to Dr Miura, Shizuoka Childrens Hospital
Cardiac Critical Care, 860 Urushiyama, Aoiku, Shizuoka 420-8660, Japan;
email: shin.nya1982@gmail.com.

2016 by The Society of Thoracic Surgeons

Published by Elsevier

We performed a retrospective chart review of neonates

aged 30 days or younger who underwent cardiac surgery
and were admitted to the cardiac ICU at Shizuoka Childrens Hospital between September 2010 and February
0003-4975/$36.00
http://dx.doi.org/10.1016/j.athoracsur.2016.08.001

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MIURA ET AL
EXTUBATION IN NEONATAL CARDIAC SURGERIES

2016. The exclusion criteria were unplanned extubation,

subsequent extubation after initial failure, previous
extubation that was already included in the analysis,
admission to the neonatal intensive care unit (NICU) of
premature infants, and no extubation attempt. The Institutional Review Board of Shizuoka Childrens Hospital
approved the study, and the need for informed consent
was waived.

Setting
Shizuoka Childrens Hospital is an academic hospital
with 279 beds for children with complex diseases, and it is
a referral center for children with congenital heart
diseases. During the study period, 269 neonatal cardiac
surgeries were performed. All the children, except
premature neonates, were admitted to a 12-bed cardiac
ICU after surgery. Perioperative intensive care was
provided by six pediatric intensivists 24 hours a day.

Routine Airway Management and Ventilation

Planned intubation was performed nasally in the operating room by an anesthesiologist, and emergent
intubation was performed in the cardiac ICU by a cardiac
intensivist or in the delivery room by a neonatologist. All
neonates were primarily ventilated using Servo-I
(Maquet Critical Care, Solna, Sweden) with a 3.0-mm
cuffed Mallinckrodt endotracheal tube (Covidien, Manseld, MA). During ventilation, the cuff volume was
adjusted by senior nurses to a pressure less than 20
cmH2O to regulate air leakage. The ventilation was
initially started with pressure-regulated volume control,
and after the patients started breathing spontaneously
and were ready for weaning, the ventilation mode was
switched to volume-support ventilation. Extubation
readiness was examined based on hemodynamic stability;
adequate respiratory ability was determined with the
spontaneous breathing test using the following ventilator
settings: fraction of inspired oxygen 0.4 or less, positive
end-expiratory pressure 5 cmH2O or less, and pressure
support 8 cmH2O or less; air leakage around endotracheal
tube; and level of consciousness with adequate airway
protection reex. We administered 0.1 mg/kg dexamethasone every 6 hours before extubation in all neonates,
with few exceptions, such as those with short duration of
mechanical ventilation and hyperglycemia. For patients
who failed extubation, reintubation was determined
according to the following criteria: (1) airway obstruction;
(2) respiratory dysfunction (signicant hypoxia, worsening hypercarbia, signicant respiratory effort, respiratory fatigue, and massive atelectasis); (3) hemodynamic
instability; (4) major bleeding; (5) deteriorated level of
consciousness; and (6) cardiac arrest. The decisions for
extubation and reintubation were made by an attending
intensivist and the team caring for the patient.

Data Collection and Denitions

Extubation failure was dened as reintubation within 48
hours after extubation. Preoperative data included age
at surgery, sex, body weight, prematurity (less than
36 weeks of gestation), mechanical ventilation before

Ann Thorac Surg

2016;-:--

surgery, cardiac anomalies, underlying diseases, and

noncardiac factors (chromosomal abnormalities, airway
diseases, lung diseases, and neuromuscular diseases).
Intraoperative data included surgical procedure, cardiopulmonary bypass time, aortic cross clamp time, and
deep hypothermic circulatory arrest. Postoperative data
included duration of mechanical ventilation after surgery,
delayed sternal closure in the ICU, subsequent surgery,
extracorporeal membrane oxygenation use in the ICU,
nitric oxide use, arrhythmia requiring medical intervention, use of narcotics, sedatives, or muscle relaxants, and
complications (diaphragm paralysis, vocal cord paralysis,
and pleural effusion). Preextubation data collected
immediately before extubation included positive
end-expiratory pressure, existence of atelectasis, pneumonia, steroid use before extubation, sedation score for
any narcotics or sedatives used in the 24 hours before
extubation [20], and arterial blood gas analysis.
The complexity of each surgical procedure was
assessed using The Society of Thoracic Surgeons
European Association for Cardio-thoracic Surgery
Congenital Heart Surgery (STAT) mortality score [21].
Patients who had left-to-right or right-to-left shunts after
surgery were included in the palliative group. Patients
were classied with an airway anomaly if they had any
major upper airway or laryngotracheobronchus abnormality that could be a risk factor for extubation [22]. The
diagnosis of a laryngotracheobronchus abnormality was
conrmed before extubation by respiratory surgeons or
otolaryngologists, using bedside bronchoscopy and
laryngoscopy when clinically suspected. The clinical
outcomes included the success or failure of extubation,
length of stay in the ICU after surgery, mortality at the
hospital, subsequent extubation results, and the need for
surgical reintervention in EF cases.

Statistical Analysis
For the patient characteristics, continuous variables are
presented as median (interquartile range), and categoric
variables are presented as number (percentage). We
compared baseline patient characteristics, operative data,
and perioperative data using Fishers exact test or
Students t test for categoric and continuous variables,
respectively. The variables in the bivariate analyses
included age at surgery, sex, underlying background,
mechanical ventilation before surgery, prolonged
duration of mechanical ventilation, delayed sternal
closure, extracorporeal membrane oxygenation use,
preextubation sedation score, presence of a single
ventricle, cyanotic physiology, STAT score, nitric oxide
use, steroid use, and postoperative complications.
Multiple logistic regression models were used to obtain
adjusted odds ratio and 95% condence interval, with EF
as the outcome variable. We included the variables that
were signicantly different between groups in the bivariate comparison or considered clinically relevant. In the
bivariate analysis, continuous variables were converted
into categoric variables with quartiles or based on
categories used in previous reports. All statistical analyses were performed using R software, version 3.2.1

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Ann Thorac Surg

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MIURA ET AL
EXTUBATION IN NEONATAL CARDIAC SURGERIES

(R Foundation for Statistical Computing, Vienna,

Austria). Two-tailed p values less than 0.05 were considered signicant.

Results
During the study period, 269 neonatal cardiac surgeries
were performed. After the exclusion of cases who were
admitted to the NICU (n 69), did not undergo an
extubation attempt (n 22), or the second surgery within
the neonatal period (n 22), the study included 156 cases.
The median age at surgery was 10 days (range, 0 to 30),
and the median body weight was 2.9 kg (range, 1.7 to
3.8 kg). The baseline characteristics and surgical variables
are presented in Table 1. The median duration of mechanical ventilation after surgery was 5 days (range, 3 to 8).
Extubation failure occurred in 25 extubations (16.0%; 95%
condence interval: 10.6% to 22.7%). The most common
etiology was respiratory dysfunction (n 16), followed by
hemodynamic instability (n 4), upper airway obstruction
(n 4), and gastrointestinal bleeding (n 1).
Among the 16 cases who had EF due to respiratory
dysfunction, signicant hypoxia was noted in 5 cases,
worsening hypercarbia was noted in 5 cases, and significant respiratory effort was noted in 12 cases. With
multilateral diagnostic assessments for respiratory issues,
the diverse causes were identied in detail (Table 2). All
4 cases of upper airway obstruction needed intubation
within 1 hour after extubation. Among the 25 failed cases,
Table 1. Baseline Characteristics and Surgical Variables
(n 156)

Characteristics
Age at surgery, days
Male
Body weight, kg
Prematurity, <36 weeks
Chromosomal abnormality
Mechanical ventilation before surgery
Single-ventricle physiology
Corrective repair
Palliative procedure
Blalock-Taussig shunt
RV-PA conduit
Pulmonary artery banding
STAT mortality category
2
3
4
5
Use of cardiopulmonary bypass
Cardiopulmonary bypass time, minutes
Aortic cross-clamp time, minutes
Deep hypothermic circulation arrest

10
99
2.9
6
24
41
63
62
94
30
7
50

(417)
(63)
(2.53.2)
(4)
(15)
(26)
(40)
(40)
(60)
(19)
(4)
(32)

14
24
105
13
101
171
75
8

(9)
(15)
(67)
(8)
(65)
(132213)
(5296)
(5)

Values are median (interquartile range) or n (%).

RV-PA right ventricle to pulmonary artery;
STAT Society of
Thoracic SurgeonsEuropean Association for Cardio-thoracic Surgery
Congenital Heart Surgery.

17 (68%) were successfully extubated in the second or

third attempt without any surgical reintervention, with an
additional mechanical ventilation duration of 7 days
(range, 2 to 47). Of the remaining 8 cases, 4 needed
mechanical ventilation until subsequent cardiac surgery,
3 needed a tracheostomy after a subsequent failed extubation attempt, and 1 needed extracorporeal cardiopulmonary resuscitation and cardiac reintervention owing to
acute deteriorating hemodynamics; however, this patient
died in the ICU 2 months later. After successful extubation, 2 patients needed diaphragmatic plication owing
to respiratory instability, and 1 patient needed a tracheostomy because weaning from noninvasive positive
pressure ventilation was difcult. Patients with an
airway disease had tracheomalacia (n 2), tracheobronchomalacia (n 2), tracheal stenosis (n 2), bronchial
stenosis (n 1), choanal atresia (n 2), micrognathia with
glossoptosis (n 1), or cleft palate (n 3). The median
length of stay in the ICU was 12 days (range, 7 to 31), and
the overall inhospital mortality rate was 2.6%.
The comparison of variables is presented in Table 3.
The factors associated with EF were young age at surgery,
mechanical ventilation before surgery, airway disease,
prolonged duration of mechanical ventilation, and
delayed sternal closure. The length of stay in the ICU was
46 days (range, 33 to 87) for those with EF and 10 days
(range, 7 to 20) for those without EF. The mortality rate
was not different between patients with and patients
without EF (8.0% versus 1.5%, p 0.12).
Young age at surgery, mechanical ventilation before
surgery, airway disease, prolonged duration of mechanical ventilation, and delayed sternal closure were
considered candidates for the multivariable analyses.
Consequently, the multiple logistic regression models
revealed that the signicant factors were airway diseases
and mechanical ventilation for more than 7 days (Table 4).

Comment
The present study found that the prevalence of EF was
16.0% (25 of 156); the most common etiology of EF was
respiratory dysfunction (n 16), followed by hemodynamic instability (n 4), upper airway disease (n 4),
and gastrointestinal bleeding (n 1); and the independent risk factors for EF were airway diseases and
prolonged mechanical ventilation. This study contributes
to our comprehensive knowledge of EF in neonatal
cardiac surgery, as previous studies excluded neonates,
palliative surgery cases, or children who had been intubated previously. Moreover, this is the rst study to
investigate the etiologies for each case with EF in detail.
The EF prevalence of 16.0% in our study is relatively
high when compared with the recently reported EF
prevalence of 3% to 7% among children after cardiac
surgery [79, 12, 15]. This difference in the EF prevalence
might have resulted from our study being focused on the
neonatal population. Thaiagrajan and colleagues [18]
reported EF rates of 21% in neonates, 9% in infants and
children. Neonates possess anatomic and physiologic
features that increase the possibility of EF. Some of the

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EXTUBATION IN NEONATAL CARDIAC SURGERIES

Ann Thorac Surg

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Table 2. Causes of 25 Cases of Failed Extubation, Subsequent Extubation, and Surgical Reintervention
Causes of Failure
Respiratory dysfunction
Diaphragmatic paralysis
Atelectasis
Malacia
Tracheal stenosis
Weak cough
Pleural effusion
Pneumothorax
Respiratory muscle weakness
Pulmonary congestion
GERD
Hemodynamic instability
Low output syndrome
Onset of sepsis
Upper airway obstruction
Excessive secretion
Vocal cord paralysis
Glossoptosis
Gastrointestinal bleeding
a

Number of Cases

Success at Subsequent Extubationa

Surgical Reintervention

(n 16)
3
3
2
1
2
1
1
1
1
1
(n 4)
3
1
(n 4)
2
1
1
1

(n 12)
2
2
1
1
1
1
1
1
1
1
(n 2)
1
1
(n 2)
1
1
0
1

(n 4)
1 tracheostomy
1 cardiac surgery
1 tracheostomy
0
1 tracheostomy
0
0
0
0
0
(n 2)
1 cardiac surgery, 1 ECPR
0
(n 2)
1 cardiac surgery
0
1 cardiac surgery
0

Cases with successful extubation after initial extubation failure without any surgical intervention.

ECPR extracorporeal cardiopulmonary resuscitation;

GERD gastroesophageal reux disease.

features are immature and weak intercostal muscles, a

small residual lung volume, a small-diameter airway that
can increase airway resistance, and a narrow subglottic
portion of the airway that is vulnerable to mucosal edema
after endotracheal tube placement. In addition, neonates
undergoing cardiac surgery are likely to present with
postanesthesia apnea, functional immaturity of the organ
systems, and poor nutritional status [4, 13, 14, 19]. These
neonatal features might have increased the incidence of
EF in our study.
The denition EF varies among studies. Some studies
have dened EF as reintubation within 24 hours, whereas
others have dened EF as reintubation within 48 hours
[1315]. Gupta and associates [16] reported that EF
frequently evolves slowly in children with congenital
heart disease. There are some possible theories to support
this nding, such as neonatal vulnerabilities that have
been mentioned above. Therefore, we dened EF as
reintubation within 48 hours. Eventually, we found that
20% of the failed cases had been reintubated within 24 to
48 hours.
In our study, the etiologies of EF were diverse, which
supports previous ndings [1215]. Harrison and associates [23] reported that the common causes of EF were
cardiac dysfunction, lung disease, and airway edema. Our
further investigation of respiratory etiologies revealed
that diaphragm paralysis, atelectasis, malacia, and weak
cough were common. Hari and coworkers [24] reported a
high incidence of respiratory problems, such as tracheobronchomalacia (6%) and phrenic nerve palsy (7%),
postoperatively in young children. They concluded that
early evaluation for pulmonary conditions should be

considered postoperatively in children with EF, as young

children are particularly vulnerable to pulmonary complications. We also believe that prompt assessment for
respiratory issues should be performed with physical
examination, radiography, ultrasonography, and uoroscopy for diaphragm function, laryngoscopy, and bronchoscopy, as the identication of the main cause is crucial
to achieve a stable respiratory condition to avoid reintubation or decide on reintubation to prevent cardiac arrest.
Moreover, in reintubated patients, recognition of the
main cause of EF is important to optimize the respiratory
status for subsequent extubation. In our study, 12 (75%) of
16 patients with EF due to respiratory factors were successfully extubated in subsequent attempts without any
surgical intervention.
Four patients failed extubation owing to hemodynamic
instability; all of these patients had parallel circulation or
a shunt. Their backgrounds indicated that they might be
unable to tolerate any hemodynamic change induced by
extubation. According to studies on EF in young infants
with parallel circulation [17], sudden removal of positivepressure ventilation may lead to pulmonary edema and
imbalance between the pulmonary and systemic circulations, mostly followed by increased pulmonary circulation. These postextubation changes could worsen work of
breathing, which might eventually increase metabolic
demand. Conversely, poor systemic perfusion might
result from the imbalanced parallel circulation, with
sudden cardiac arrest as the worst possible outcome.
Different approaches can be attempted to avoid EF. As
hemodynamically signicant residual lesions have been
considered to be detrimental to extubation attempts, they

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EXTUBATION IN NEONATAL CARDIAC SURGERIES

Table 3. Bivariate Analysis

Extubation
Failure
(n 25)

Variables
Demographics and
comorbidities
Age at surgery <4 days
Male
Body weight <2.47 kg
Chromosomal
abnormality
MV before surgery
Airway diseases
Lung diseases
Single-ventricle
physiology
Intraoperative
Palliative procedure
STAT mortality score
>1.9
CPB time >183 minutes
Aortic cross-clamp time
>81 minutes
Deep hypothermic
circulatory arrest
Postoperative
MV after surgery >7 days
Nitric oxide use
Delayed sternal closure
ECMO use
Diaphragmatic paralysis
Periextubation
Cyanotic physiology
Steroid use
Preextubation sedation
score >12

Extubation
Success
(n 131)

p
Value

12
17
5
5

(48)
(68)
(20)
(20)

23
82
37
19

(18)
(63)
(28)
(15)

0.003
0.66
0.62
0.55

11
8
1
12

(44)
(32)
(4)
(48)

30
5
3
51

(23)
(4)
(2)
(39)

0.04
<0.001
0.51
0.51

18 (72)
9 (36)

76 (58)
29 (22)

0.27
0.20

8 (32)
5 (20)

31 (24)
34 (26)

0.45
0.62

3 (12)

5 (4)

0.12

18
12
13
2
3

(72)
(48)
(52)
(8)
(12)

18 (72)
22 (88)
4 (16)

28
49
29
2
6

(21)
(37)
(22)
(2)
(5)

66 (50)
105 (80)
35 (27)

<0.001
0.37
<0.001
0.12
0.16
0.05
0.58
0.32

Values are n (%).

CPB cardiopulmonary bypass;
ECMO extracorporeal membrane
oxygenation;
MV mechanical ventilation;
STAT Society of
Thoracic SurgeonsEuropean Association for Cardio-thoracic Surgery
Congenital Heart Surgery.

need to be ruled out before extubation. Furthermore, it

has been reported that the evaluation of cardiac reserve
function is important for the recognition of extubation
readiness and that low ventricle contraction on echocardiograph before extubation could be a risk factor [4, 7].
However, the appropriate method to evaluate adequate
cardiac function for extubation has not been studied in
single-ventricle physiology. Although we performed
Table 4. Multivariable Analysis
Factors
Airway disease
MV after surgery >7 days
CI condence interval;
odds ratio.

Adjusted OR (95% CI)

p Value

18.2 (3.888.6)
8.2 (1.934.9)

0.0003
0.0046

MV mechanical ventilation;

OR

transesophageal or transthoracic echocardiography for all

postoperative children to rule out residual cardiac lesions,
our conservative extubation readiness assessment failed
to predict postextubation hemodynamic instabilities in
neonates with a single ventricle. Therefore, neonates with
single-ventricle physiology might need a more cautious
approach after cardiac surgery, including the evaluation
of the cardiac reserve function, and that should be studied
in the future.
Four patients with upper airway obstruction required
reintubation. After cardiac surgery, infants often
have weak airway protection owing to their narrow
airway, weak cough, and vocal cord paralysis. Because
the prediction of airway obstruction has been considered
difcult, it is imperative to promptly recognize postextubation airway obstruction to aid the decision making
regarding reintubation and avoid cardiopulmonary arrest, especially in neonates with single-ventricle
physiology.
In the multivariable analysis, airway disease was the
strongest risk factor for EF. Children with congenital heart
disease might be at high risk for airway compression by
virtue of the anatomic proximity of the cardiac chambers
and major vessels to the central airways [2528]. Tracheobronchomalacia has been reported in 4% to 12% of young
infants with congenital heart disease [16, 17, 24, 29].
Additionally, it is not uncommon for patients with
congenital cardiac disease to have a dysmorphic upper
airway and genetic disorders. Neonates with airway diseases might require careful monitoring, including the
preparation of diagnostic procedures to reevaluate airway
abnormalities because they are at risk of various respiratory problems, as listed in Table 2.
Prolonged mechanical ventilation after surgery was
also an independent risk factor, supporting the ndings
of previous studies [7, 8, 16, 17]. Prolonged postoperative
mechanical ventilation was associated with higher rates
of tracheal tube- or ventilator-associated complications,
poorer nutritional status, and a greater need for pharmacologic interventions such as inotropes, narcotics, and
lines [10]. In our center, fast-track protocols were not
adopted for neonatal surgeries, except in few simple
cases. If the protocols could be safely indicated for more
neonatal surgeries, the incidence of EF might be reduced.
Further studies are needed to investigate the indications
for neonatal heart surgeries.
We found that half of the cases of EF in our study
needed further surgical intervention, consistent with
previous ndings [12, 24]. The mortality was not different
between patients with and without EF, which is also
consistent with previous ndings [7, 9, 15].
In our study, surgical procedures and cardiac anomalies
were not associated with EF. A number of studies found no
association between surgical complexity and cardiac
diagnosis with EF [7, 21], similar to our ndings. Although
previous studies have reported that a history of pulmonary hypertension [7, 23], prolonged cardiopulmonary
bypass duration [7, 24], deep hypothermic circulation
arrest [7, 23], chromosomal abnormalities [13, 23], and a
high dose of narcotics [10, 11] were risk factors for EF, in

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MIURA ET AL
EXTUBATION IN NEONATAL CARDIAC SURGERIES

our study, these factors were not signicantly different

between patients with and patients without EF.
Our study has several limitations. First, this study was
limited by the number of cases with failed extubation,
potentially underpowering the statistical analysis. For
analyzing the mortality rate with EF and without EF,
many more patients need to be included to improve the
power of the assessment. Second, this study was limited
by the single-center design; therefore, the ndings might
not be generalizable. For example, the ventilation weaning protocols and extubation readiness test can vary
among ICUs. Third, the prevalence of airway diseases can
vary with the intensity of surgical ablation, pulmonary
artery dilation, and available diagnostic procedures.
Despite these limitations, the prevalence of EF and the
airway diseases in this study were comparable with
recently published studies including high-risk cardiac
patients. However, our outcomes and possible risk factors
need to be conrmed by larger multicenter studies.
In conclusion, this study demonstrates the relatively
high incidence and diverse etiologies of EF in neonatal
cardiac surgery. Our investigation of the etiology of EF
suggests that postextubation respiratory issues should be
promptly assessed with diagnostic procedures to identify
the primary pathology, which will help optimize subsequent extubation attempts. The current extubationreadiness test might need to be modied to evaluate the
cardiac reserve function in single-ventricle neonates. The
multivariable analysis identied that airway diseases and
prolonged mechanical ventilation are possible risk factors
for EF, and patients with these risk factors require a more
cautious approach.

Ann Thorac Surg

2016;-:--

10.

11.

12.

13.
14.
15.
16.
17.
18.
19.
20.

21.
22.

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