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Standardisation of management after Norwood operation has not improved 1-year outcomes

Published online by Cambridge University Press:  26 October 2020

Andrea Pisesky Open the ORCID record for Andrea Pisesky [Opens in a new window] ,
Shilpa Shah ,
Michael Seed ,
Steven M. Schwartz ,
Jennifer Russell ,
Paula Pereira-Solomos ,
Jennifer Thomas ,
Glen Van Arsdell  and
Alejandro Floh
Andrea Pisesky*
Affiliation:
Division of Paediatric Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
Shilpa Shah
Affiliation:
Department of Anesthesiology and Critical Care Medicine, Children’s Hospital, Los Angeles, CA, USA Keck School of Medicine, Department of Paediatrics, University of Southern California, Los Angeles, CA, USA
Michael Seed
Affiliation:
Division of Paediatric Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
Steven M. Schwartz
Affiliation:
Division of Paediatric Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada Department of Critical Care Medicine, Labatt Family Heart Centre, Toronto, Ontario, Canada
Jennifer Russell
Affiliation:
Division of Paediatric Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
Paula Pereira-Solomos
Affiliation:
Division of Paediatric Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
Jennifer Thomas
Affiliation:
Division of Paediatric Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
Glen Van Arsdell
Affiliation:
Department of Surgery, Ronald Reagan UCLA Medical Center, University of California, Los Angeles, CA, USA
Alejandro Floh
Affiliation:
Division of Paediatric Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada Department of Critical Care Medicine, Labatt Family Heart Centre, Toronto, Ontario, Canada
*
Author for correspondence: Dr Andrea Pisesky, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada M5G 1X8. Tel: +1 416 813 7500; Fax: +1 416 813 7299. E-mail: andrea.pisesky@sickkids.ca
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Abstract

Introduction:

Treatment of hypoplastic left heart syndrome varies across institutions. This study examined the impact of introducing a standardised programme.

Methods:

This retrospective cohort study evaluated the effects of a comprehensive strategy on 1-year transplant-free survival with preserved ventricular and atrioventricular valve (AVV) function following a Norwood operation. This strategy included standardised operative and perioperative management and dedicated interstage monitoring. The post-implementation cohort (C2) was compared to historic controls (C1). Outcomes were assessed using logistic regression and Kaplan–Meier analysis.

Results:

The study included 105 patients, 76 in C1 and 29 in C2. Groups had similar baseline characteristics, including percentage with preserved ventricular (96% C1 versus 100% C2, p = 0.28) and AVV function (97% C1 versus 93% C2, p = 0.31). Perioperatively, C2 had higher indexed oxygen delivery (348 ± 67 ml/minute/m2 C1 versus 402 ± 102ml/minute/m2 C2, p = 0.015) and lower renal injury (47% C1 versus 3% C2, p = 0.004). The primary outcome was similar in both groups (49% C1 and 52% C2, p = 0.78), with comparable rates of death and transplantation (36% C1 versus 38% C2, p = 0.89) and ventricular (2% C1 versus 0% C2, p = 0.53) and AVV dysfunction (11% C1 versus 11% C2, p = 0.96) at 1-year. When accounting for cohort and 100-day freedom from hospitalisation, female gender (OR 3.7, p = 0.01) increased and ventricular dysfunction (OR 0.21, p = 0.02) and CPR (OR 0.11, p = 0.002) or ECMO use (OR 0.15, p = 001) decreased the likelihood of 1-year transplant-free survival.

Conclusions:

Standardised perioperative management was not associated with improved 1-year transplant-free survival. Post-operative ventricular or AVV dysfunction was the strongest predictor of 1-year mortality.

Keywords

Hypoplastic left heartNorwood proceduretricuspid regurgitation
Type
Original Article
Information
Cardiology in the Young , Volume 31 , Issue 1 , January 2021 , pp. 105 - 113
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Copyright
© The Author(s), 2020. Published by Cambridge University Press

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References

Ghanayem, NS, Allen, KR, Tabbutt, S, et al. Interstage mortality after the Norwood procedure: results of the multicenter Single Ventricle Reconstruction trial. J Thorac Cardiovasc Surg 2012; 144: 896–906.CrossRefGoogle ScholarPubMed
Newburger, JW, Sleeper, LA, William Gaynor, J, et al. Transplant-free survival and interventions at 6 years in the SVR trial. Circulation 2018; 137: 2246–2253.CrossRefGoogle ScholarPubMed
Simsic, JM, Bradley, SM, Stroud, MR, Atz, AM. Risk factors for interstage death after the Norwood procedure. Pediatr Cardiol 2005; 26: 400–403.CrossRefGoogle ScholarPubMed
Azakie, A, Merklinger, SL, McCrindle, BW, et al. Evolving strategies and improving outcomes of the modified norwood procedure: a 10-year single-institution experience. Ann Thorac Surg 2001; 72: 1349–1353.CrossRefGoogle ScholarPubMed
Furck, AK, Uebing, A, Hansen, JH, et al. Outcome of the Norwood operation in patients with hypoplastic left heart syndrome: a 12-year single-center survey. J Thorac Cardiovasc Surg 2010; 139: 359–365.CrossRefGoogle ScholarPubMed
Dobrolet, NC, Nieves, JA, Welch, EM, et al. New approach to interstage care for palliated high-risk patients with congenital heart disease. J Thorac Cardiovasc Surg 2011; 142: 855–860.CrossRefGoogle ScholarPubMed
Rudd, NA, Frommelt, MA, Tweddell, JS, et al. Improving interstage survival after Norwood operation: outcomes from 10 years of home monitoring. J Thorac Cardiovasc Surg 2014; 148: 1540–1547.CrossRefGoogle ScholarPubMed
Ghanayem, NS, Cava, JR, Jaquiss, RDB, Tweddell, JS. Home monitoring of infants after stage one palliation for hypoplastic left heart syndrome. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2004; 7:32–38.CrossRefGoogle ScholarPubMed
Pasquali, SK, Ohye, RG, Lu, M, et al. Variation in perioperative care across centers for infants undergoing the Norwood procedure. J Thorac Cardiovasc Surg 2012; 144: 915–921.CrossRefGoogle ScholarPubMed
Eckhauser, A, Pasquali, SK, Ravishankar, C, et al. Variation in care for infants undergoing the Stage II palliation for hypoplastic left heart syndrome. Cardiol Young 2018; 28: 1109–1115.CrossRefGoogle ScholarPubMed
Mouzaki, M, Schwartz, SM, Mtaweh, H, et al. Can Vco2-based estimates of resting energy expenditure replace the need for indirect calorimetry in critically ill children? J Parenter Enter Nutr 2017; 41: 619–624.CrossRefGoogle ScholarPubMed
Li, J, Schulze-Neick, I, Lincoln, C, et al. Oxygen consumption after cardiopulmonary bypass surgery in children: determinants and implications. J Thorac Cardiovasc Surg 2000; 119: 525–533.CrossRefGoogle ScholarPubMed
Rubenfeld, GD, Angus, DC, Pinsky, MR, Curtis, JR, Connors, AF, Bernard, GR. Outcomes research in critical care: results of the American Thoracic Society Critical Care Assembly Workshop on Outcomes Research. The Members of the Outcomes Research Workshop. Am J Respir Crit Care Med 1999; 160: 358–367.CrossRefGoogle ScholarPubMed
Schoenfeld, DA, Bernard, GR, Network, A. Statistical evaluation of ventilator-free days as an efficacy measure in clinical trials of treatments for acute respiratory distress syndrome. Crit Care Med 2002; 30: 1772–1777.CrossRefGoogle ScholarPubMed
Wernovsky, G, Kuijpers, M, Van rossem, MC, et al. Postoperative course in the cardiac intensive care unit following the first stage of Norwood reconstruction. Cardiol Young 2007; 17: 652–665.CrossRefGoogle ScholarPubMed
Baker-Smith, CM, Neish, SR, Klitzner, TS, et al. Variation in postoperative care following stage I palliation for single-ventricle patients: a report from the Joint Council on Congenital Heart Disease National Quality Improvement Collaborative. Congenit Heart Dis 2011; 6: 116–127.CrossRefGoogle Scholar
Anderson, JB, Beekman, RH, Kugler, JD, et al. Improvement in interstage survival in a national pediatric cardiology learning network. Circ Cardiovasc Qual Outcomes 2015; 8: 428–436.CrossRefGoogle Scholar
Pasquali, SK, Jacobs, JP, He, X, et al. The complex relationship between center volume and outcome in patients undergoing the Norwood operation. Ann Thorac Surg 2012; 93: 1556–1562.CrossRefGoogle ScholarPubMed
Hirsch, JC, Gurney, JG, Donohue, JE, Gebremariam, A, Bove, EL, Ohye, RG. Hospital mortality for Norwood and arterial switch operations as a function of institutional volume. Pediatr Cardiol 2008; 29: 713–717.CrossRefGoogle ScholarPubMed
Hoffman, GM, Mussatto, KA, Brosig, CL, et al. Systemic venous oxygen saturation after the Norwood procedure and childhood neurodevelopmental outcome. J Thorac Cardiovasc Surg 2005; 130: 1094–1100.CrossRefGoogle ScholarPubMed
Mills, KI, Kaza, AK, Walsh, BK, et al. Phosphodiesterase inhibitor-based vasodilation improves oxygen delivery and clinical outcomes following stage 1 palliation. J Am Heart Assoc 2016; 5: e003554.CrossRefGoogle ScholarPubMed
De Oliveira, NC, Ashburn, DA, Khalid, F, et al Prevention of early sudden circulatory collapse after the Norwood operation. Circulation 2004; 110 (Suppl 1): II133–II138.CrossRefGoogle ScholarPubMed
Tabbutt, S, Duncan, BW, McLaughlin, D, Wessel, DL, Jonas, RA, Laussen, PC. Delayed sternal closure after cardiac operations in a pediatric population. J Thorac Cardiovasc Surg 1997; 113: 886–893.CrossRefGoogle Scholar
Hakimi, M, Walters, HL, Pinsky, WW, Gallagher, MJ, Lyons, JM. Delayed sternal closure after neonatal cardiac operations. J Thorac Cardiovasc Surg 1994; 107: 925–933.CrossRefGoogle ScholarPubMed
Hoffman, GM, Tweddell, JS, Ghanayem, NS, et al. Alteration of the critical arteriovenous oxygen saturation relationship by sustained afterload reduction after the Norwood procedure. J Thorac Cardiovasc Surg 2004; 127: 738–745.CrossRefGoogle ScholarPubMed
Hansen, JH, Schlangen, J, Voges, I, et al. Impact of afterload reduction strategies on regional tissue oxygenation after the Norwood procedure for hypoplastic left heart syndrome. Eur J Cardiothorac Surg 2014; 45: e13–e19.CrossRefGoogle ScholarPubMed
Hansen, JH, Furck, AK, Petko, C, et al. Use of surveillance criteria reduces interstage mortality after the Norwood operation for hypoplastic left heart syndrome. Eur J Cardiothorac Surg 2012; 41: 1013–1018.CrossRefGoogle ScholarPubMed
Siehr, SL, Norris, JK, Bushnell, JA, et al. Home monitoring program reduces interstage mortality after the modified Norwood procedure. J Thorac Cardiovasc Surg 2014; 147: 718–723.e711.CrossRefGoogle ScholarPubMed
Petit, CJ, Fraser, CD, Mattamal, R, Slesnick, TC, Cephus, CE, Ocampo, EC. The impact of a dedicated single-ventricle home-monitoring program on interstage somatic growth, interstage attrition, and 1-year survival. J Thorac Cardiovasc Surg 2011; 142: 1358–1366.CrossRefGoogle ScholarPubMed
Anderson, JB, Beekman, RH, Kugler, JD, et al. Improvement in interstage survival in a national pediatric cardiology learning network. Circ Cardiovasc Qual Outcomes 2015; 8: 428–436.CrossRefGoogle Scholar
Oster, ME, Ehrlich, A, King, E, et al. Association of interstage home monitoring with mortality, readmissions, and weight gain: a multicenter study from the national pediatric cardiology quality improvement collaborative. Circulation 2015; 132: 502–508.CrossRefGoogle ScholarPubMed
Altmann, K, Printz, BF, Solowiejczky, DE, Gersony, WM, Quaegebeur, J, Apfel, HD. Two-dimensional echocardiographic assessment of right ventricular function as a predictor of outcome in hypoplastic left heart syndrome. Am J Cardiol 2000; 86: 964–968.CrossRefGoogle ScholarPubMed
Hormaza, VM, Conaway, M, Schneider, DS, Vergales, JE. The effect of right ventricular function on survival and morbidity following stage 2 palliation: an analysis of the single ventricle reconstruction trial public data set. Congenit Heart Dis 2019; 14: 274–279.CrossRefGoogle ScholarPubMed
Barber, G, Helton, JG, Aglira, BA, et al. The significance of tricuspid regurgitation in hypoplastic left-heart syndrome. Am Heart J 1988; 116: 1563–1567.CrossRefGoogle ScholarPubMed
Sano, S, Huang, SC, Kasahara, S, Yoshizumi, K, Kotani, Y, Ishino, K. Risk factors for mortality after the Norwood procedure using right ventricle to pulmonary artery shunt. Ann Thorac Surg 2009; 87: 178–185.CrossRefGoogle ScholarPubMed
Kulkarni, A, Patel, N, Singh, TP, Mossialos, E, Mehra, MR. Risk factors for death or heart transplantation in single-ventricle physiology (tricuspid atresia, pulmonary atresia, and heterotaxy): a systematic review and meta-analysis. J Heart Lung Transplant 2019; 38: 739–747.CrossRefGoogle ScholarPubMed