Skip to main content Accessibility help

Variation in care for infants undergoing the Stage II palliation for hypoplastic left heart syndrome

  • Aaron Eckhauser (a1), Sara K. Pasquali (a2), Chitra Ravishankar (a3), Linda M. Lambert (a1), Jane W. Newburger (a4) (a5), Andrew M. Atz (a6), Nancy Ghanayem (a7), Steven M. Schwartz (a8), Chong Zhang (a9), Jeffery P. Jacobs (a10) and L. LuAnn Minich (a1)...



The Single Ventricle Reconstruction trial randomised neonates with hypoplastic left heart syndrome to a systemic-to-pulmonary-artery shunt strategy. Patients received care according to usual institutional practice. We analysed practice variation at the Stage II surgery to attempt to identify areas for decreased variation and process control improvement.


Prospectively collected data were available in the Single Ventricle Reconstruction public-use database. Practice variation across 14 centres was described for 397 patients who underwent Stage II surgery. Data are centre-level specific and reported as interquartile ranges across all centres, unless otherwise specified.


Preoperative Stage II median age and weight across centres were 5.4 months (interquartile range 4.9–5.7) and 5.7 kg (5.5–6.1), with 70% performed electively. Most patients had pre-Stage-II cardiac catheterisation (98.5–100%). Digoxin was used by 11/14 centres in 25% of patients (23–31%), and 81% had some oral feeds (68–84%). The majority of the centres (86%) performed a bidirectional Glenn versus hemi-Fontan. Median cardiopulmonary bypass time was 96 minutes (75–113). In aggregate, 26% of patients had deep hypothermic circulatory arrest >10 minutes. In 13/14 centres using deep hypothermic circulatory arrest, 12.5% of patients exceeded 10 minutes (8–32%). Seven centres extubated 5% of patients (2–40) in the operating room. Postoperatively, ICU length of stay was 4.8 days (4.0–5.3) and total length of stay was 7.5 days (6–10).


In the Single Ventricle Reconstruction Trial, practice varied widely among centres for nearly all perioperative factors surrounding Stage II. Further analysis may facilitate establishing best practices by identifying the impact of practice variation.


Corresponding author

Author for correspondence: A. Eckhauser, MD, MS, Division of Pediatric Cardiothoracic Surgery, University of Utah, 100 N. Mario Capecchi Dr, Suite 2200, Salt Lake City, UT 84113, USA. Tel: 801 662 5566; Fax: 801 662 5571; E-mail:


Hide All
1. America CoQoHCi. Crossing the Quality Chasm/A New Health System for the 21st Century. Washington, DC.: National Academy Press; 2001.
2. James, B. Quality improvement opportunities in health care making it easy to do it right. J Manag Care Pharm 2002; 8: 394399.
3. James, BC, Hammond, ME. The challenge of variation in medical practice. Arch Pathol Lab Med 2000; 124: 10011003.
4. Burstein, DS, Rossi, AF, Jacobs, JP, et al. Variation in models of care delivery for children undergoing congenital heart surgery in the United States. World J Pediatr Congenit Heart Surg 2010; 1: 814.
5. Johnson, JN, Jaggers, J, Li, S, et al. Center variation and outcomes associated with delayed sternal closure after stage 1 palliation for hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2010; 139: 12051210.
6. Wallace, MC, Jaggers, J, Li, JS, et al. Center variation in patient age and weight at Fontan operation and impact on postoperative outcomes. Ann Thorac Surg 2011; 91: 14451452.
7. Ohye, RG, Sleeper, LA, Mahony, L, et al. Comparison of shunt types in the Norwood procedure for single-ventricle lesions. N Engl J Med 2010; 362: 19801992.
8. 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: 915921.
9. 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: 428436.
10. Anderson, JB, Beekman, RH, Kugler, JD, et al. Use of a learning network to improve variation in interstage weight gain after the Norwood operation. Congenit Heart Dis 2014; 9: 512520.
11. Mahle, WT, Nicolson, SC, Hollenbeck-Pringle, D, et al. Utilizing a collaborative learning model to promote early extubation following infant heart surgery. Pediatr Crit Care Med 2016; 17: 939947.
12. Vener, DF, Gaies, M, Jacobs, JP, Pasquali, SK. Clinical databases and registries in congenital and pediatric cardiac surgery, cardiology, critical care, and anesthesiology worldwide. World J Pediatr Congenit Heart Surg 2017; 8: 7787.
13. Lambert, LM, Pike, NA, Medoff-Cooper, B, et al. Variation in feeding practices following the Norwood procedure. J Pediatr 2014; 164: 23742 e1.
14. Brown, DW, Mangeot, C, Anderson, JB, et al. Digoxin use is associated with reduced interstage mortality in patients with no history of arrhythmia after stage I palliation for single ventricle heart disease. J Am Heart Assoc 2016; 5: e002376.
15. Oster, ME, Kelleman, M, McCracken, C, Ohye, RG, Mahle, WT. Association of digoxin with interstage mortality: results from the pediatric heart network single ventricle reconstruction trial public use dataset. J Am Heart Assoc 2016; 5: e002566.
16. Cnota, JF, Allen, KR, Colan, S, et al. Superior cavopulmonary anastomosis timing and outcomes in infants with single ventricle. J Thorac Cardiovasc Surg 2013; 145: 12881296.



Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed