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Central Surgical Association

49th Annual Meeting

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Steadily Improving Interstage Outcomes Following the Norwood Procedure
Neil Venardos, *Matthew L. Stone, *Max Mitchell, *David N. Campbell, *James Jaggers
Cardiac Surgery, Children's Hospital Colorado, Aurora, Colorado, United States

Objective: Survival for staged palliation (Norwood Procedure) has improved significantly over the last 2 decades. While survival to discharge following this operation has improved, there persists a significant risk of interstage mortality and decreased transplant free survival in the first year of life. With implementation of a rigorous interstage surveillance program, interstage mortality can be minimized. The intent of this study was to review one-year outcomes of staged palliation of HLHS at a single center in the current era and define risk factors for mortality and failure to achieve palliation.
Methods: Data were collected on patients undergoing a Norwood procedure between 2010 and 2021. Statistics were performed with SPSS software (p<0.05).
Results: Data were collected on all patients (215) undergoing staged palliation at our institution over a 11-year period (N=215). Patients underwent surgery at a median age and weight of 5 days and 3.29kg, respectively, and 196 (91%) had HLHS (or variants). Twelve (5.6%) underwent a hybrid approach. Other group characteristics: obstructed pulmonary venous return (PVR) (n=32/215, 15%), major extracardiac anomaly (MEA) (n=24/215, 11%), at least moderate ventricular dysfunction (RVF) (n=7/215, 3.4%), and low birth weight (LBW) (n=15/215, 7%). Twenty-nine (13.4%) of these patients required postoperative mechanical circulatory support (ECMO). Operative survival (STS CHDB definition) for initial palliation was (196/215) 91%, 84% (181/215) at one year, and transplant-free survival at one year was 80% (171/215). Univariate analysis identified increased mortality in patients with LBW (<2.5kg), obstructed PVR, postoperative ECMO, RVF, and MEA as risk factors. LBW and MEA were associated with reduced transplant-free survival (p<0.05). Multivariate analysis found that postoperative ECMO was a risk factor for reduced operative, transplant free, and 1-yr survival. LBW and RVF were risk factors for 1-year mortality.
Excluding hybrid patients, overall interstage mortality was 10% (n=21/203). LBW and postoperative ECMO were risk factors for mortality in the interstage period (via multivariate analysis). After implementing an interstage management program in March of 2016, interventions for either shunt, pulmonary artery, or aortic arch obstruction increased. Hospital length of stay increased from 25 days to 42 days. Postoperatively, 79 patients (39%, n=79/203) underwent stenting/balloon angioplasty in the cath lab. Interstage mortality decreased significantly between the early era (2010-2016) (14.9%, n=15/101) and later era (2017-2021) (5.9%, n=6/102).
Conclusions: Despite improved survival with Norwood palliation in our center, risk factors remain very relevant. With increased surveillance, interstage mortality may be significantly curtailed, and the use of transplantation in those patients that fail to progress can significantly improve survival.


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