Morbidities in patients with hypoplastic left heart syndrome

Site of interstage care, resource utilization, and interstage mortality: a report from the NPC-QIC registry

Morbidity and mortality remain high for patients with hypoplastic left heart syndrome during the interstage period between Norwood and Glenn despite ongoing QI efforts. We sought to identify associations between the site of interstage care, interstage events, and mortality. Data for patients enrolled in the National Pediatric Cardiology Quality Improvement Collaborative registry from July 2008 through February 2013 were reviewed. Patients had outpatient interstage care at (1) the surgical site (SS) performing Norwood, (2) a non-surgical site (NSS), or (3) a combination. Interstage events were compared among these groups and, when applicable, by distance from SS to NSS. 688 patients from 47 sites met entry criteria. Patients were followed at the SS 411 (60%), NSS 121 (17%), or a combination 143 (21%). Data were not available for 13 (2%). There were 66 deaths (10%) among the entire cohort: 37 (9%) at SS, 13 (11%) at NSS, 15 (10%) at a combination. The proportion of deaths among these groups was not statistically significant (p = 0.60), nor was there a difference based on SS-to-NSS distance. Patients followed at the SS were more likely to have problems detected with feeding (p = 0.03) and breathing (p = 0.002), and ED visits (p < 0.001). The site of interstage care was not associated with mortality, nor was there a difference based on SS-to-NSS distance. Patients followed at the SS had more detected breathing and feeding problems, and ED visits. Further study is required to elucidate the clinical significance of these differences.

The impact of a dedicated single-ventricle home-monitoring program on interstage somatic growth, interstage attrition, and 1-year survival

OBJECTIVE

There has been considerable improvement in survival after the first stage of palliation for single-ventricle heart disease. Yet, interstage mortality continues to plague this population. Home monitoring has been proposed to reduce interstage mortality. We review our experience after creation of a Single Ventricle Program.

METHODS

All infants with a single ventricle heart defect who were admitted to Texas Children's Hospital from the inception of the Single Ventricle Program on September 1, 2007, to January 1, 2010, were included in the Single Ventricle Program cohort. Infants with a single ventricle presenting between January 1, 2002, and August 31, 2007, comprised the pre-Single Ventricle Program group. Anatomic, operative, and postoperative details were noted for all patients. End points included in-hospital death after the first stage of palliation, interstage death (defined as after discharge from the first stage of palliation and before the second stage of palliation), and death or heart transplantation by 1 year of age. Interstage weight gain was also compared.

RESULTS

A total of 137 infants with a single ventricle were included in the pre-Single Ventricle Program cohort, and 93 infants were included in the Single Ventricle Program cohort. Anatomic subtypes were similar between groups. There was significant improvement in rate of interstage weight gain, whereas age at the second stage of palliation was significantly reduced in the Single Ventricle Program group. In-house mortality decreased during the Single Ventricle Program era (P = .021). Interstage mortality did not significantly decrease in the Single Ventricle Program group. However, 1-year transplant-free survival improved during the Single Ventricle Program era (P = .002).

CONCLUSIONS

The Single Ventricle Program improved interstage weight gain, thereby allowing for early second-stage palliation at an equivalent patient weight. Interstage mortality was not significantly reduced by our program. However, 1-year transplant-free survival was significantly improved in patients in the Single Ventricle Program.

Attitudes and practices of cardiologists and surgeons who manage HLHS

OBJECTIVE

We conducted a survey to determine which management options pediatric cardiologists and cardiac surgeons in North America discuss and recommend when counseling parents after the diagnosis of hypoplastic left heart syndrome (HLHS).

METHODS

Pediatric cardiologists and cardiac surgeons across North America were asked to complete an anonymous, Internet-based survey about their attitudes and practices regarding the management of HLHS.

RESULTS

We contacted 1621 pediatric cardiologists and surgeons, of whom 749 (46%) completed the survey. When counseling parents of newborns with HLHS, 99.7% of respondents discussed staged palliative surgery, 67% discussed cardiac transplantation, and 62.2% discussed compassionate care without surgery. Only a minority (14.9%) discussed all of those options. Staged palliative surgery was recommended over cardiac transplantation or compassionate care without surgery by 76.2% of respondents. When counseling parents after prenatal diagnosis of HLHS, 98.8% of respondents discussed continuation of pregnancy with staged palliative surgery after birth, 53.5% discussed continuation of pregnancy with cardiac transplantation after birth, 56.9% discussed continuation of pregnancy with compassionate care after birth, and 74.3% discussed termination of pregnancy. Only 36.5% discussed all of those options. Continuation of pregnancy with staged palliative surgery after birth was recommended over the other options by 56% of respondents.

CONCLUSIONS

Virtually all North American pediatric cardiologists and cardiac surgeons surveyed discuss a surgical intervention when counseling parents about the care of their child or fetus with HLHS. However, only a minority discuss all options. Most physicians recommend staged palliative surgery for management of HLHS.

Decreasing number of deaths of infants with hypoplastic left heart syndrome

OBJECTIVE

To assess mortality rates and demographic characteristics for infants with hypoplastic left heart syndrome (HLHS) in California.

STUDY DESIGN

We used California death registry files from 1990 to 2004 to compare overall mortality and demographic characteristics between infants with HLHS (n = 856) who received surgical intervention and those who received comfort care. The California discharge database was used to calculate the annual incidence of disease and survival rates for infants with HLHS undergoing surgery between 1995 and 1999.

RESULTS

The annual number of deaths for infant with HLHS decreased by nearly 50% over the study period, even though the incidence of the disease remained constant during this period. For all deaths, the proportion of infants receiving comfort care decreased significantly over time compared with those infants who underwent surgery. Although the total number of deaths in infants with HLHS who underwent surgical intervention increased, the mortality rate for this cohort decreased. Interstage unexpected mortality and the median age at death both increased in the infants who underwent surgery.

CONCLUSIONS

Over the study period of 1990 to 2004 in California, fewer families chose comfort care for infants diagnosed with HLHS, and the number of deaths for those infants who underwent surgical intervention increased. These changes likely reflect improved treatment outcomes and an increased number of families desiring surgical intervention in higher-risk infants.

Outcomes of surgical treatment of infants with hypoplastic left heart syndrome: an institutional experience 1983-2004

AIM

To determine outcomes of surgical treatment of infants with hypoplastic left heart syndrome (HLHS).

METHODS

Retrospective analysis of medical records of infants with HLHS.

RESULTS

129 of 206 (63%) infants with HLHS were managed surgically over the period 1983-2004. Survival from all stages of surgical repair was 52 (40%) patients with significantly different (P < 0.001) survival according to surgical techniques and post-operative intensive care management recognisable in three eras. During 1983-1995 a classical Norwood stage 1 operation with a systemic-pulmonary shunt was performed for 61 infants with 13 (21%) survivors. From 1996 to 2002, pulmonary vasoconstriction and systemic vasodilatation after stage 1 operation were used to optimise systemic blood flow yielding a survival of 22 of 46 (48%) infants. From 2002 to 2004 a ventricular-pulmonary conduit was used with survival of 17 of 22 (77%) infants. Survival at 1, 6, 12 months and at 5, 10 and 15 years was 65%, 53%, 48%, 38%, 38% and 25%, respectively. The mean +/- SD number of surgical procedures was 4.5 +/- 3.7; duration of hospitalisation 53 +/- 52 days (median 38); number of hospital admissions 3.0 +/- 3.5; duration in intensive care 18 +/- 20 days (median 11); hours of mechanical ventilation 278 +/- 398 (median 151).

CONCLUSION

Short-term survival of HLHS has improved substantially over recent years with a ventricular-pulmonary conduit while long-term survival has been mediocre after arterial systemic-pulmonary shunts. Irrespective of type of primary surgery, infants undergo many operations and spend long periods in hospital and intensive care.

Growth and correlates of nutritional status among infants with hypoplastic left heart syndrome (HLHS) after stage 1 Norwood procedure

BACKGROUND

Protein-energy malnutrition is common among infants with congenital heart disease. We hypothesized that infants with hypoplastic left heart syndrome (HLHS) are at risk for malnutrition.

OBJECTIVE

To determine the prevalence of and risk factors for malnutrition in infants undergoing palliative surgery for HLHS.

METHODS

Retrospective chart review of 50 infants with HLHS who underwent both stage 1 Norwood and bidirectional Glenn (BDG) procedures over 4.5 y.

RESULTS

After a median hospital stay of 21 d, median discharge weight was 3.4 kg, unchanged from admission. Adjusting for weight on admission, children with longer length of hospital stay, longer intensive care unit stay, shorter duration of parental nutrition therapy, and higher diuretic dosage at discharge had a lower weight-for-age Z score at discharge (R2=0.85). On admission for BDG, median weight-for-age Z score was -2.0. After adjusting for weight on discharge from the initial hospitalization, children with fewer calories/ounce of their enteral nutrition at discharge, worse right ventricular function, more frequent readmissions, and higher oxygen saturation at discharge had a lower weight-for-age Z score at BDG (R2=0.49).

CONCLUSIONS

Malnutrition is common in infants with HLHS after stage 1 palliation. Variables associated with more complex postoperative course and imbalance between systemic and pulmonary blood flow were all associated with poorer nutritional status. When adjusting for these factors, the use of parenteral nutrition and high calorie enteral feeds were associated with improved nutritional status. Aggressive parenteral and enteral nutritional therapy might help reduce the prevalence of growth faltering in infants who have HLHS.

Initial transcatheter palliation of hypoplastic left heart syndrome

Initial percutaneous transcatheter palliation of hypoplastic left heart syndrome is now feasible. The primary procedures for palliation include stenting of the ductus arteriosus with a self expanding nitinol stent to secure an adequate systemic blood flow, placement of an internal pulmonary arterial band to protect the pulmonary vascular bed and to prevent pulmonary overcirculation, and widening of the interatrial communication by blade and balloon septostomy or static balloon dilation to decompress the left atrium. Anatomic variations of the ductus arteriosus have important implications for technical success with ductal stenting. Patients who have undergone complete transcatheter palliation with the internal pulmonary band appear to have less immediate morbidity at the time of transplant, with preserved integrity and growth of the branch pulmonary arteries at one year follow-up.

Hypoplastic left heart syndrome: Rheumatic heart disease of the fetus?

Hypoplastic left heart syndrome (HLHS) accounts for nearly 25% of deaths among neonates with congenital heart disease. The essential feature of HLHS is a small left ventricle (LV) incapable of supporting the circulation. The etiology of HLHS is unknown. A hypothesis is proposed implicating an immune mechanism involving maternal antibodies produced in response to pharyngitis caused by group A beta-hemolytic streptococci (GABHS) ("strep throat"). After crossing the placenta, the antibodies injure the developing fetal heart, leading to HLHS either because of direct injury to the LV or secondary to reduced blood flow through affected aortic and mitral valves. Analogy is drawn to rheumatic heart disease (RHD), a known sequela of strep throat. In RHD a misdirected immune response originally intended for GABHS leads to cardiac injury through "molecular mimicry"; the normal heart antigens supposedly mimic the GABHS antigens. A similar pathogenesis is proposed for HLHS and related heart defects. HLHS may represent an extreme form of injury, while a milder insult may present as only mild aortic stenosis or a bicuspid aortic valve, conditions with wide prevalence among the general population. The injury may indeed superimpose on many other congenital heart defects, leading to a variable presentation of these other diseases. Beside remarkable likenesses between HLHS and RHD, the hypothesis is also supported by increasing evidence for the role of deleterious transplacental antibodies in the pathogenesis of other fetal diseases. Implications for other congenital heart diseases and the broader picture of global public health are discussed.

Clinical outcomes and secondary diagnoses for infants born with hypoplastic left heart syndrome

OBJECTIVE

To explore clinical outcomes and secondary diagnoses present at discharge for infants born with hypoplastic left heart syndrome (HLHS), from a national perspective.

METHODS

We examined hospitalizations for infants < or =30 days of age who were born with HLHS, using hospital discharge data from the 1997 Kids Inpatient Database. To explore treatment choices, clinical outcomes, and resource use, we used International Classification of Diseases, 9th Revision, Clinical Modification diagnostic and procedure codes to classify discharges according to type of surgical intervention versus no surgical intervention. To investigate outcomes in more detail, we identified secondary diagnoses noted at discharge, using International Classification of Diseases, 9th Revision, Clinical Modification codes, and stratified results according to type of surgical intervention.

RESULTS

Of a total of 550 patients with HLHS, 234 underwent the Norwood procedure, 17 underwent orthotopic heart transplantation, and 106 died in the hospital with no reported surgical intervention. Although we found no demographic variables to be significantly associated with the type of treatment received, discharged patients who died without surgical intervention were significantly more likely to have received care in hospitals identified as small (odds ratio [OR]: 1.5; 95% confidence interval [CI]: 1.03-3.1) or not children's hospitals (OR: 2.02; 95% CI: 1.13-3.6). Secondary diagnoses of cardiac arrest (OR: 2.0; 95% CI: 1.1-3.4) and seizures (OR: 2.6; 95% CI: 1.2-5.5) occurred more frequently in orthotopic heart transplantation cases than in Norwood procedure cases.

CONCLUSIONS

These data from a national perspective reflect outcomes of infants with HLHS during a time when rates of initial survival after surgical intervention were considered to be improved. These findings may be useful to clinicians when they are considering and recommending initial medical and surgical strategies currently being proposed for the treatment of HLHS.