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Arch intervention following stage 1 palliation in hypoplastic left heart syndrome is associated with slower feed advancement: a report from the National Pediatric Quality Cardiology Improvement Collaborative. Cardiol Young 2020; 30:396-401. [PMID: 32008590 DOI: 10.1017/s1047951120000177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Infants undergoing stage 1 palliation for hypoplastic left heart syndrome may have post-operative feeding difficulties. Although the cause of feeding difficulties in these patients is multi-factorial, residual arch obstruction may affect gut perfusion, contributing to feeding intolerance. We hypothesised that undergoing arch reintervention following stage 1 palliation would be associated with post-operative feeding difficulties. METHODS This was a retrospective cohort study. We analysed data from the National Pediatric Cardiology Quality Improvement Collaborative, which maintains a multicentre registry for infants with hypoplastic left heart syndrome discharged home following stage 1 palliation. Patients who underwent arch reintervention (percutaneous or surgical) prior to discharge following stage 1 palliation were compared with those who underwent non-aortic arch interventions after stage 1 palliation and those who underwent no intervention. Median post-operative days to full enteral feeds and weight for age z-scores were compared. Predictors of post-operative days to full feeds were identified. RESULTS Among patients who underwent arch reintervention, post-operative days to full enteral feeds were greater than for those who underwent non-aortic arch interventions (25 versus 16, p = 0.003) or no intervention (median days 25 versus 12, p < 0.001). Arch intervention, multiple interventions, gestational age, and the presence of a gastrointestinal anomaly were predictors of days to full feeds. CONCLUSIONS Repeat arch intervention is associated with a longer time to achieve full enteral feeding in patients with hypoplastic left heart syndrome after stage 1 palliation. Further investigation of this association is needed to understand the role of arch obstruction in feeding problems in these patients.
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Devlin PJ, McCrindle BW, Kirklin JK, Blackstone EH, DeCampli WM, Caldarone CA, Dodge-Khatami A, Eghtesady P, Meza JM, Gruber PJ, Guleserian KJ, Alsoufi B, Lambert LM, O'Brien JE, Austin EH, Jacobs JP, Karamlou T. Intervention for arch obstruction after the Norwood procedure: Prevalence, associated factors, and practice variability. J Thorac Cardiovasc Surg 2018; 157:684-695.e8. [PMID: 30669228 DOI: 10.1016/j.jtcvs.2018.09.130] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 08/28/2018] [Accepted: 09/12/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Arch obstruction after the Norwood procedure is common and contributes to mortality. We determined the prevalence, associated factors, and practice variability of arch reintervention and assessed whether arch reintervention is associated with mortality. METHODS From 2005 to 2017, 593 neonates in the Congenital Heart Surgeons' Society Critical Left Heart Obstruction cohort underwent a Norwood procedure. Median follow-up was 3.7 years. Multivariable parametric models, including a modulated renewal analysis, were performed. RESULTS Of the 593 neonates, 146 (25%) underwent 218 reinterventions for arch obstruction after the Norwood procedure: catheter-based (n = 168) or surgical (n = 50) at a median age of 4.3 months (quartile 1-quartile 3, 2.6-5.7). Interdigitation of the distal aortic anastomosis was protective against arch reintervention. Development of ≥ moderate tricuspid valve regurgitation and right ventricular dysfunction at any point was associated with arch reintervention. Nonsignificant variables for arch reintervention included shunt type and preoperative aortic measurements. Surgical arch reintervention was protective against arch reintervention, but transcatheter reintervention was associated with increased reintervention. Arch reintervention was not associated with increased mortality. There was wide institutional variation in incidence of arch reintervention (range, 0-40 reinterventions per 100 years patient follow-up) and in preintervention gradient (range, 0-64 mm Hg). CONCLUSIONS Interdigitation of the distal aortic anastomosis during the Norwood procedure decreased the risk of arch reintervention. Surgical arch reintervention is more definitive than transcatheter. Arch reintervention after the Norwood procedure is not associated with increased mortality. Serial surveillance for arch obstruction, integrated with changes in right ventricular function and tricuspid valve regurgitation, is recommended after the Norwood procedure to improve outcomes.
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Affiliation(s)
- Paul J Devlin
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Brian W McCrindle
- Division of Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - James K Kirklin
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | - Eugene H Blackstone
- Division of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - William M DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Fla
| | | | - Ali Dodge-Khatami
- Division of Pediatric Cardiac Surgery, The University of Mississippi Medical Center, Jackson, Miss
| | - Pirooz Eghtesady
- Department of Pediatric Cardiothoracic Surgery, Washington University Medical School, St Louis, Mo
| | - James M Meza
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Peter J Gruber
- Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | | | - Bahaaladin Alsoufi
- Cardiovascular Surgery, Norton Children's Hospital, University of Louisville, Louisville, Ky
| | - Linda M Lambert
- Department of Pediatrics, Primary Children's Hospital, Salt Lake City, Utah
| | - James E O'Brien
- The Ward Family Heart Center, Children's Mercy Hospitals and Clinics, Kansas City, Mo
| | - Erle H Austin
- Cardiovascular Surgery, Norton Children's Hospital, University of Louisville, Louisville, Ky
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, Johns Hopkins All Children's Hospital, St Petersburg, Fla
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery, Rady Children's Hospital, San Diego, Calif
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