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Olds A, Gray WH, Bojko M, Weaver C, Cleveland JD, Bowdish ME, Wells WJ, Starnes VA, Kumar SR. Surgical pulmonary arterioplasty at bidirectional cavopulmonary anastomosis leads to favorable pulmonary hemodynamics at final stage palliation. JTCVS OPEN 2024; 18:180-192. [PMID: 38690435 PMCID: PMC11056446 DOI: 10.1016/j.xjon.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 01/18/2024] [Accepted: 02/02/2024] [Indexed: 05/02/2024]
Abstract
Objective Pulmonary arterioplasty (PA plasty) at bidirectional cavopulmonary anastomosis (BDCA) is associated with increased morbidity, but outcomes to final stage palliation are unknown. We sought to determine the influence of PA plasty on pulmonary artery growth and hemodyamics at Fontan. Methods We retrospectively reviewed clinical data and outcomes for BDCA patients from 2006 to 2018. PA plasty was categorized by extent (type 1-4), as previously described. Outcomes included pulmonary artery reintervention and mortality before final palliation. Results Five hundred eighty-eight patients underwent BDCA. One hundred seventy-nine patients (30.0%) underwent concomitant PA plasty. Five hundred seventy (97%) patients (169 [94%] PA plasty) survived to BDCA discharge. One hundred forty out of 570 survivors (25%) required PA/Glenn reintervention before final stage palliation (59 out of 169 [35%]) PA plasty; 81 out of 401 (20%) non-PA plasty; P < .001). Twelve-, 24-, and 36-month freedom from reintervention after BDCA was 80% (95% CI, 74-86%), 75% (95% CI, 69-82%), and 64% (95% CI, 57-73%) for PA plasty, and 95% (95% CI, 93-97%), 91% (95% CI, 88-94%), and 81% (95% CI, 76-85%) for non-PA plasty (P < .001). Prefinal stage mortality was 37 (6.3%) (14 out of 169 PA plasty; 23 out of 401 non-PA plasty; P = .4). Five hundred four (144 PA plasty and 360 non-PA plasty) patients reached final stage palliation (471 Fontan, 26 1.5-ventricle, and 7 2-ventricular repair). Pre-Fontan PA pressure and pulmonary vascular resistance were 10 mm Hg (range, 9-12 mm Hg) and 1.6 mm Hg (range, 1.3-1.9 mm Hg) in PA plasty and 10 mm Hg (range, 8-12 mm Hg) and 1.5 mm Hg (range, 1.3-1.9 mm Hg) in non-PA plasty patients, respectively (P = .29, .6). Fontan hospital mortality, length of stay, and morbidity were similar. Conclusions PA plasty at BDCA does not confer additional mortality risk leading to final palliation. Despite increased pulmonary artery reintervention, there was reliable pulmonary artery growth and favorable pulmonary hemodynamics at final stage palliation.
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Affiliation(s)
- Anna Olds
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
- Division of Cardiac Surgery, Heart Institute, Children's Hospital of Los Angeles, Los Angeles, Calif
| | - W. Hampton Gray
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
- Division of Cardiac Surgery, Heart Institute, Children's Hospital of Los Angeles, Los Angeles, Calif
| | - Markian Bojko
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
- Division of Cardiac Surgery, Heart Institute, Children's Hospital of Los Angeles, Los Angeles, Calif
| | - Carly Weaver
- Division of Cardiac Surgery, Heart Institute, Children's Hospital of Los Angeles, Los Angeles, Calif
| | - John D. Cleveland
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
- Division of Cardiac Surgery, Heart Institute, Children's Hospital of Los Angeles, Los Angeles, Calif
| | - Michael E. Bowdish
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Winfield J. Wells
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
- Division of Cardiac Surgery, Heart Institute, Children's Hospital of Los Angeles, Los Angeles, Calif
| | - Vaughn A. Starnes
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
- Division of Cardiac Surgery, Heart Institute, Children's Hospital of Los Angeles, Los Angeles, Calif
| | - S. Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
- Division of Cardiac Surgery, Heart Institute, Children's Hospital of Los Angeles, Los Angeles, Calif
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, Calif
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Staehler H, Schaeffer T, Wasner J, Lemmer J, Adam M, Burri M, Hager A, Ewert P, Hörer J, Ono M, Heinisch PP. Impact of home monitoring program on interstage mortality after the Norwood procedure. Front Cardiovasc Med 2023; 10:1239477. [PMID: 37900558 PMCID: PMC10600023 DOI: 10.3389/fcvm.2023.1239477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 09/19/2023] [Indexed: 10/31/2023] Open
Abstract
Objective While early outcome after the Norwood operation for hypoplastic left heart syndrome has improved, interstage mortality until bidirectional cavopulmonary shunt (BCPS) remains a concern. Our aim was to institute a home monitoring program to (HMP) decrease interstage mortality. Methods Among 264 patients who survived Norwood procedure and were discharged before BCPS, 80 patients were included in the HMP and compared to the remaining 184 patients regarding interstage mortality. In patients with HMP, events during the interstage period were evaluated. Results Interstage mortality was 8% (n = 21), and was significantly lower in patients with HMP (2.5%, n = 2), compared to those without (10.3%, n = 19, p = 0.031). Patients with interstage mortality had significantly lower birth weight (p < 0.001) compared to those without. Lower birth weight (p < 0.001), extra corporeal membrane oxygenation support (p = 0.002), and lack of HMP (p = 0.048) were risk factors for interstage mortality. Most frequent event during home monitoring was low saturation (<70%) in 14 patients (18%), followed by infection in 6 (7.5%), stagnated weight gain in 5 (6.3%), hypoxic shock in 3 (3.8%) and arrhythmias in 2 (2.5%). An unexpected readmission was needed in 24 patients (30%). In those patients, age (p = 0.001) and weight at BCPS (p = 0.007) were significantly lower compared to those without readmission, but the survival after BCPS was comparable between the groups. Conclusions Interstage HMP permits timely intervention and led to an important decrease in interstage mortality. One-third of the patients with home monitoring program needed re-admission and demonstrated the need for earlier stage 2 palliation.
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Affiliation(s)
- Helena Staehler
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Thibault Schaeffer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Johanna Wasner
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Julia Lemmer
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Michel Adam
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Alfred Hager
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Peter Ewert
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Paul Philipp Heinisch
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
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Clark JB. Commentary: Successful pairing of the Norwood and bidirectional Glenn in select older infants. J Thorac Cardiovasc Surg 2021; 163:1601-1602. [PMID: 34955282 DOI: 10.1016/j.jtcvs.2021.10.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 10/28/2021] [Accepted: 10/29/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Joseph B Clark
- Division of Pediatric Cardiac Surgery, Department of Pediatrics, Penn State Health Children's Hospital, Hershey, Pa.
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Seaman CS, d'Udekem Y, Jones BO, Brizard CPR, Cheung MMH. Augmentation of Pulmonary Arterial Growth in Single Ventricle Patients by Interim Selective Shunts. Semin Thorac Cardiovasc Surg 2020; 33:483-489. [PMID: 32977010 DOI: 10.1053/j.semtcvs.2020.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 09/08/2020] [Indexed: 11/11/2022]
Abstract
Stenosis or diffuse hypoplasia of central pulmonary arteries (PA) is common in patients with single ventricle physiology, often requiring surgical patching. Such repairs are prone to failure, particularly with low pressure venous flow (bidirectional cavopulmonary connection or Fontan). We describe our experience of disconnection of central PA and selective systemic-PA shunt to the hypoplastic vessel. Single ventricle patients (n = 12) with diffuse left pulmonary artery (LPA) hypoplasia (LPA:right pulmonary artery diameter <0.7) underwent PA disconnection (ligation clip) and selective arterial shunt to the LPA. Patients with ≤mild atrioventricular valve regurgitation, and no more than mild systolic dysfunction on echocardiogram were considered. Following systemic-LPA shunt, patients were reassessed by cardiac catheterization prior to further surgery, with follow-up catheterization later performed and description of changes observed. Increased volume loading was well tolerated with no greater than mild atrioventricular valve regurgitation and preserved systolic function (normal or mildly reduced). Selective arterial shunting increased the caliber of the LPA from 4.1 mm (1.2-5.6) to 6.5 mm (1.7-11.9) and this increase was preserved post-Fontan (6.7 mm [1.3-8.0]) (median [range]). Ventricular end diastolic pressure increased with arterial shunting but resolved after shunt takedown and Fontan completion (median +3 and -4 mm Hg respectively). Post-Fontan hospital length of stay was not prolonged (median 11 days, range 7-14). No deaths occurred. In univentricular hearts and PA hypoplasia, selective systemic-PA shunting physiologically increases the caliber of the distal vessels. In selected patients this can be done safely with maintenance of PA growth and resolution of the elevated end diastolic pressure with Fontan completion.
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Affiliation(s)
- Cameron S Seaman
- Department of Cardiology, The Royal Children's Hospital Melbourne, Victoria, Australia; Heart Research Group, Murdoch Childrens Research Institute, Victoria, Australia; Department of Pediatrics, University of Melbourne, Victoria, Australia
| | - Yves d'Udekem
- Department of Cardiac Surgery, The Royal Children's Hospital Melbourne, Victoria, Australia; Heart Research Group, Murdoch Childrens Research Institute, Victoria, Australia; Department of Pediatrics, University of Melbourne, Victoria, Australia
| | - Bryn O Jones
- Department of Cardiology, The Royal Children's Hospital Melbourne, Victoria, Australia; Heart Research Group, Murdoch Childrens Research Institute, Victoria, Australia; Department of Pediatrics, University of Melbourne, Victoria, Australia
| | - Christian P R Brizard
- Department of Cardiac Surgery, The Royal Children's Hospital Melbourne, Victoria, Australia; Heart Research Group, Murdoch Childrens Research Institute, Victoria, Australia; Department of Pediatrics, University of Melbourne, Victoria, Australia
| | - Michael M H Cheung
- Department of Cardiology, The Royal Children's Hospital Melbourne, Victoria, Australia; Heart Research Group, Murdoch Childrens Research Institute, Victoria, Australia; Department of Pediatrics, University of Melbourne, Victoria, Australia.
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Marrone C, Galletti L. On rough road of hypoplastic left heart syndrome after Norwood procedure. J Thorac Dis 2019; 11:S465-S467. [PMID: 30997249 DOI: 10.21037/jtd.2018.11.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Chiara Marrone
- Cardiology Department, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Lorenzo Galletti
- Cardiac Surgery Department, Hospital Papa Giovanni XXIII, Bergamo, Italy
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Tran S, Sullivan PM, Cleveland J, Kumar SR, Takao C. Elevated Pulmonary Artery Pressure, Not Pulmonary Vascular Resistance, is an Independent Predictor of Short-Term Morbidity Following Bidirectional Cavopulmonary Connection. Pediatr Cardiol 2018; 39:1572-1580. [PMID: 29948033 DOI: 10.1007/s00246-018-1932-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 06/07/2018] [Indexed: 11/24/2022]
Abstract
Single ventricle palliation relies on the pulmonary vasculature accommodating non-pulsatile systemic venous return. Mean pulmonary artery pressure (MPAP) and indexed pulmonary vascular resistance (PVRi) are two measures that impact pulmonary blood flow following bidirectional cavopulmonary connection (BCPC). The purpose of the study was to determine which hemodynamic features are associated with adverse outcomes after BCPC. Pre-operative hemodynamic data and post-operative morbidity and mortality in 250 patients undergoing BCPC at a single center from 2008 to 2014 were reviewed. Patients were then separated into 5 physiologic states based on MPAP, PVRi, and degree of pulmonary to systemic blood flow (Qp:Qs). There were 9 (3.6%) deaths, and 49 patients (20%) sustained major morbidity. An ROC curve identified MPAP > 16 mmHg as an inflection point. Pre-BCPC sildenafil and oxygen use, ventricular dysfunction, and MPAP > 16 mmHg (OR 4.1 [95% CI 1.8-9.2]) were independently associated with morbidity. MPAP > 16 mmHg (OR 6.7 [95% CI 1.6-28]) and pre-BCPC oxygen use were associated with hospital mortality. PVRi was not associated with morbidity or mortality. Of the five physiologic states, patients with high MPAP, low PVRi, and low Qp:Qs fared the worst, with the highest risk of major morbidity (OR 8.6 [3.0-24.9]) and highest risk of mortality (OR 8.0 [1.5-41.3]) when compared to their reference groups (low MPAP, low PVRi). Elevated MPAP, need for pre-operative oxygen support, sildenafil use, and systemic ventricular systolic dysfunction predict morbidity following BCPC. Specifically, patients with elevated MPAP not due to elevated PVRi or pulmonary blood flow had the highest risk of morbidity and mortality.
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Affiliation(s)
- Susanna Tran
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, USA. .,, PO Box 572007, Tarzana, CA, 91357, USA.
| | - Patrick M Sullivan
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, USA.,Department of Pediatrics, University of South California, Los Angeles, USA
| | - John Cleveland
- Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, Los Angeles, USA.,Department of Surgery, Keck School of Medicine, University of South California, Los Angeles, USA
| | - S Ram Kumar
- Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, Los Angeles, USA.,Department of Pediatrics, University of South California, Los Angeles, USA.,Department of Surgery, Keck School of Medicine, University of South California, Los Angeles, USA
| | - Cheryl Takao
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, USA.,Department of Pediatrics, University of South California, Los Angeles, USA
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Cleveland JD, Tran S, Takao C, Wells WJ, Starnes VA, Kumar SR. Need for Pulmonary Arterioplasty During Glenn Independently Predicts Inferior Surgical Outcome. Ann Thorac Surg 2018; 106:156-164. [DOI: 10.1016/j.athoracsur.2018.03.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Revised: 03/05/2018] [Accepted: 03/06/2018] [Indexed: 11/17/2022]
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Cua CL, McConnell PI, Meza JM, Hill KD, Zhang S, Hersey D, Karamlou T, Jacobs JP, Jacobs ML, Galantowicz M. Hybrid Palliation: Outcomes After the Comprehensive Stage 2 Procedure. Ann Thorac Surg 2018; 105:1455-1460. [DOI: 10.1016/j.athoracsur.2017.11.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 10/17/2017] [Accepted: 11/10/2017] [Indexed: 12/20/2022]
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Cutrì E, Meoli A, Dubini G, Migliavacca F, Hsia TY, Pennati G. Patient-specific biomechanical model of hypoplastic left heart to predict post-operative cardio-circulatory behaviour. Med Eng Phys 2017; 47:85-92. [DOI: 10.1016/j.medengphy.2017.06.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 05/02/2017] [Accepted: 06/01/2017] [Indexed: 10/19/2022]
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Riveros Perez E, Riveros R. Mathematical Analysis and Physical Profile of Blalock-Taussig Shunt and Sano Modification Procedure in Hypoplastic Left Heart Syndrome: Review of the Literature and Implications for the Anesthesiologist. Semin Cardiothorac Vasc Anesth 2017; 21:152-164. [PMID: 28118786 DOI: 10.1177/1089253216687857] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The first stage of surgical treatment for hypoplastic left heart syndrome (HLHS) includes the creation of artificial systemic-to-pulmonary connections to provide pulmonary blood flow. The modified Blalock-Taussig (mBT) shunt has been the technique of choice for this procedure; however, a right ventricle-pulmonary artery (RV-PA) shunt has been introduced into clinical practice with encouraging but still conflicting outcomes when compared with the mBT shunt. The aim of this study is to explore mathematical modeling as a tool for describing physical profiles that could assist the surgical team in predicting complications related to stenosis and malfunction of grafts in an attempt to find correlations with clinical outcomes from clinical studies that compared both surgical techniques and to assist the anesthesiologist in making decisions to manage patients with this complex cardiac anatomy. Mathematical modeling to display the physical characteristics of the chosen surgical shunt is a valuable tool to predict flow patterns, shear stress, and rate distribution as well as energetic performance at the graft level and relative to ventricular efficiency. Such predictions will enable the surgical team to refine the technique so that hemodynamic complications be anticipated and prevented, and are also important for perioperative management by the anesthesia team.
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Baker-Smith CM, Goldberg SW, Rosenthal GL. Predictors of Prolonged Hospital Length of Stay Following Stage II Palliation of Hypoplastic Left Heart Syndrome (and Variants): Analysis of the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) Database. Pediatr Cardiol 2015; 36:1630-41. [PMID: 26036350 DOI: 10.1007/s00246-015-1208-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 05/15/2015] [Indexed: 11/28/2022]
Abstract
The objective of this study is to identify predictors of prolonged hospital length of stay (LOS) for single ventricle patients following stage 2 palliation (S2P), excluding patients who underwent a hybrid procedure. We explore the impact of demographic features, stage 1 palliation (S1P), interstage I (IS1) management, S2P, and post-surgical care on hospital LOS following S2P. We conducted a retrospective analysis of the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) database. The NPC-QIC database is an established registry of patients with hypoplastic left heart syndrome (HLHS) and its variants. It contains detailed information regarding the demographic features, S1P, IS1, S2P, and interstage 2 (IS2) management of children with HLHS and related single ventricle cardiac malformations. Between 2008 and 2012, there were 477 participants with recorded LOS data in the NPC-QIC registry. Excluding the 29 patients who underwent hybrid procedure, there were 448 participants who underwent a Norwood (or Norwood-variant procedure) as S1P. In order to be included in the NPC-QIC database, participants were discharged to home following S1P and prior to S2P. We found that postoperative LOS among the 448 S2P procedure recipients is most strongly influenced by the need for reoperation following S2P, the need for an additional cardiac catheterization procedure following S2P, the use of non-oral methods of nutrition (e.g., nasogastric tube, total parental nutrition, gastrostomy tube), and the development of postoperative complications. Factors such as age at the time of S2P, the presence of a major non-cardiac anomaly, site participant volume, IS1 course, the type and number of vasoactive agents used following S2P, and the need for more than 1 intensive care unit (ICU) hospitalization (following discharge to the ward but prior to discharge to home) were significant predictors by univariate analysis but not by multivariate analysis. We excluded participants undergoing the hybrid procedure as S1P from this analysis given that the S2P following the initial hybrid is typically a more complicated procedure. Hospital LOS following S2P among children undergoing the Norwood or Norwood-variant procedure as S1P is most strongly influenced by events following S2P and not demographic or S1P factors. Factors most predictive of prolonged LOS include the need for reoperation, the need for an additional cardiac catheterization procedure following S2P, the need for non-oral methods of nutrition, and the development of postoperative complications.
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Affiliation(s)
- Carissa M Baker-Smith
- Division of Pediatric Cardiology, University of Maryland School of Medicine, 110 S. Paca Street, 7th Floor, Baltimore, MD, 21201, USA.
| | | | - Geoffrey L Rosenthal
- Division of Pediatric Cardiology, University of Maryland School of Medicine, 110 S. Paca Street, 7th Floor, Baltimore, MD, 21201, USA
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Survival and right ventricular performance for matched children after stage-1 Norwood: Modified Blalock-Taussig shunt versus right-ventricle-to-pulmonary-artery conduit. J Thorac Cardiovasc Surg 2015; 150:1440-50, 1452.e1-8; discussion 1450-2. [PMID: 26254760 DOI: 10.1016/j.jtcvs.2015.06.069] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 06/04/2015] [Accepted: 06/06/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Early survival advantages after Norwood with right-ventricle-(RV)-to-pulmonary-artery conduit (NW-RVPA) over Norwood-operation with a Blalock-Taussig shunt (NW-BT) are offset by concerns regarding delayed RV dysfunction. We compared trends in survival, RV dysfunction, and tricuspid valve regurgitation (TR) between NW-RVPA and NW-BT for propensity-matched neonates with critical left ventricular outflow tract obstruction (LVOTO). METHODS In an inception cohort (2005-2014; 21 institutions), 454 neonates with critical LVOTO underwent Norwood stage 1. Propensity-score matching paired 169 NW-RVPA patients with 169 NW-BT patients. End-states were compared between NW-RVPA and NW-BT using competing-risks, multiphase, parametric, hazard analysis. Post-Norwood echocardiogram reports (n = 2993) were used to grade RV dysfunction and TR. Time-related prevalence of ≥moderate RV dysfunction and TR were characterized using nonlinear mixed-model regression, and compared between groups via multiphase, parametric models. RESULTS Overall 6-year survival was better after NW-RVPA (70%) versus NW-BT (55%; P < .001). Additionally, transplant-free survival during this time was better after NW-RVPA (64%) versus NW-BT (53%; P = .004). Overall prevalence of ≥moderate RV dysfunction reached 11% within 3 months post-Norwood. During this time, RV dysfunction after NW-BT was 16% versus 6% after NW-RVPA (P = .02), and coincided temporally with an increased early hazard for death. For survivors, late RV dysfunction was <5% and was not different between groups (P = .36). Overall prevalence of ≥moderate TR reached 13% at 2 years post-Norwood and was increased after NW-BT (16%) versus NW-RVPA (11%; P = .003). Late TR was similar between groups. CONCLUSIONS Among propensity-score-matched neonates with critical LVOTO, NW-RVPA offers superior 6-year survival with no greater prevalence of RV dysfunction or TR than conventional NW-BT operations.
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Rahkonen O, Chaturvedi RR, Benson L, Honjo O, Caldarone CA, Lee KJ. Pulmonary artery stenosis in hybrid single-ventricle palliation: High incidence of left pulmonary artery intervention. J Thorac Cardiovasc Surg 2015; 149:1102-10.e2. [DOI: 10.1016/j.jtcvs.2014.11.080] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 11/17/2014] [Accepted: 11/28/2014] [Indexed: 10/24/2022]
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Sathanandam SK, Philip R, Van Bergen A, Roberson DA, Cui W, Ilbawi MN, Javois AJ, Husayni TS. Significance of low peak Doppler velocity in the proximal sano conduit in hypoplastic left heart syndrome. Ann Thorac Surg 2014; 98:1378-85. [PMID: 25134864 DOI: 10.1016/j.athoracsur.2014.05.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 01/02/2014] [Accepted: 05/06/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Sano modification of the Norwood operation is a well-established first step palliation for hypoplastic left heart syndrome (HLHS). Theoretically, the first point of resistance to pulmonary flow should be in the proximal Sano, generating high Doppler flow velocity. Paradoxically, however, some patients have low gradients in the proximal Sano conduit. The objective of this study was to determine the hemodynamic and anatomic significance of low proximal Sano Doppler flow velocity and its clinical implications. METHODS Doppler-derived peak gradients in the proximal Sano conduits were measured in HLHS patients after Norwood-Sano surgery over a 4-year period and confirmed by cardiac catheterization within 2 to 4 weeks. Clinical outcomes of patients with proximal Sano gradients of 30 mm Hg or less (group 1) were compared with patients whose gradient was greater than 30 mm Hg (group 2). RESULTS Of the 53 patients, 21 (40%) belonged to group 1. Patients in group 1 had smaller ostial right and left pulmonary artery (PA) diameter (3.2 ± 1.2 mm versus 4.5 ± 1.8 mm, p = 0.03; and 3.4 ± 1.2 mm versus 5.6 ± 2.1 mm, p = 0.01) when compared with patients in group 2. Patients (7 of 10) who needed either balloon angioplasty of a distal Sano or proximal branch PA were from group 1 (p = 0.01). Patients in group 1 had higher rates of unintended PA interventions (33% versus 9%) and complications (48% versus 16%) compared with group 2. CONCLUSIONS Low peak Doppler flow velocity in the proximal Sano correlates with the presence of either distal Sano stenosis or proximal branch PA stenosis. These patients require close follow-up in the interstage period and may need earlier intervention.
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Affiliation(s)
- Shyam K Sathanandam
- The Heart Institute for Children, Advocate Hope Children's Hospital, Oak Lawn, Illinois; Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ranjit Philip
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee.
| | - Andrew Van Bergen
- The Heart Institute for Children, Advocate Hope Children's Hospital, Oak Lawn, Illinois
| | - David A Roberson
- The Heart Institute for Children, Advocate Hope Children's Hospital, Oak Lawn, Illinois
| | - Wei Cui
- The Heart Institute for Children, Advocate Hope Children's Hospital, Oak Lawn, Illinois
| | - Michel N Ilbawi
- The Heart Institute for Children, Advocate Hope Children's Hospital, Oak Lawn, Illinois
| | - Alexander J Javois
- The Heart Institute for Children, Advocate Hope Children's Hospital, Oak Lawn, Illinois
| | - Tarek S Husayni
- The Heart Institute for Children, Advocate Hope Children's Hospital, Oak Lawn, Illinois
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In Search of the Ideal Pulmonary Blood Source for the Norwood Procedure: A Meta-Analysis and Systematic Review. Ann Thorac Surg 2014; 98:142-50. [DOI: 10.1016/j.athoracsur.2014.02.078] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 02/23/2014] [Accepted: 02/25/2014] [Indexed: 11/17/2022]
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Abstract
Hypoplastic left heart syndrome, the most common complex congenital heart malformation, is characterized by underdeveloped left-sided heart structures. The Norwood procedure followed by two-staged operations has permitted the extended survival of many of these patients. Survival, however, remains suboptimal with most of the morbidity and mortality occurring during the Norwood procedure hospitalization. The modified Blalock-Taussig shunt has been implicated in contributing to the mortality risk due to decreased systemic diastolic blood pressure and coronary perfusion. Therefore, the right ventricle-to-pulmonary artery shunt was recently reevaluated as a lower-risk source of pulmonary blood flow in the Norwood procedure. The Pediatric Heart Network Single Ventricle Reconstruction trial, sponsored by the NIH National Heart, Lung and Blood Institute, evaluated the two types of shunts during the Norwood procedure. This randomized clinical trial has yielded important insight into the effects of shunt selection on morbidity, mortality, hemodynamics and overall current outcomes for hypoplastic left heart syndrome.
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Affiliation(s)
- Ming-Sing Si
- Department of Cardiac Surgery, Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Room 11-735, 1540 E. Hospital Drive/SPC 4204, Ann Arbor, MI 48109-4204, USA
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17
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Han BK, Vezmar M, Lesser JR, Michalak G, Grant K, Dassenko D, Maresh J, Overman DM. Selective use of cardiac computed tomography angiography: an alternative diagnostic modality before second-stage single ventricle palliation. J Thorac Cardiovasc Surg 2014; 148:1548-54. [PMID: 24930614 DOI: 10.1016/j.jtcvs.2014.04.047] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 03/26/2014] [Accepted: 04/24/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To assess the accuracy and risk of substituting cardiac computed tomography for cardiac catheterization in select patients for evaluation of anatomy before second-stage single ventricle palliation. METHODS This is a retrospective review of consecutive diagnostic cardiac catheterization (n=16) and computed tomography studies (n=16) performed before second-stage single ventricle palliation from March 2010 to July 2012 at a single institution. Risk (anesthesia, vascular access, contrast, and radiation exposure), accuracy, and postoperative course were compared. Nonparametric analysis was used to compare differences in group medians. RESULTS General anesthesia was used for 16 of 16 cardiac catheterization studies and 1 of 16 computed tomography studies. Vascular access was central venous and/or arterial for all cardiac catheterization studies and a peripheral intravenous line for all computed tomography studies. Median age- and size-adjusted radiation dose was 14.0 mSv for cardiac catheterization and 1.1 mSv for computed tomography. Contrast dose was 4.8 mL/kg for the cardiac catheterization group and 2 mL/kg for the computed tomography group. There were no computed tomography discrepancies and 1 discrepancy between cardiac catheterization and surgical findings. There were 8 adverse events in 6 patients in the cardiac catheterization group and 1 adverse event in the computed tomography group. There was no difference between groups in postoperative course or need for repeat intervention. CONCLUSIONS Cardiac computed tomography and cardiac catheterization are equally accurate for evaluation of anatomy before second-stage single ventricle palliation when compared with surgical findings. Computed tomography may be the preferred test in select patients because of decreased vascular access and anesthesia risk, lower radiation and contrast exposure, and fewer adverse events.
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Affiliation(s)
- B Kelly Han
- Advanced Cardiac Imaging, Minneapolis Heart Institute and Foundation, Minneapolis, Minn; Division of Cardiology and Cardiothoracic Surgery, Children's Heart Clinic, Minneapolis, Minn; Children's Hospitals and Clinics of Minnesota, Minneapolis, Minn.
| | - Marko Vezmar
- Division of Cardiology and Cardiothoracic Surgery, Children's Heart Clinic, Minneapolis, Minn
| | - John R Lesser
- Advanced Cardiac Imaging, Minneapolis Heart Institute and Foundation, Minneapolis, Minn
| | | | | | - David Dassenko
- Children's Hospitals and Clinics of Minnesota, Minneapolis, Minn
| | - Jill Maresh
- Children's Hospitals and Clinics of Minnesota, Minneapolis, Minn
| | - David M Overman
- Division of Cardiology and Cardiothoracic Surgery, Children's Heart Clinic, Minneapolis, Minn; Children's Hospitals and Clinics of Minnesota, Minneapolis, Minn
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18
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Fate of ventricular and valve performance following early bidirectional Glenn procedure after Norwood operation controlled for hypoplastic left heart syndome anatomic subtype. Pediatr Cardiol 2014; 35:332-43. [PMID: 24126954 DOI: 10.1007/s00246-013-0780-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 08/14/2013] [Indexed: 10/26/2022]
Abstract
The Norwood operation (NO) with a right ventricle (RV)-to-pulmonary artery (PA) shunt (NRVPA) is reportedly associated with early hemodynamic advantage. Shunt strategy has been implicated in ventricular function. Outcomes after NRVPA compared with classic procedure as part of a strategy involving early bidirectional Glenn (BDG) procedure were analyzed with reference to RV, tricuspid, and neoaortic valve performance. Between January 2005 and December 2010, 128 neonates with hypoplastic left heart syndrome (HLHS) underwent NO. Controlled for aortic/mitral stenosis (AS-MS) subtype, 28 patients underwent NRVPA (group A), and 26 patients had classic procedure (group B). The patients with a non-HLHS single-ventricle anatomy and those who had undergone a hybrid approach for HLHS were excluded from the study. The mean age at NO was 6.8 ± 3.5 days in group A and 6.9 ± 3.6 days in group B. Transthoracic echocardiographic evaluation (TTE) after NO (TTE-1) at the midinterval between NO and BDG (TTE-2), before BDG (TTE-3), before Fontan (TTE-4), and at the last follow-up evaluation (TTE-5) was undertaken. Cardiac catheterization was used to assess hemodynamic parameters before the Glenn and Fontan procedures. The operative, interstage, and pre-Fontan survival rates for AS-MS after NO were respectively 88.1 % (90.3 % in group A vs. 84.7 % in group B; p = 0.08), 82.5 % (82.7 % in group A vs. 81.8 % in group B; p = 0.9), and 80.7 % (79.5 % in group A vs. 81.8 % in group B; p = 0.9). The median follow-up period was 39.6 months (interquartile range 2.7-4.9 months). The RV global function, mid- and longitudinal indexed dimensions, fractionated area change before BDG (TTE-1, TTE-2, TTE-3) and after BDG (TTE-4, TTE-5), and right ventricular end-diastolic pressure did not differ statistically between the groups (p > 0.05). No statistically significant difference in tricuspid or neoaortic intervention was found between the groups (p > 0.05). Controlled for the AS-MS HLHS subtype, shunt strategy showed no midterm survival or hemodynamic (ventricular or valve) impact. At midterm, the follow-up need for neoaortic or tricuspid valve surgical intervention was not affected by shunt selection. The structural ventricular adaptation after reversal of shunt physiology was irrespective of shunt strategy.
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Risk factors for prolonged length of stay after the stage 2 procedure in the single-ventricle reconstruction trial. J Thorac Cardiovasc Surg 2013; 147:1791-8, 1798.e1-4. [PMID: 24075564 DOI: 10.1016/j.jtcvs.2013.07.063] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 07/05/2013] [Accepted: 07/26/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND The single-ventricle reconstruction trial randomized patients with single right ventricle lesions to a modified Blalock-Taussig or right ventricle-to-pulmonary artery shunt at the Norwood. This analysis describes outcomes at the stage 2 procedure and factors associated with a longer hospital length of stay (LOS). METHODS We examined the association of shunt type with stage 2 hospital outcomes. Cox regression and bootstrapping were used to evaluate risk factors for longer LOS. We also examined characteristics associated with in-hospital death. RESULTS There were 393 subjects in the analytic cohort. Median stage 2 procedure hospital LOS (8 days; interquartile range [IQR], 6-14 days), hospital mortality (4.3%), transplantation (0.8%), median ventilator time (2 days; IQR, 1-3 days), median intensive care unit LOS (4 days; IQR, 3-7 days), number of additional cardiac procedures or complications, and serious adverse events did not differ by shunt type. Longer LOS was associated (R(2) = 0.26) with center, longer post-Norwood LOS (hazard ratio [HR], 1.93 per log day; P < .001), nonelective timing of the stage 2 procedure (HR, 1.78; P < .001), and pulmonary artery (PA) stenosis (HR, 1.56; P < .001). By univariate analysis, nonelective stage 2 (65% vs 32%; P = .009), moderate or greater atrioventricular valve (AVV) regurgitation (75% vs 24%; P < .001), and AVV repair (53% vs 9%; P < .001) were among the risk factors associated with in-hospital death. CONCLUSIONS Norwood LOS, PA stenoses, and nonelective stage 2 procedure, but not shunt type, are independently associated with longer LOS. Nonelective stage 2 procedure, moderate or greater AVV regurgitation, and need for AVV repair are among the risk factors for death.
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20
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Abstract
Pediatric cardiac critical care has made, and continues to make, significant strides in improving outcomes. It is a measure of these successes that much of the discussion in this article does not focus on the reduction of mortality, but rather on perioperative management strategies intended to improve neurologic outcomes. The care of children with critical cardiac disease will continue to rely on broad and collaborative efforts by specialists and primary care practitioners to build on this foundation of success.
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Affiliation(s)
- Ronald A Bronicki
- Cardiac Intensive Care Unit, Texas Children's Hospital, Baylor College of Medicine, Houston, TX 77030, USA.
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21
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Gist KM, Barrett CS, Graham DA, Crumback SL, Schuchardt EL, Erickson B, Jaggers J. Pulmonary artery interventions after Norwood procedure: Does type or position of shunt predict need for intervention? J Thorac Cardiovasc Surg 2013; 145:1485-92. [DOI: 10.1016/j.jtcvs.2013.01.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 11/19/2012] [Accepted: 01/11/2013] [Indexed: 11/15/2022]
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Siehr SL, Norris JK, Bushnell JA, Ramamoorthy C, Reddy VM, Hanley FL, Wright GE. Home monitoring program reduces interstage mortality after the modified Norwood procedure. J Thorac Cardiovasc Surg 2013; 147:718-23.e1. [PMID: 23663957 DOI: 10.1016/j.jtcvs.2013.04.006] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 03/03/2013] [Accepted: 04/03/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND From 2002 to 2005, the interstage mortality after a modified Norwood procedure was 7% in our program. An interstage home monitoring program (HMP) was established to identify Norwood procedure patients at increased risk of decompensation and to reduce interstage mortality. METHODS Results of the first 5 years of the Norwood HMP were reviewed retrospectively. Interstage was defined as the time between Norwood hospital discharge and admission for second stage surgical palliation. In the HMP, families documented oxygen saturation, heart rate, weight, and feedings daily. Nurse practitioners called each family at least weekly, and when issues arose, action plans were determined based on symptom severity. RESULTS Between October 2005 and October 2010 there were 46 Norwood procedure patients who survived to hospital discharge. All were enrolled in the HMP. Forty-five patients had a Norwood procedure with right ventricle to pulmonary artery conduit, and 1 patient had a modified Blalock-Taussig shunt. Interstage survival was 100%. Nineteen patients (41%) were admitted interstage; 5 patients were admitted twice, 1 patient was admitted 4 times. Seventeen patients (37%) required interstage interventions. Eight patients (17%) required major interventions: conduit stenting, aortic arch balloon angioplasty, emergent shunt, or early Glenn surgery. Minor interventions included supplemental oxygen, blood transfusion, intravenous hydration, diuresis, anti-arrhythmic therapy, or feeding adjustments. CONCLUSIONS In the first 5 years of the HMP, all infants discharged after a modified Norwood procedure survived the interstage period. The HMP altered clinical management in 37% of patients. Home monitoring of oxygen saturation, heart rate, weight, and feedings, along with comprehensive care coordination, allowed timely interventions and reduced interstage mortality from 7% to 0%.
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Affiliation(s)
- Stephanie L Siehr
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, Calif
| | - Jana K Norris
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, Calif
| | - Julie A Bushnell
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, Calif
| | - Chandra Ramamoorthy
- Department of Anesthesia, Stanford University School of Medicine, Palo Alto, Calif
| | - V Mohan Reddy
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, Calif
| | - Frank L Hanley
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, Calif
| | - Gail E Wright
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, Calif.
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23
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Kon AA, Prsa M, Rohlicek CV. Choices doctors would make if their infant had hypoplastic left heart syndrome: comparison of survey data from 1999 and 2007. Pediatr Cardiol 2013; 34:348-53. [PMID: 23011191 DOI: 10.1007/s00246-012-0455-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 07/13/2012] [Indexed: 10/28/2022]
Abstract
Data suggest that despite improved surgical outcomes for infants with hypoplastic left heart syndrome (HLHS), the past two decades have seen little change in parents' decisions whether to choose surgery or palliative treatment without life-prolonging intervention. Data also suggest that doctors' predictions of the choices they would make if their own infant were diagnosed with HLHS do not correlate with their predictions of surgical outcomes. Although previous studies have compared rates of surgery and palliative treatment without life-prolonging intervention over time, no studies have assessed changes in doctors' attitudes. The current study used descriptive and quantitative statistics to compare responses from American pediatric cardiologists and congenital cardiac surgeons from studies conducted in 1999 and 2007. These doctors were asked what choice they believe they would make for their own affected infant. Comparison of responses from 1999 and 2007 showed no difference in the responses of cardiologists: 1999 (44 % surgery, 17 % palliative treatment, 40 % uncertain) versus 2007 (45 % surgery, 20 % palliative treatment, 35 % uncertain). Among surgeons, there was a non-statistically significant trend away from choosing surgery: 1999 (77 % surgery, 5 % palliative treatment, 18 % uncertain) versus 2007 (56 % surgery, 8 % palliative treatment, 36 % uncertain). In conclusion, these analyses suggest that despite improving surgical outcomes, doctors are no more likely to predict that they would choose surgery for their own hypothetical infant with HLHS. Further research is needed to determine what factors influence choice making in the care of infants with HLHS.
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Affiliation(s)
- Alexander A Kon
- Pediatric Intensive Care Unit, Naval Medical Center San Diego, University of California San Diego School of Medicine, 34800 Bob Wilson Drive, San Diego, CA 92134, USA.
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Polimenakos AC, Sathanandam SK, Blair C, el Zein CF, Husayni TS, Ilbawi MN. Shunt Reintervention and Time-Related Events After Norwood Operation: Impact of Shunt Strategy. Ann Thorac Surg 2012; 94:1551-61. [DOI: 10.1016/j.athoracsur.2012.04.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Revised: 04/03/2012] [Accepted: 04/06/2012] [Indexed: 11/30/2022]
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Interstage feeding and weight gain in infants following the Norwood operation: can we change the outcome? Cardiol Young 2012; 22:520-7. [PMID: 22269036 DOI: 10.1017/s1047951111002083] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Poor weight gain is common in infants after Stage I Norwood operation and can negatively impact outcomes. OBJECTIVES The purpose of this study was to examine the impact of feeding strategy on interstage weight gain. METHODS In a multi-centre study, 158 infants discharged following the Norwood operation were enrolled prospectively. Weight and feeding data were obtained at 2-week intervals. Differences between feeding regimens in average daily weight gain and change in weight-for-age z-score between Stage I discharge and Stage II surgery were examined. RESULTS Discharge feeding regimens were oral only in 52%, oral with tube supplementation in 33%, and by nasogastric/gastrostomy tube only in 15%. There were significant differences in the average daily interstage weight gain among the feeding groups - oral only 25.0 grams per day, oral/tube 21.4 grams per day, and tube only 22.3 grams per day - p = 0.019. Tube-only-fed infants were significantly older at Stage II (p = 0.004) and had a significantly greater change in weight-for-age z-score (p = 0.007). The overall rate of weight gain was 16-32 grams per day, similar to infant norms. The rate of weight gain declined over time, with earlier decline observed for oral- and oral/tube-fed infants (less than 15 grams per day at 5.4 months) in comparison with tube-only-fed infants (less than 15 grams per day at 8.6 months). CONCLUSION Following Stage I Norwood, infants discharged on oral feeding had better average daily weight gain than infants with tube-assisted feeding. The overall weight gain was within the normal limits in all feeding groups, but the rate of weight gain decreased over time, with an earlier decline in infants fed orally.
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Feinstein JA, Benson DW, Dubin AM, Cohen MS, Maxey DM, Mahle WT, Pahl E, Villafañe J, Bhatt AB, Peng LF, Johnson BA, Marsden AL, Daniels CJ, Rudd NA, Caldarone CA, Mussatto KA, Morales DL, Ivy DD, Gaynor JW, Tweddell JS, Deal BJ, Furck AK, Rosenthal GL, Ohye RG, Ghanayem NS, Cheatham JP, Tworetzky W, Martin GR. Hypoplastic left heart syndrome: current considerations and expectations. J Am Coll Cardiol 2012; 59:S1-42. [PMID: 22192720 PMCID: PMC6110391 DOI: 10.1016/j.jacc.2011.09.022] [Citation(s) in RCA: 349] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 09/06/2011] [Accepted: 09/20/2011] [Indexed: 01/25/2023]
Abstract
In the recent era, no congenital heart defect has undergone a more dramatic change in diagnostic approach, management, and outcomes than hypoplastic left heart syndrome (HLHS). During this time, survival to the age of 5 years (including Fontan) has ranged from 50% to 69%, but current expectations are that 70% of newborns born today with HLHS may reach adulthood. Although the 3-stage treatment approach to HLHS is now well founded, there is significant variation among centers. In this white paper, we present the current state of the art in our understanding and treatment of HLHS during the stages of care: 1) pre-Stage I: fetal and neonatal assessment and management; 2) Stage I: perioperative care, interstage monitoring, and management strategies; 3) Stage II: surgeries; 4) Stage III: Fontan surgery; and 5) long-term follow-up. Issues surrounding the genetics of HLHS, developmental outcomes, and quality of life are addressed in addition to the many other considerations for caring for this group of complex patients.
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Affiliation(s)
- Jeffrey A Feinstein
- Department of Pediatrics, Stanford University School of Medicine, Lucile Salter Packard Children's Hospital, Palo Alto, California 94304, USA.
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Abstract
Outcomes for staged palliation for single-ventricle heart disease have improved over the past two decades. As outcomes improve, parental expectations for survival and quality of life have risen accordingly. Nevertheless, the number of interventions and complications these patients must endure remain high. The final surgical destination of the single-ventricle patient, the total cavopulmonary connection (or Fontan operation) successfully separates systemic venous and pulmonary venous blood flow but does so at great cost. Fontan patients remain at significant risk of complications despite what are perceived to be "favorable" hemodynamics. The outcomes in this population are discussed in this review, with particular attention to the history behind our current strategies as well as to recent salient studies.
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Affiliation(s)
- Christopher J Petit
- Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX 77030, USA.
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28
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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; 142:1358-66. [PMID: 21703635 DOI: 10.1016/j.jtcvs.2011.04.043] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 03/09/2011] [Accepted: 04/06/2011] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Christopher J Petit
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, The Baylor College of Medicine, Houston, TX, USA.
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29
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Johnson JN, Ansong AK, Li JS, Xu M, Gorentz J, Hehir DA, del Castillo SL, Lai WW, Uzark K, Pasquali SK. Celiac artery flow pattern in infants with single right ventricle following the Norwood procedure with a modified Blalock-Taussig or right ventricle to pulmonary artery shunt. Pediatr Cardiol 2011; 32:479-86. [PMID: 21331516 PMCID: PMC3139997 DOI: 10.1007/s00246-011-9906-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 01/31/2011] [Indexed: 01/24/2023]
Abstract
A potential advantage of the right ventricle to pulmonary artery versus modified Blalock-Taussig shunt in patients undergoing the Norwood procedure is limitation of diastolic runoff from the systemic to pulmonary circulation. We evaluated mesenteric flow patterns and gastrointestinal outcomes following the Norwood procedure associated with either shunt type. Patients randomized to a right ventricle to pulmonary artery versus modified Blalock-Taussig shunt in the Pediatric Heart Network Single Ventricle Reconstruction Trial at centers participating in this ancillary study were eligible for inclusion; those with active necrotizing enterocolitis, sepsis, or end-organ dysfunction were excluded. Celiac artery flow characteristics and gastrointestinal outcomes were collected at discharge. Forty-four patients (five centers) were included. Median age at surgery was 5 days [interquartile range (IQR) = 4-8 days]. Median celiac artery resistive index (an indicator of resistance to perfusion) was higher in the modified Blalock-Taussig shunt group (n = 19) versus the right ventricle to pulmonary artery shunt group (n = 25) [1.00 (IQR = 0.84-1.14) vs. 0.82 (IQR = 0.74-1.00), p = 0.02]. There was no difference in interstage weight gain, necrotizing enterocolitis, or feeding intolerance episodes between the groups. The celiac artery resistive index was higher in patients with the modified Blalock-Taussig shunt versus the right ventricle to pulmonary artery shunt but was not associated with measured gastrointestinal outcomes.
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Affiliation(s)
- Jason N. Johnson
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Annette K. Ansong
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Jennifer S. Li
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Mingfen Xu
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Jessica Gorentz
- Division of Pediatric Cardiology and Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Wisconsin, Milwaukee, WI, USA
| | - David A. Hehir
- Division of Pediatric Cardiology and Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Wisconsin, Milwaukee, WI, USA
| | - Sylvia L. del Castillo
- Division of Critical Care Medicine, Departments of Anesthesiology Critical Care Medicine and Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Wyman W. Lai
- Division of Pediatric Cardiology, Columbia College of Physicians and Surgeons, New York, NY, USA
| | - Karen Uzark
- Division of Pediatric Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Sara K. Pasquali
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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Friedman KG, Salvin JW, Wypij D, Gurmu Y, Bacha EA, Brown DW, Laussen PC, Scheurer MA. Risk factors for failed staged palliation after bidirectional Glenn in infants who have undergone stage one palliation. Eur J Cardiothorac Surg 2011; 40:1000-6. [PMID: 21377892 DOI: 10.1016/j.ejcts.2011.01.056] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Revised: 01/17/2011] [Accepted: 01/20/2011] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The bidirectional Glenn procedure (BDG) is a routine intermediary step in single-ventricle palliation. In this study, we examined risk factors for death or transplant and failure to reach Fontan completion after BDG in patients, who had previously undergone stage one palliation (S1P). METHODS All patients at our institution, who underwent BDG following S1P between 2002 and 2009 (n=194), were included in the analysis. RESULTS Transplant-free survival through 18 months post BDG was 91%. Univariable competing risk analyses showed atrioventricular valve regurgitation (AVVR) >mild, age ≤ 3 months at BDG, ventricular dysfunction >mild, and prolonged hospital stay after S1P to be associated with increased risk of death or orthotopic heart transplant. Multivariable competing risk analysis through 5 years of follow-up showed >mild AVVR (hazard ratio (HR) 7.5, 95% confidence interval (CI) 3.0-18.8), prolonged hospitalization after S1P (HR 4.5, 95% CI 1.8-11.5), and age ≤ 3 months at BDG (HR 6.8, 95% CI 2.3-20.0) to be independent risk factors for death or transplant. Concomitantly, > mild AVVR and age ≤ 3 months were independently associated with an overall decreased rate of Fontan completion. CONCLUSIONS Pre-BDG AVVR, age ≤ 3 months at time of BDG, and prolonged hospitalization after S1P are independently associated with decreased successful progression of staged palliation in midterm follow-up after BDG.
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Affiliation(s)
- Kevin G Friedman
- Department of Cardiology, Children's Hospital Boston, Boston, MA, USA
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Bautista-Hernandez V, Scheurer M, Thiagarajan R, Salvin J, Pigula FA, Emani S, Fynn-Thompson F, Loyola H, Schiff J, del Nido PJ, Bacha EA. Right ventricle and tricuspid valve function at midterm after the Fontan operation for hypoplastic left heart syndrome: impact of shunt type. Pediatr Cardiol 2011; 32:160-6. [PMID: 21107554 DOI: 10.1007/s00246-010-9835-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Accepted: 11/01/2010] [Indexed: 11/29/2022]
Abstract
This study aimed to evaluate clinical outcomes including hemodynamics, right ventricle (RV) function, and tricuspid valve (TV) function in patients with hypoplastic left heart syndrome (HLHS) at midterm after completion of staged palliation based on the source of pulmonary blood flow provided at stage 1. The records of all patients with HLHS who completed Fontan palliation between 2001 and 2007 were retrospectively reviewed. The outcome variables were RV dysfunction, TV, and neo-atrioventricular (neo-AV) regurgitation (from latest echocardiogram), cardiac index (CI), pulmonary vascular resistance (PVR), pulmonary artery pressure (PAp), and right ventricular end-diastolic pressure (RVEDp) (from latest catheterization). Clinical status was obtained from medical records and by contact with the referring cardiologist if necessary. Of 118 patients undergoing a Fontan for HLHS, 116 had a fenestrated lateral tunnel and 2 had an extracardiac conduit. At the time of stage 1 palliation, 36 patients had a right ventricle-to-pulmonary artery (RV-PA) conduit, and 82 patients had a modified Blalock-Taussig shunt (mBTS). All the patients except one who died of sepsis on extracorporeal membrane oxygenation (ECMO) survived the Fontan operation and were discharged home. At a mean follow-up post-Fontan period of 28.4 months (range, 0.16-95.3 months), three patients had died (2 on the transplantation list and 1 from pulmonary vein stenosis), and one patient had the Fontan circulation taken down. No patient had a heart transplantation. A follow-up echocardiogram was performed for 115 patients (after a mean of 15.6 months for RV-PA and 32.1 months for BTS), and 66 patients underwent a post-Fontan catheterization (after a mean of 15.8 months for RV-PA and 29.3 months for BTS). The hemodynamic results for RV-PA conduit versus BTS were a CI of 3.4 ± 0.8 versus 3.4 ± 1.2, a PVR of 1.8 ± 0.7 versus 1.7 ± 0.8, a PAp of 14.3 ± 3.1 versus 14.2 ± 4.5, and an RVEDp of 7.1 ± 3.3 versus 8.9 ± 5.3. No statistically significant differences were found between shunt types regarding survival or degree of RV dysfunction or in terms of neo-AV regurgitation, CI, PVR, PAp, RVEDp, or rhythm problems. Patients in the BTS group required more tricuspid valvuloplasties and had more tricuspid regurgitation at follow-up evaluation. The patients in the RV-PA group had more PA interventions. In conclusion, the contemporary results after Fontan palliation for HLHS were excellent. At the midterm follow-up evaluation, outcomes and hemodynamic data were similar between shunt types. However, the patients in the BTS group exhibited more tricuspid regurgitation, and the patients in the RV-PA group had increased pulmonary artery interventions.
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Affiliation(s)
- Victor Bautista-Hernandez
- Department of Cardiac Surgery, Children's Hospital Boston, 300 Longwood Avenue Bader 273, Boston, MA 02115, USA
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Ballweg JA, Dominguez TE, Ravishankar C, Gaynor JW, Nicolson SC, Spray TL, Tabbutt S. A contemporary comparison of the effect of shunt type in hypoplastic left heart syndrome on the hemodynamics and outcome at Fontan completion. J Thorac Cardiovasc Surg 2010; 140:537-44. [DOI: 10.1016/j.jtcvs.2010.03.045] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2009] [Revised: 01/11/2010] [Accepted: 03/21/2010] [Indexed: 10/19/2022]
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Graham EM, Zyblewski SC, Phillips JW, Shirali GS, Bradley SM, Forbus GA, Bandisode VM, Atz AM. Comparison of Norwood shunt types: do the outcomes differ 6 years later? Ann Thorac Surg 2010; 90:31-5. [PMID: 20609743 DOI: 10.1016/j.athoracsur.2010.03.078] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2009] [Revised: 03/10/2010] [Accepted: 03/16/2010] [Indexed: 11/26/2022]
Abstract
BACKGROUND A modification to the Norwood procedure involving a right ventricle-to-pulmonary artery (RV-PA) shunt may improve early postoperative outcomes. Concerns remain about the effect of the right ventriculotomy required with this shunt on long-term ventricular function. METHODS Between January 2000 and April 2005, 76 patients underwent the Norwood procedure, 35 with a modified Blalock-Taussig shunt (mBTS) and 41 with a RV-PA shunt. Patients were monitored until death or September 1, 2009, with an average follow-up of 6.8 years. Cardiac catheterization, echocardiograms, perioperative Fontan courses, and need for cardiac transplantation were compared between groups. RESULTS Cumulative survival was 63% (22 of 35) in the mBTS group vs 78% (32 of 41) in the RV-PA group (p = 0.14). Pre-Fontan echocardiography revealed poorer ventricular function in RV-PA patients (p = 0.03). Cardiac transplantation was required in 6 of 32 (19%) patients with a prior RV-PA shunt vs 1 of 23 (4%) in the mBTS group (p = 0.06). This results in an almost identical cumulative transplant-free survival between groups; 60% (21 of 35) in the mBTS group and 63% (26 of 41) in the RV-PA group (p = 0.95). CONCLUSIONS Neither shunt offers a clear survival advantage through an average follow-up of 6.8 years. The RV-PA shunt results in impaired late ventricular function that may result in an increased need for cardiac transplantation.
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Affiliation(s)
- Eric M Graham
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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Ohye RG, Sleeper LA, Mahony L, Newburger JW, Pearson GD, Lu M, Goldberg CS, Tabbutt S, Frommelt PC, Ghanayem NS, Laussen PC, Rhodes JF, Lewis AB, Mital S, Ravishankar C, Williams IA, Dunbar-Masterson C, Atz AM, Colan S, Minich LL, Pizarro C, Kanter KR, Jaggers J, Jacobs JP, Krawczeski CD, Pike N, McCrindle BW, Virzi L, Gaynor JW. Comparison of shunt types in the Norwood procedure for single-ventricle lesions. N Engl J Med 2010; 362:1980-92. [PMID: 20505177 PMCID: PMC2891109 DOI: 10.1056/nejmoa0912461] [Citation(s) in RCA: 677] [Impact Index Per Article: 48.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Norwood procedure with a modified Blalock-Taussig (MBT) shunt, the first palliative stage for single-ventricle lesions with systemic outflow obstruction, is associated with high mortality. The right ventricle-pulmonary artery (RVPA) shunt may improve coronary flow but requires a ventriculotomy. We compared the two shunts in infants with hypoplastic heart syndrome or related anomalies. METHODS Infants undergoing the Norwood procedure were randomly assigned to the MBT shunt (275 infants) or the RVPA shunt (274 infants) at 15 North American centers. The primary outcome was death or cardiac transplantation 12 months after randomization. Secondary outcomes included unintended cardiovascular interventions and right ventricular size and function at 14 months and transplantation-free survival until the last subject reached 14 months of age. RESULTS Transplantation-free survival 12 months after randomization was higher with the RVPA shunt than with the MBT shunt (74% vs. 64%, P=0.01). However, the RVPA shunt group had more unintended interventions (P=0.003) and complications (P=0.002). Right ventricular size and function at the age of 14 months and the rate of nonfatal serious adverse events at the age of 12 months were similar in the two groups. Data collected over a mean (+/-SD) follow-up period of 32+/-11 months showed a nonsignificant difference in transplantation-free survival between the two groups (P=0.06). On nonproportional-hazards analysis, the size of the treatment effect differed before and after 12 months (P=0.02). CONCLUSIONS In children undergoing the Norwood procedure, transplantation-free survival at 12 months was better with the RVPA shunt than with the MBT shunt. After 12 months, available data showed no significant difference in transplantation-free survival between the two groups. (ClinicalTrials.gov number, NCT00115934.)
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Affiliation(s)
- Richard G Ohye
- University of Michigan Medical School, Ann Arbor, MI, USA.
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Raja SG. Right ventricle to pulmonary artery shunt modification of the Norwood procedure. Expert Rev Cardiovasc Ther 2010; 8:675-684. [DOI: 10.1586/erc.10.24] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Schreiber C, Kasnar-Samprec J, Hörer J, Eicken A, Cleuziou J, Prodan Z, Lange R. Ring-Enforced Right Ventricle-to-Pulmonary Artery Conduit in Norwood Stage I Reduces Proximal Conduit Stenosis. Ann Thorac Surg 2009; 88:1541-5. [DOI: 10.1016/j.athoracsur.2009.07.081] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2009] [Revised: 07/04/2009] [Accepted: 07/10/2009] [Indexed: 10/20/2022]
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Pruetz JD, Badran S, Dorey F, Starnes VA, Lewis AB. Differential branch pulmonary artery growth after the Norwood procedure with right ventricle–pulmonary artery conduit versus modified Blalock–Taussig shunt in hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2009; 137:1342-8. [DOI: 10.1016/j.jtcvs.2009.03.019] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2008] [Revised: 10/17/2008] [Accepted: 03/09/2009] [Indexed: 10/20/2022]
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Schmitz C, Schirrmeister J, Herberg U, Kozlik-Feldmann R, Stüber F, Welz A, Breuer J. "Rapid two-stage" Norwood operation in a child with multiorgan failure. Pediatr Cardiol 2009; 30:77-9. [PMID: 18626682 DOI: 10.1007/s00246-008-9261-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2007] [Revised: 04/07/2008] [Accepted: 06/06/2008] [Indexed: 10/21/2022]
Abstract
The Norwood I operation continues to be a procedure with significant operative mortality. One well-accepted risk factor for death after the first step of the Norwood operation is critical preoperative status. We describe herein a new concept for the treatment of patients with hypoplastic left heart syndrome (HLHS) in very poor preoperative condition. This is a case report of a child who was born in a rural hospital. On the second day of life he was referred to our center in multiorgan failure. There were signs of liver dysfunction and the child was anuric. Therapy was started immediately with prostaglandin and vasodilators as well as diuretics, milrinone, and dobutamine. However, systemic perfusion continued to be insufficient. Finally, the child was placed on a ventilator. On the fourth day of life, bilateral pulmonary artery (PA) banding was performed and circulation stabilized immediately. Two hours after the operation urine output started. Liver function stabilized over the next couple of days. Two days after PA banding the child was weaned from the ventilator. On the 12th day of life a Norwood operation with PA debanding and a right ventricle-PA conduit was performed, and 2 days postoperatively the child was weaned from the ventilator. Twenty days after the operation he was discharged home. When the boy was 4 months old a bidirectional cavopulmonary anastomosis was performed. In selected cases of patients with HLHS with very poor hemodynamic conditions, a rapid two-stage approach with bilateral banding followed by a Norwood operation after cardiac stabilization can be recommended.
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Affiliation(s)
- C Schmitz
- Department of Cardiac Surgery, University of Munich, Marchioninistr. 15, 81377 Munich, Germany.
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Bradley SM, Erdem CC, Hsia TY, Atz AM, Bandisode V, Ringewald JM. Right Ventricle-to-Pulmonary Artery Shunt: Alternative Palliation in Infants With Inadequate Pulmonary Blood Flow Prior to Two-Ventricle Repair. Ann Thorac Surg 2008; 86:183-8; discussion 188. [DOI: 10.1016/j.athoracsur.2008.03.047] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2007] [Revised: 03/14/2008] [Accepted: 03/21/2008] [Indexed: 11/24/2022]
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Survival and Clinical Course at Fontan After Stage One Palliation With Either a Modified Blalock-Taussig Shunt or a Right Ventricle to Pulmonary Artery Conduit. J Am Coll Cardiol 2008; 52:52-9. [DOI: 10.1016/j.jacc.2008.03.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2007] [Revised: 02/27/2008] [Accepted: 03/11/2008] [Indexed: 11/22/2022]
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Galantowicz M, Cheatham JP, Phillips A, Cua CL, Hoffman TM, Hill SL, Rodeman R. Hybrid approach for hypoplastic left heart syndrome: intermediate results after the learning curve. Ann Thorac Surg 2008; 85:2063-70; discussion 2070-1. [PMID: 18498821 DOI: 10.1016/j.athoracsur.2008.02.009] [Citation(s) in RCA: 260] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Revised: 02/01/2008] [Accepted: 02/04/2008] [Indexed: 11/18/2022]
Abstract
BACKGROUND Lessons learned during the development of a novel hybrid approach have resulted in a reliable, reproducible alternative treatment for hypoplastic left heart syndrome (HLHS). Herein we report our results using this hybrid approach in a uniform risk cohort. METHODS This is a review of prospectively collected data on patients treated for HLHS using a hybrid approach (n = 40) between July 2002 and June 2007. The hybrid approach includes pulmonary artery bands, a ductal stent, and atrial septostomy as a neonate, comprehensive stage 2 procedure resulting in Glenn shunt physiology at six months and Fontan completion at two years. RESULTS Forty patients had a hybrid stage 1 with 36 undergoing a comprehensive stage 2 procedure. Fifteen patients have completed the Fontan procedure with 17 pending. Overall survival was 82.5% (33 of 40). The seven deaths included one at stage 1, two between stages 1 and 2, three at stage 2, and one between stages 2 and 3. One patient had successful heart transplantation during the interstage period. CONCLUSIONS The hybrid approach can yield acceptable intermediate results that are comparable with a traditional Norwood strategy. Potential advantages of the hybrid approach include the avoidance of circulatory arrest and shifting the major surgical stage to later in life. These data provide the platform for a prospective trial comparing these two surgical options to assess whether there is less cumulative impact with the hybrid approach, thereby improving end organ function, quality, and quantity of life.
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Affiliation(s)
- Mark Galantowicz
- The Heart Center, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA.
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Sersar SI. Grey zone area for Glenn and future Fontan candidates. J Thorac Cardiovasc Surg 2008; 135:1405. [PMID: 18544407 DOI: 10.1016/j.jtcvs.2007.07.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2007] [Accepted: 07/30/2007] [Indexed: 11/16/2022]
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Design and rationale of a randomized trial comparing the Blalock-Taussig and right ventricle-pulmonary artery shunts in the Norwood procedure. J Thorac Cardiovasc Surg 2008; 136:968-75. [PMID: 18954638 DOI: 10.1016/j.jtcvs.2008.01.013] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2007] [Accepted: 01/16/2008] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The initial palliative procedure for patients born with hypoplastic left heart syndrome and related single right ventricle anomalies, the Norwood procedure, remains among the highest risk procedures in congenital heart surgery. The classic Norwood procedure provides pulmonary blood flow with a modified Blalock-Taussig shunt. Improved outcomes have been reported in a few small, nonrandomized studies of a modification of the Norwood procedure that uses a right ventricle-pulmonary artery shunt to provide pulmonary blood flow. Other nonrandomized studies have shown no differences between the two techniques. METHODS The Pediatric Heart Network designed a randomized clinical trial to compare outcomes for subjects undergoing a Norwood procedure with either the right ventricle-pulmonary artery or modified Blalock-Taussig shunt. Infants with a diagnosis of single, morphologically right ventricle anomaly who are undergoing a Norwood procedure are eligible for inclusion in this study. The primary outcome is death or cardiac transplant 12 months after random assignment. Secondary outcomes include postoperative morbidity after Norwood and stage II palliation procedures, right ventricular function and pulmonary arterial growth at stage II palliation, and neurodevelopmental outcomes at 14 months old. Incidence of adverse events will also be compared between treatment groups. CONCLUSION This study will make an important contribution to the care of patients with hypoplastic left heart syndrome and related forms of single, morphologically right ventricle. It also establishes a model with which other operative interventions for patients with congenital cardiovascular malformations can be evaluated in the future.
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