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Alphonso N, Angelini A, Barron DJ, Bellsham-Revell H, Blom NA, Brown K, Davis D, Duncan D, Fedrigo M, Galletti L, Hehir D, Herberg U, Jacobs JP, Januszewska K, Karl TR, Malec E, Maruszewski B, Montgomerie J, Pizzaro C, Schranz D, Shillingford AJ, Simpson JM. Guidelines for the management of neonates and infants with hypoplastic left heart syndrome: The European Association for Cardio-Thoracic Surgery (EACTS) and the Association for European Paediatric and Congenital Cardiology (AEPC) Hypoplastic Left Heart Syndrome Guidelines Task Force. Eur J Cardiothorac Surg 2020; 58:416-499. [DOI: 10.1093/ejcts/ezaa188] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Nelson Alphonso
- Queensland Pediatric Cardiac Service, Queensland Children’s Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Annalisa Angelini
- Department of Cardiac, Thoracic Vascular Sciences and Public health, University of Padua Medical School, Padua, Italy
| | - David J Barron
- Department of Cardiovascular Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Katherine Brown
- Paediatric Intensive Care, Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah Davis
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, USA
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Daniel Duncan
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Marny Fedrigo
- Department of Cardiac, Thoracic Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Lorenzo Galletti
- Unit of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - David Hehir
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | | | - Katarzyna Januszewska
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | | | - Edward Malec
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | - Bohdan Maruszewski
- Department for Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - James Montgomerie
- Department of Anesthesia, Birmingham Children’s Hospital, Birmingham, UK
| | - Christian Pizzaro
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University, Giessen, Germany
| | - Amanda J Shillingford
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Cao JY, Phan K, Ayer J, Celermajer DS, Winlaw DS. Long term survival of hypoplastic left heart syndrome infants: Meta-analysis comparing outcomes from the modified Blalock-Taussig shunt and the right ventricle to pulmonary artery shunt. Int J Cardiol 2018; 254:107-116. [PMID: 29407078 DOI: 10.1016/j.ijcard.2017.10.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 10/09/2017] [Accepted: 10/12/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Stage 1 palliation of hypoplastic left heart syndrome (HLHS) involves the Norwood procedure combined with a modified Blalock-Taussig shunt (mBTS) or right ventricle to pulmonary artery shunt (RVPAS). Short-term survival has been described previously, whereas longer-term outcomes remain a subject of debate. This meta-analysis aimed to describe the short and long-term survival outcomes of these two shunts, and explore factors that might influence survival. METHODS Medline, Cochrane Libraries and EMBASE were systematically searched, and 32 studies were included for statistical synthesis, comprising 1348 mBTS and 1258 RVPAS patients. RESULTS While early in-hospital survival was superior in the RVPAS group (RR=1.5, p<0.05, 95% CI: 1.21-1.85), this difference was lost from 2years post-stage 1 palliation (RR=0.91, p>0.05, 95% CI: 0.79-1.04), and maintained unchanged up to 6years. This shift in survival was also reflected in inter-stage survival, with superior RVPAS outcomes between stage 1 and 2 (RR=1.62, p<0.05, 95% CI: 1.39-1.88), and equivalent outcomes between stage 2 and 3. Potential contributors to this included a significantly higher rate of pulmonary artery stenosis in the RVPAS group and an increased requirement for shunt re-intervention in this group prior to stage 2. CONCLUSIONS Despite early advantages, RVPAS and mBTS for palliation of hypoplastic left heart syndrome produced comparable long-term survival. The RVPAS patients experienced more pulmonary artery stenosis and requirement for shunt re-intervention. The impact of shunt type on quality and survival with a Fontan is yet to be assessed.
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Affiliation(s)
- Jacob Y Cao
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Kevin Phan
- Sydney Medical School, University of Sydney, Sydney, Australia; NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia
| | - Julian Ayer
- Sydney Medical School, University of Sydney, Sydney, Australia; The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - David S Celermajer
- Sydney Medical School, University of Sydney, Sydney, Australia; Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - David S Winlaw
- Sydney Medical School, University of Sydney, Sydney, Australia; The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia.
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4
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Meza JM, Hickey EJ, Blackstone EH, Jaquiss RDB, Anderson BR, Williams WG, Cai S, Van Arsdell GS, Karamlou T, McCrindle BW. The Optimal Timing of Stage 2 Palliation for Hypoplastic Left Heart Syndrome: An Analysis of the Pediatric Heart Network Single Ventricle Reconstruction Trial Public Data Set. Circulation 2017; 136:1737-1748. [PMID: 28687711 DOI: 10.1161/circulationaha.117.028481] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 06/26/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND In infants requiring 3-stage single-ventricle palliation for hypoplastic left heart syndrome, attrition after the Norwood procedure remains significant. The effect of the timing of stage 2 palliation (S2P), a physician-modifiable factor, on long-term survival is not well understood. We hypothesized that an optimal interval between the Norwood and S2P that both minimizes pre-S2P attrition and maximizes post-S2P survival exists and is associated with individual patient characteristics. METHODS The National Institutes of Health/National Heart, Lung, and Blood Institute Pediatric Heart Network Single Ventricle Reconstruction Trial public data set was used. Transplant-free survival (TFS) was modeled from (1) Norwood to S2P and (2) S2P to 3 years by using parametric hazard analysis. Factors associated with death or heart transplantation were determined for each interval. To account for staged procedures, risk-adjusted, 3-year, post-Norwood TFS (the probability of TFS at 3 years given survival to S2P) was calculated using parametric conditional survival analysis. TFS from the Norwood to S2P was first predicted. TFS after S2P to 3 years was then predicted and adjusted for attrition before S2P by multiplying by the estimate of TFS to S2P. The optimal timing of S2P was determined by generating nomograms of risk-adjusted, 3-year, post-Norwood, TFS versus the interval from the Norwood to S2P. RESULTS Of 547 included patients, 399 survived to S2P (73%). Of the survivors to S2P, 349 (87%) survived to 3-year follow-up. The median interval from the Norwood to S2P was 5.1 (interquartile range, 4.1-6.0) months. The risk-adjusted, 3-year, TFS was 68±7%. A Norwood-S2P interval of 3 to 6 months was associated with greatest 3-year TFS overall and in patients with few risk factors. In patients with multiple risk factors, TFS was severely compromised, regardless of the timing of S2P and most severely when S2P was performed early. No difference in the optimal timing of S2P existed when stratified by shunt type. CONCLUSIONS In infants with few risk factors, progressing to S2P at 3 to 6 months after the Norwood procedure was associated with maximal TFS. Early S2P did not rescue patients with greater risk factor burdens. Instead, referral for heart transplantation may offer their best chance at long-term survival. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT00115934.
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Affiliation(s)
- James M Meza
- From Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B.); Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, TX (R.D.B.J.); Division of Pediatric Cardiology, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ (T.K.); and Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada (B.W.M.).
| | - Edward J Hickey
- From Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B.); Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, TX (R.D.B.J.); Division of Pediatric Cardiology, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ (T.K.); and Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada (B.W.M.)
| | - Eugene H Blackstone
- From Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B.); Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, TX (R.D.B.J.); Division of Pediatric Cardiology, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ (T.K.); and Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada (B.W.M.)
| | - Robert D B Jaquiss
- From Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B.); Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, TX (R.D.B.J.); Division of Pediatric Cardiology, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ (T.K.); and Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada (B.W.M.)
| | - Brett R Anderson
- From Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B.); Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, TX (R.D.B.J.); Division of Pediatric Cardiology, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ (T.K.); and Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada (B.W.M.)
| | - William G Williams
- From Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B.); Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, TX (R.D.B.J.); Division of Pediatric Cardiology, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ (T.K.); and Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada (B.W.M.)
| | - Sally Cai
- From Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B.); Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, TX (R.D.B.J.); Division of Pediatric Cardiology, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ (T.K.); and Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada (B.W.M.)
| | - Glen S Van Arsdell
- From Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B.); Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, TX (R.D.B.J.); Division of Pediatric Cardiology, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ (T.K.); and Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada (B.W.M.)
| | - Tara Karamlou
- From Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B.); Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, TX (R.D.B.J.); Division of Pediatric Cardiology, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ (T.K.); and Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada (B.W.M.)
| | - Brian W McCrindle
- From Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B.); Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, TX (R.D.B.J.); Division of Pediatric Cardiology, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ (T.K.); and Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada (B.W.M.)
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5
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Başaran M, Tunçer E, Güzelmeriç F, Cine N, Oner N, Yildirim A, Savluk O, Tüzün B, Ceyran H. Introduction to a Norwood program in an emerging economy: learning curve of a single center. Heart Surg Forum 2015; 16:E313-8. [PMID: 24370799 DOI: 10.1532/hsf98.2013222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND There has been a notable improvement in the outcome of stage 1 palliation for hypoplastic left heart syndrome (HLHS) in recent years. Nevertheless, developing a new Norwood program requires a steep learning curve, especially in emerging economies where rapid population growth brings a high volume of patients but, on the other hand, resources are limited. In this paper we aimed to summarize the initial results of a single center. METHODS Hospital records of 21 patients were reviewed for all patients having a stage 1 palliation procedure for HLHS between May 2011 and May 2013. There were 13 male (62%) and 8 female (38%) patients. Median age was 14 days (range, 4-74 days) and median weight was 3030 g (2600-3900 g). HLHS was defined as mitral or aortic stenosis or atresia (or both) in the presence of normally related great vessels and a hypoplastic left ventricle. Transthoracic echocardiography was the diagnostic modality used in all patients. All procedures but one were performed using an antegrade selective cerebral perfusion method and moderate hypothermia. Cerebral perfusion was monitored with cerebral oximetry in all patients. Modified ultrafiltration was routinely used in all patients. RESULTS Overall hospital mortality was 47.6% (n = 10). Mortality rates considerably decreased from the first year to second year (69% and 12.5% respectively). No risk factors were identified for mortality. CONCLUSIONS Surgical palliation of neonates with hypoplastic left heart syndrome continues to be a challenge. To decrease the overall mortality nationwide and improve outcomes, a referral center with a dedicated team is necessary in emerging economies.
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Affiliation(s)
- Murat Başaran
- Department of Pediatric Cardiac Surgery, Kosuyolu Heart Center, Istanbul, Turkey
| | - Eylem Tunçer
- Department of Pediatric Cardiac Surgery, Kosuyolu Heart Center, Istanbul, Turkey
| | - Füsun Güzelmeriç
- Department of Anesthesiology and Reanimation, Kosuyolu Heart Center, Istanbul, Turkey
| | - Nihat Cine
- Department of Pediatric Cardiac Surgery, Kosuyolu Heart Center, Istanbul, Turkey
| | - Naci Oner
- Department of Pediatric Cardiology, Kosuyolu Heart Center, Istanbul, Turkey
| | - Ayşe Yildirim
- Department of Pediatric Cardiology, Kosuyolu Heart Center, Istanbul, Turkey
| | - Omer Savluk
- Department of Anesthesiology and Reanimation, Kosuyolu Heart Center, Istanbul, Turkey
| | - Behzat Tüzün
- Department of Pediatric Cardiac Surgery, Kosuyolu Heart Center, Istanbul, Turkey
| | - Hakan Ceyran
- Department of Pediatric Cardiac Surgery, Kosuyolu Heart Center, Istanbul, Turkey
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