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Zampi JD, Sower CT, Lancaster TS, Sood V, Romano JC. Hybrid Interventions in Congenital Heart Disease: A Review of Current Practice and Rationale for Use. Ann Thorac Surg 2024; 118:329-337. [PMID: 38462049 DOI: 10.1016/j.athoracsur.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/14/2024] [Accepted: 03/04/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Hybrid interventions have become a common option in the management for a variety of patients with congenital heart disease. In this review, we discuss the data that have driven decision making about hybrid interventions to date. METHODS The existing literature on various hybrid approaches was reviewed and summarized. In addition, the key tenants to creating a successful hybrid program within a congenital heart center are elucidated. RESULTS Hybrid strategies for single-ventricle patients, pulmonary atresia with intact ventricular septum, branch pulmonary artery stenosis, and muscular ventricular septal defect closure have important benefits and limitations compared with traditional approaches. CONCLUSION A growing body of evidence supports the use of hybrid interventions in congenital heart disease. But important questions remain regarding improved survival and other long-term outcomes, such as neurocognition, that might impact widespread adoption as a primary treatment strategy.
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Affiliation(s)
- Jeffrey D Zampi
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan.
| | - C Todd Sower
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Timothy S Lancaster
- Section of Pediatric Cardiovascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Vikram Sood
- Section of Pediatric Cardiovascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jennifer C Romano
- Section of Pediatric Cardiovascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
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2
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Nealon E, Phelps C, Krawczeski C, Alexander R, Stiver C, Ball MK, Carrillo SA, Texter K. Impact of Maternal-Fetal Environment on Outcomes Following the Hybrid Procedure in the Single Ventricle Population. Pediatr Cardiol 2024; 45:1258-1266. [PMID: 36462027 DOI: 10.1007/s00246-022-03063-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 11/21/2022] [Indexed: 12/05/2022]
Abstract
Treatment of infants with hypoplastic left heart syndrome (HLHS) remains challenging, and those affected remain with significant risks for mortality and morbidity throughout their lifetimes. The maternal-fetal environment (MFE) has been shown to affect outcomes for infants with HLHS after the Norwood procedure. The hybrid procedure, comprised of both catheterization and surgical components, is a less invasive option for initial intervention compared to the Norwood procedure. It is unknown how the MFE impacts outcomes following the hybrid procedure. This is a single-center, retrospective study of infants born with HLHS who underwent hybrid palliation from January 2009 to August 2021. Predictor variables analyzed included fetal, maternal, and postnatal factors. The primary outcome was mortality prior to Stage II palliation. We studied a 144-subject cohort. There was a statistically significant difference in mortality prior to stage II palliation in infants with prematurity, small for gestational age, and aortic atresia subtype (p < 0.001, p = 0.009, and p = 0.008, respectively). There was no difference in mortality associated with maternal diabetes, hypertension, obesity, smoking or illicit drug use, or advanced maternal age. State and national area deprivation index scores were associated with increased risk of mortality in the entire cohort, such that infants born in areas with higher deprivation had a higher incidence of mortality. Several markers of an impaired MFE, including prematurity, small for gestational age, and higher deprivation index scores, are associated with mortality following hybrid palliation. Individual maternal comorbidities were not associated with higher mortality. The MFE may be a target for prenatal counseling and future interventions to improve pregnancy and neonatal outcomes in this population.
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Affiliation(s)
- Erin Nealon
- Division of Pediatric Cardiology, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Christina Phelps
- Division of Pediatric Cardiology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Catherine Krawczeski
- Division of Pediatric Cardiology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Robin Alexander
- Department of Statistics, The Ohio State University, Columbus, OH, USA
| | - Corey Stiver
- Division of Pediatric Cardiology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Molly K Ball
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Sergio A Carrillo
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Karen Texter
- Division of Pediatric Cardiology, Nationwide Children's Hospital, Columbus, OH, USA
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Iskander C, Nwankwo U, Kumanan KK, Chiwane S, Exil V, Lowrie L, Tan C, Huddleston C, Agarwal HS. Comparison of Morbidity and Mortality Outcomes between Hybrid Palliation and Norwood Palliation Procedures for Hypoplastic Left Heart Syndrome: Meta-Analysis and Systematic Review. J Clin Med 2024; 13:4244. [PMID: 39064284 PMCID: PMC11277754 DOI: 10.3390/jcm13144244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/20/2024] [Accepted: 07/05/2024] [Indexed: 07/28/2024] Open
Abstract
Background/Objectives: Hybrid palliation (HP) procedures for hypoplastic left heart syndrome (HLHS) are increasing. Our objective was to compare mortality and morbidity following HP and NP (Norwood palliation) procedures. Methods: Systematic review and meta-analysis of HLHS patients of peer-reviewed literature between 2000 and 2023. Mortality and/or heart transplantation in HP versus NP in the neonatal period, interstage period, and at 1, 3 and 5 years of age, and morbidity including completion of Stage II and Stage III palliation, unexpected interventions, pulmonary artery pressures, right ventricle function, neurodevelopmental outcomes and length of hospital stay were evaluated. Results: Twenty-one (meta-analysis: 16; qualitative synthesis: 5) studies evaluating 1182 HLHS patients included. HP patients had higher interstage mortality (RR = 1.61; 95% CI: 1.10-2.33; p = 0.01) and 1-year mortality (RR = 1.22; 95% CI: 1.03-1.43; p = 0.02) compared to NP patients without differences in 3- and 5-years mortality. HP procedure in high-risk HLHS patients had lower mortality (RR = 0.48; 95% CI: 0.27-0.87; p = 0.01) only in the neonatal period. HP patients underwent fewer Stage II (RR = 0.90; 95% CI: 0.81-1.00; p = 0.05) and Stage III palliation (RR = 0.78; 95% CI: 0.69-0.90; p < 0.01), had more unplanned interventions (RR = 3.38; 95% CI: 2.04-5.59; p < 0.01), and longer hospital stay after Stage I palliation (weighted mean difference = 12.88; 95% CI: 1.15-24.62; p = 0.03) compared to NP patients. Conclusions: Our study reveals that HP, compared to NP for HLHS, is associated with increased morbidity risk without an improved survival rate.
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Affiliation(s)
- Christopher Iskander
- Division of Pediatric Cardiology, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.I.); (U.N.); (V.E.)
| | - Ugonna Nwankwo
- Division of Pediatric Cardiology, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.I.); (U.N.); (V.E.)
| | - Krithika K. Kumanan
- Advanced Data Health Institution, Saint Louis University, Saint Louis, MO 63104, USA;
| | - Saurabh Chiwane
- Division of Pediatric Critical Care Medicine, Loma Linda University, Loma Linda, CA 92354, USA;
| | - Vernat Exil
- Division of Pediatric Cardiology, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.I.); (U.N.); (V.E.)
| | - Lia Lowrie
- Division of Pediatric Critical Care Medicine, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA;
| | - Corinne Tan
- Department of Pediatric Cardio-Thoracic Surgery, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.T.); (C.H.)
| | - Charles Huddleston
- Department of Pediatric Cardio-Thoracic Surgery, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA; (C.T.); (C.H.)
| | - Hemant S. Agarwal
- Division of Pediatric Critical Care Medicine, Cardinal Glennon Children’s Hospital, Saint Louis, MO 63104, USA;
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4
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Wilson HC, Sood V, Romano JC, Zampi JD, Lu JC, Yu S, Lowery RE, Kleeman K, Balasubramanian S. Hypoplastic Left Heart Syndrome with Mitral Stenosis and Aortic Atresia-Echocardiographic Findings and Early Outcomes. J Am Soc Echocardiogr 2024; 37:603-612. [PMID: 38432347 DOI: 10.1016/j.echo.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 02/13/2024] [Accepted: 02/13/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Mitral stenosis/aortic atresia (MS/AA) has been reported as a high-risk variant of hypoplastic left heart syndrome (HLHS), potentially related to ventriculocoronary connections (VCCs) or endocardial fibroelastosis (EFE) and myocardial hypoperfusion. We aimed to identify echocardiographic and clinical factors associated with early death or transplant in this group. METHODS Patients with HLHS MS/AA treated at our center between 2000 and 2020 were included. Pre-stage I palliation echocardiograms were reviewed. Certain imaging factors, such as determination of VCC, EFE, and measurement of tricuspid annular plane systolic excursion were measured from retrospective review of preoperative images; others were derived from clinical reports. Groups were compared according to primary outcome of death or transplant prior to stage II palliation. RESULTS Of 141 patients included, 39 (27.7%) experienced a primary outcome. Ventriculocoronary connections were identified in 103 (73.0%) patients and EFE in 95 (67.4%) patients. Among imaging variables, smaller ascending aorta size (median, 2.2 [interquartile range (IQR) 1.7-2.8] vs 2.6 [2.2-3.4] mm, P = .01) was associated with primary outcome. There was similar frequency of VCC (74.4% vs 72.5%, P = .83), EFE (59.0% vs 72.5%, P = .19), moderate or greater tricuspid regurgitation (5.1% vs 5.9%, P = 1.00), and similar right ventricular systolic function (indexed tricuspid annular plane systolic excursion 32.5 ± 7.3 vs 31.4 ± 7.2 mm/m2, P = .47) in the primary outcome group compared to other patients. Clinical factors associated with primary outcome included lower birth weight (mean, 2.8 ± SD 0.8 vs 3.3 ± 0.5 kg, P = .0003), gestational age <37 weeks (31.6% vs 4.9%, P < .0001), longer cardiopulmonary bypass time (median, 112 [IQR, 93-162] vs 82 [71-119] minutes, P = .001), longer intensive care unit length of stay (median, 19 [IQR, 10-30] vs 10 [7-15] days, P = .001), and extracorporeal membrane oxygenation following stage I palliation (43.6% vs 8.8%, P < .0001). Presence of VCCs and EFE was not associated with death or transplant after controlling for birth weight and era of stage I palliation. CONCLUSIONS In one of the largest reported single-center cohorts of HLHS MS/AA, there were few pre-stage I palliation imaging characteristics associated with primary outcome. Imaging findings evaluated in this study, including the presence of VCC and/or EFE as determined using highly sensitive echocardiogram criteria, should not preclude intervention, although impact on long-term outcomes requires further evaluation.
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Affiliation(s)
- Hunter C Wilson
- Division of Pediatric Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Vikram Sood
- Division of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jennifer C Romano
- Division of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jeffrey D Zampi
- Division of Pediatric Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Jimmy C Lu
- Division of Pediatric Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Sunkyung Yu
- Division of Pediatric Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Ray E Lowery
- Division of Pediatric Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Kellianne Kleeman
- Division of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
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Chen JM, Ittenbach RF, Lawrence KM, Hunt ML, Kaplinski M, Mahle M, Fuller S, Maeda K, Nuri MAK, Gardner MM, Mavroudis CD, Mascio CE, Spray TL, Gaynor JW. Increased utilization of the hybrid procedure is not associated with improved early survival for newborns with hypoplastic left heart syndrome: a single-centre experience. Eur J Cardiothorac Surg 2024; 65:ezae164. [PMID: 38608188 DOI: 10.1093/ejcts/ezae164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 02/27/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
OBJECTIVES The primary objectives were to examine utilization of the Hybrid versus the Norwood procedure for patients with hypoplastic left heart syndrome or variants and the impact on hospital mortality. The Hybrid procedure was 1st used at our institution in 2004. METHODS Review of all subjects undergoing the Norwood or Hybrid procedure between 1 January 1984 and 31 December 2022. The study period was divided into 8 eras: era 1, 1984-1988; era 2, 1989-1993; era 3, 1994-1998; era 4, 1999-2003; era 5, 2004-2008; era 6, 2009-2014; era 7, 2015-2018 and era 8, 2019-2022. The primary outcome was in-hospital mortality. Mortality rates were computed using standard binomial proportions with 95% confidence intervals. Rates across eras were compared using an ordered logistic regression model with and adjusted using the Tukey-Kramer post-hoc procedure for multiple comparisons. In the risk-modelling phase, logistic regression models were specified and tested. RESULTS The Norwood procedure was performed in 1899 subjects, and the Hybrid procedure in 82 subjects. Use of the Hybrid procedure increased in each subsequent era, reaching 30% of subjects in era 8. After adjustment for multiple risk factors, use of the Hybrid procedure was significantly and positively associated with hospital mortality. CONCLUSIONS Despite the increasing use of the Hybrid procedure, overall mortality for the entire cohort has plateaued. After adjustment for risk factors, use of the Hybrid procedure was significantly and positively associated with mortality compared to the Norwood procedure.
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Affiliation(s)
- Jonathan M Chen
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Richard F Ittenbach
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kendall M Lawrence
- Division of Cardiothoracic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mallory L Hunt
- Division of Cardiothoracic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michelle Kaplinski
- Department of Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Marlene Mahle
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Katsuhide Maeda
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Muhammad A K Nuri
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Monique M Gardner
- Division of Cardiac Critical Care Medicine, Department of Anesthesia Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Constantine D Mavroudis
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher E Mascio
- Division of Pediatric Cardiothoracic Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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6
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Jacquemyn X, Singh TP, Gossett JG, Averin K, Kutty S, Zühlke LJ, Abdullahi LH, Kulkarni A. Mortality and Heart Transplantation After Hybrid Palliation of Hypoplastic Left Heart Syndrome: A Systematic Review and Meta-Analysis. World J Pediatr Congenit Heart Surg 2024; 15:215-223. [PMID: 38404131 DOI: 10.1177/21501351231224323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
BACKGROUND Newborns with hypoplastic left heart syndrome (HLHS) who are considered at increased risk for death following Norwood/Sano surgery often undergo hybrid palliation (HP) as initial surgery. We aimed to compile the HP experience in HLHS and its variants and assess the rates of, and risk factors for, death and heart transplantation. METHODS CINAHL, CINAHL PLUS, PubMed/MEDLINE, and SCOPUS were systematically searched for HP outcome studies of death or heart transplantation in HLHS between 1998 and 2022. Pooled incidence was estimated, and potential risk factors were identified using random-effects meta-analysis and reconstructed time-to-event data from Kaplan-Meier curves. RESULTS Thirty-three publications were included in our review. Overall, of 1,162 patients 417 died and 57 underwent heart transplantation, resulting in a combined outcome of 40.7%, (474/1,162). There was a trend toward decreasing mortality risk across the stages of palliation. Pooled mortality between HP and comprehensive stage 2 palliation was 25%, after stage 2 up to Fontan palliation was 16%, and 6% post-Fontan. The incidence of death or heart transplantation was higher in high-risk patients-43% died and 10% received heart transplantation. CONCLUSION Our systematic review and meta-analysis found high rates of death or heart transplantation in HP of HLHS patients between HP and Fontan surgeries. All patients should be closely followed during the initial interstage period, which is associated with the highest hazard. Prospective studies on appropriate patient selection, indications, and / or alternatives, as well as refining HP strategies for managing newborns with HLHS are needed to improve outcomes.
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Affiliation(s)
- Xander Jacquemyn
- Helen B. Taussig Heart Center, Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD, USA
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Tajinder P Singh
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Jeffrey G Gossett
- Cohen Children's Heart Center, Donald and Barbara Zucker School of Medicine at Hofstra/ Northwell, New Hyde Park, NY, USA
| | - Konstantin Averin
- Cohen Children's Heart Center, Donald and Barbara Zucker School of Medicine at Hofstra/ Northwell, New Hyde Park, NY, USA
| | - Shelby Kutty
- Helen B. Taussig Heart Center, Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Liesl J Zühlke
- President's Office, South African Medical Research Council, Cape Town, South Africa
- Division of Paediatric Cardiology, Department of Paediatrics, Institute of Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Leila H Abdullahi
- Save the Children International (SCI), Somalia/Somaliland Country Office. Nairobi, Kenya
| | - Aparna Kulkarni
- Cohen Children's Heart Center, Donald and Barbara Zucker School of Medicine at Hofstra/ Northwell, New Hyde Park, NY, USA
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Miller-Tate H, Fichtner S, Davis JA, Alvarado C, Conroy S, Bigelow AM, Wright L, Galantowicz M, Cua CL. Utility of the NEONATE Score at an Institution that Routinely Performs the Hybrid Procedure for Hypoplastic Left Heart Syndrome. Pediatr Cardiol 2023; 44:1684-1690. [PMID: 37632588 DOI: 10.1007/s00246-023-03223-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/26/2023] [Indexed: 08/28/2023]
Abstract
NEONATE score > 17 has been proposed as a risk factor for interstage mortality/cardiac transplant (IM/T) for patients with single ventricle physiology. Hybrid procedure is assigned 6 points, the highest possible score for that surgical variable. Most centers reserve the hybrid procedure for high-risk patients. Goal of this study was to evaluate the NEONATE score at a center that routinely performs the hybrid procedure. Retrospective chart review of patients undergoing the hybrid procedure was performed (2008-2021). Demographics and variables used for the NEONATE score were collected. Maximization of Youden's J Statistic used to determine cohort-specific optimal threshold for patients undergoing comprehensive Stage II procedure (H-CSII) versus those with IM/T (H-IM/T). Total of 120 patients met inclusion criteria (H-CSII = 105, H-IM/T = 15). Gestational age was median 39 weeks (IQR 38, 39) and birth weight was 3.18 kg (2.91, 3.57). No patient was discharged with opiates or required post-operative extracorporeal circulatory support. Optimal threshold, as selected by maximizing Youden's J Statistic, was 22. Score > 22 had a positive predictive value of 0.33 (95% CI 0.12-0.62), negative predictive values of 0.90 (95% CI 0.83-0.95), and accuracy of 0.83 (95% CI 0.75-0.90) for IM/T. At a center that routinely performs the hybrid procedure, value of > 22 had the highest accuracy. This suggests that the hybrid procedure is not necessarily intrinsically a risk-factor for IM/T, but rather patient selection for the hybrid procedure may play a larger role at centers that do not routinely perform this procedure.
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Affiliation(s)
- Holly Miller-Tate
- Heart Center, Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Samantha Fichtner
- Heart Center, Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Jo Ann Davis
- Heart Center, Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Chance Alvarado
- Heart Center, Nationwide Children's Hospital, Columbus, OH, 43205, USA
- Biostatistics Resource, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, 43205, USA
- The Ohio Perinatal Research Network, Center for Perinatal Research, Nationwide Children's Hospital, Columbus, OH, 43205, USA
- Center for Biostatistics, The Ohio State University, Wexner Medical Center, Columbus, OH, 43210, USA
| | - Sara Conroy
- Biostatistics Resource, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, 43205, USA
- The Ohio Perinatal Research Network, Center for Perinatal Research, Nationwide Children's Hospital, Columbus, OH, 43205, USA
- Center for Biostatistics, The Ohio State University, Wexner Medical Center, Columbus, OH, 43210, USA
| | - Amee M Bigelow
- Heart Center, Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Lydia Wright
- Heart Center, Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Mark Galantowicz
- Heart Center, Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Clifford L Cua
- Heart Center, Nationwide Children's Hospital, Columbus, OH, 43205, USA.
- Department of Pediatrics, Heart Center, Nationwide Children's Hospital, Columbus, OH, 43205, USA.
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8
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Argo MB, Barron DJ, Bondarenko I, Eckhauser A, Gruber PJ, Lambert LM, Paramananthan T, Rahman M, Winlaw DS, Yerebakan C, Alsoufi B, DeCampli WM, Honjo O, Kirklin JK, Prospero C, Ramakrishnan K, St Louis JD, Turek JW, O'Brien JE, Pizarro C, Anagnostopoulos PV, Blackstone EH, Jacobs ML, Jegatheeswaran A, Karamlou T, Stephens EH, Polimenakos AC, Haw MP, McCrindle BW. Hybrid palliation versus nonhybrid management for a multi-institutional cohort of infants with critical left heart obstruction. J Thorac Cardiovasc Surg 2023; 166:1300-1313.e2. [PMID: 37164059 DOI: 10.1016/j.jtcvs.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/11/2023] [Accepted: 04/19/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE To compare patient characteristics and overall survival for infants with critical left heart obstruction after hybrid palliation (bilateral pulmonary artery banding with or without ductal stenting) versus nonhybrid management (eg, Norwood, primary transplantation, biventricular repair, or transcatheter/surgical aortic valvotomy). METHODS From 2005 to 2019, 1045 infants in the Congenital Heart Surgeons' Society critical left heart obstruction cohort underwent interventions across 28 institutions. Using a balancing score propensity analysis, 214 infants who underwent hybrid palliation and 831 infants who underwent nonhybrid management were proportionately matched regarding variables significantly associated with mortality and variables noted to significantly differ between groups. Overall survival between the 2 groups was adjusted by applying balancing scores to nonparametric estimates. RESULTS Compared with the nonhybrid management group, infants who underwent hybrid palliation had lower birth weight, smaller gestational age, and higher prevalence of in-utero interventions, noncardiac comorbidities, preoperative mechanical ventilation, absent interatrial communication, and moderate or severe mitral valve stenosis (all P values < .03). Unadjusted 12-year survival after hybrid palliation and nonhybrid management, was 55% versus 69%, respectively. After matching, 12-year survival after hybrid palliation versus nonhybrid management was 58% versus 63%, respectively (P = .37). Among matched infants born weighing <2.5 kg, 2-year survival after hybrid palliation versus nonhybrid management was 37% versus 51%, respectively (P = .22). CONCLUSIONS Infants born with critical left heart obstruction who undergo hybrid palliation have more high-risk characteristics and anatomy versus infants who undergo nonhybrid management. Nonetheless, after adjustment, there was no significant difference in 12-year survival after hybrid palliation versus nonhybrid management. Mortality remains high, and hybrid palliation confers no survival advantage, even for lower-birth-weight infants.
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Affiliation(s)
- Madison B Argo
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wis; Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David J Barron
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Igor Bondarenko
- Division of Cardiovascular Surgery, Children's Hospital of Michigan, Detroit, Mich
| | - Aaron Eckhauser
- Division of Cardiothoracic Surgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Peter J Gruber
- Division of Cardiothoracic Surgery, Yale New Haven Children's Hospital, New Haven, Conn
| | - Linda M Lambert
- Division of Cardiothoracic Surgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Tharini Paramananthan
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Maha Rahman
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David S Winlaw
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Can Yerebakan
- Division of Cardiac Surgery, Children's National Hospital, Washington, DC
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, Norton Children's Hospital, Louisville, Ky
| | - William M DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Fla
| | - Osami Honjo
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - James K Kirklin
- Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, Ala
| | - Carol Prospero
- Division of Pediatric Cardiology, Nemours Children's Hospital Delaware, Wilmington, Del
| | - Karthik Ramakrishnan
- Division of Pediatric Cardiovascular Surgery, LeBonheur Children's Hospital, Memphis, Tenn
| | - James D St Louis
- Division of Pediatric and Congenital Cardiac Surgery, Children's Hospital of Georgia, Augusta, Ga
| | - Joseph W Turek
- Department of Surgery, Duke Children's Hospital and Health Center, Durham, NC
| | - James E O'Brien
- Division of Pediatric Cardiovascular Surgery, Children's Mercy Kansas City, Kansas City, M
| | - Christian Pizarro
- Cardiothoracic Surgery, Nemours Children's Hospital Delaware, Wilmington, Del
| | - Petros V Anagnostopoulos
- Division of Pediatric Cardiothoracic Surgery, University of Wisconsin Health American Family Hospital, Madison, Wis
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery and Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Anusha Jegatheeswaran
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery and Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Anastasios C Polimenakos
- Division of Pediatric and Congenital Cardiac Surgery, Children's Hospital of Georgia, Augusta, Ga
| | - Marcus P Haw
- Department of Pediatric Cardiovascular Surgery, Helen DeVos Children's Hospital, Grand Rapids, Mich
| | - Brian W McCrindle
- Division of Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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9
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Argo MB, Barron DJ, Eghtesady P, Yerebakan C, DeCampli WM, Alsoufi B, Honjo O, Jacobs JP, Paramananthan T, Rahman M, Lambert LM, Jegatheeswaran A, Carrillo SA, Husain SA, Ramakrishnan K, Caldarone CA, Karamlou T, Nelson J, Mannie C, Romano JC, Turek JW, Blackstone EH, Galantowicz ME, Kirklin JK, Mitchell ME, McCrindle BW. Outcomes After Hybrid Palliation for Infants With Critical Left Heart Obstruction. J Am Coll Cardiol 2023; 82:1427-1441. [PMID: 37758438 DOI: 10.1016/j.jacc.2023.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/02/2023] [Accepted: 07/18/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Hybrid palliation (bilateral pulmonary artery banding with or without ductal stenting) is an initial management strategy for infants with critical left heart obstruction and serves as palliation until subsequent operations are pursued. OBJECTIVES This study sought to determine patient characteristics and factors associated with subsequent outcomes for infants who underwent hybrid palliation. METHODS From 2005 to 2019, 214 of 1,236 prospectively enrolled infants within the Congenital Heart Surgeons' Society's critical left heart obstruction cohort underwent hybrid palliation across 24 institutions. Multivariable hazard modeling with competing risk methodology was performed to determine risk and factors associated with outcomes of biventricular repair, Fontan procedure, transplantation, or death. RESULTS Preoperative comorbidities (eg, prematurity, low birth weight, genetic syndrome) were identified in 70% of infants (150 of 214). Median follow-up was 7 years, ranging up to 17 years. Overall 12-year survival was 55%. At 5 years after hybrid palliation, 9% had biventricular repair, 36% had Fontan procedure, 12% had transplantation, 35% died without surgical endpoints, and 8% were alive without an endpoint. Factors associated with transplantation were absence of ductal stent, older age, absent interatrial communication, smaller aortic root size, larger tricuspid valve area z-score, and larger left ventricular volume. Factors associated with death were low birth weight, concomitant genetic syndrome, cardiopulmonary bypass use during hybrid palliation, moderate to severe tricuspid valve regurgitation, and smaller ascending aortic size. CONCLUSIONS Mortality remains high after hybrid palliation for infants with critical left heart obstruction. Nonetheless, hybrid palliation may facilitate biventricular repair for some infants and for others may serve as stabilization for intended functional univentricular palliation or primary transplantation.
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Affiliation(s)
- Madison B Argo
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA; Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David J Barron
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Pirooz Eghtesady
- Division of Pediatric Cardiothoracic Surgery, St Louis Children's Hospital, St Louis, Missouri, USA
| | - Can Yerebakan
- Division of Cardiac Surgery, Children's National Hospital, Washington, DC, USA
| | - Williams M DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, Norton Children's Hospital, Louisville, Kentucky, USA
| | - Osami Honjo
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Tharini Paramananthan
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Maha Rahman
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Linda M Lambert
- Division of Cardiothoracic Surgery, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Anusha Jegatheeswaran
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Sergio A Carrillo
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - S Adil Husain
- Division of Cardiothoracic Surgery, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Karthik Ramakrishnan
- Division of Pediatric Cardiovascular Surgery, LeBonheur Children's Hospital, Memphis, Tennessee, USA
| | | | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery and Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jennifer Nelson
- Division of Pediatric Cardiovascular Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Chelsea Mannie
- Division of Pediatric Cardiothoracic Surgery, St Louis Children's Hospital, St Louis, Missouri, USA
| | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph W Turek
- Department of Surgery, Duke Children's Hospital and Health Center, Durham, North Carolina, USA
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery and Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mark E Galantowicz
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - James K Kirklin
- Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michael E Mitchell
- Division of Pediatric Cardiothoracic Surgery, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Brian W McCrindle
- Division of Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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10
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Rome JJ, O'Byrne ML. Hybrid Palliation for Critical Left Heart Obstruction Is Versatile: Risk Factors Still Impede Optimal Outcome. J Am Coll Cardiol 2023; 82:1442-1444. [PMID: 37758439 DOI: 10.1016/j.jacc.2023.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/18/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Jonathan J Rome
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Division of Cardiology at the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
| | - Michael L O'Byrne
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Division of Cardiology at the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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11
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Jacobs JP, DeCampli WM, Karamlou T, Najm HK, Marino BS, Blackstone EH, McCrindle BW, Jegatheeswaran A, St Louis JD, Austin EH, Caldarone CA, Mavroudis C, Overman DM, Dearani JA, Jacobs ML, Tchervenkov CI, Svensson LG, Barron D, Kirklin JK, Williams WG. The Academic Impact of Congenital Heart Surgeons' Society (CHSS) Studies. World J Pediatr Congenit Heart Surg 2023; 14:602-619. [PMID: 37737599 DOI: 10.1177/21501351231190916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
PURPOSE We reviewed all 64 articles ever published by The Congenital Heart Surgeons' Society (CHSS) Data Center to estimate the academic impact of these peer-reviewed articles. MATERIALS AND METHODS The Congenital Heart Surgeons' Society has performed research based on 12 Diagnostic Inception Cohorts. The first cohort (Transposition) began enrolling patients on January 1, 1985. We queried PubMed to determine the number of publications that referenced each of the 64 journal articles generated by the datasets of the 12 Diagnostic Inception Cohorts that comprise the CHSS Database. Descriptive summaries of the data were tabulated using mean with standard deviation and median with range. RESULTS Sixty-four peer-reviewed papers have been published based on the CHSS Database. Fifty-nine peer-reviewed articles have been published based on the 12 Diagnostic Inception Cohorts, and five additional articles have been published based on Data Science. Excluding the recently established Diagnostic Inception Cohort for patients with Ebstein malformation of tricuspid valve, the number of papers published per cohort ranged from 1 for coarctation to 11 for transposition of the great arteries. The 11 articles generated from the CHSS Transposition Cohort were referenced by a total of 111 articles (median number of references per journal article = 9 [range = 0-22, mean = 10.1]). Overall, individual articles were cited by an average of 11 (mean), and a maximum of 41 PubMed-listed publications. Overall, these 64 peer-reviewed articles based on the CHSS Database were cited 692 times in PubMed-listed publications. The first CHSS peer-reviewed article was published in 1987, and during the 35 years from 1987 to 2022, inclusive, the annual number of CHSS publications has ranged from 0 to 7, with a mean of 1.8 publications per year (median = 1, mode = 1). CONCLUSION Congenital Heart Surgeons' Society studies are widely referenced in the pediatric cardiac surgical literature, with over 10 citations per published article. These cohorts provide unique information unavailable in other sources of data. A tool to access this analysis is available at: [https://data-center.chss.org/multimedia/files/2022/CAI.pdf].
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Affiliation(s)
- Jeffrey Phillip Jacobs
- Congenital Heart Center, Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, FL, USA
| | - William M DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Tara Karamlou
- Pediatric and Adult Congenital Heart Center, Cleveland Clinic, Cleveland, OH, USA
| | - Hani K Najm
- Pediatric and Adult Congenital Heart Center, Cleveland Clinic, Cleveland, OH, USA
| | - Bradley S Marino
- Pediatric and Adult Congenital Heart Center, Cleveland Clinic, Cleveland, OH, USA
| | - Eugene H Blackstone
- Pediatric and Adult Congenital Heart Center, Cleveland Clinic, Cleveland, OH, USA
| | - Brian W McCrindle
- Division of Pediatric Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - James D St Louis
- Department of Cardiac Surgery, Inova Fairfax Hospital and Inova L.J Murphy Children's Hospital, Fairfax, VA, USA
- Departments of Surgery and Pediatrics, Children's Hospital of Georgia, Augusta University, Augusta, GA, USA
| | - Erle H Austin
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY, USA
- Norton Children's Hospital, Louisville, KY, USA
| | | | - Constantine Mavroudis
- Pediatric Cardiothoracic Surgery, Peyton Manning Children's Hospital, Indianapolis, IN, USA
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David M Overman
- Division of Cardiovascular Surgery, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, MN, USA
| | - Joseph A Dearani
- Division of Cardiovascular Surgery, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, MN, USA
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christo I Tchervenkov
- Division of Cardiovascular Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Québec, Canada
| | - Lars G Svensson
- Pediatric and Adult Congenital Heart Center, Cleveland Clinic, Cleveland, OH, USA
| | - David Barron
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, Birmingham, AL, USA
| | - William G Williams
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
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12
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Jegatheeswaran A, Argo MB, Devlin PJ, Callahan CP, Meza JM, Wilder TJ, Hickey EJ, Karamlou T. The Congenital Heart Surgeons' Society Kirklin/Ashburn Fellowship: The Fellows' Perspective. World J Pediatr Congenit Heart Surg 2023; 14:575-586. [PMID: 37737596 DOI: 10.1177/21501351231190087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
Since its establishment in 2001, the Congenital Heart Surgeons' Society John W. Kirklin/David Ashburn Fellowship has contributed substantially to the field of congenital heart surgery research while simultaneously training the next generation of surgeon- scientists. To date, ten fellows (and counting) have successfully completed this rigorous training, producing over 40 published articles focused on longitudinal outcomes from the various Congenital Heart Surgeons' Society cohorts. As the Kirklin/Ashburn Fellowship expands and additional fellows matriculate, its legacy, the network of support, and the contribution to congenital heart surgery research will undoubtedly hold strong.
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Affiliation(s)
- Anusha Jegatheeswaran
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, London, UK
- Children's Cardiovascular Disease, Institute of Cardiovascular Science, University College London, London, UK
| | - Madison B Argo
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, WI, USA
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul J Devlin
- Division of Cardiac Surgery and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Connor P Callahan
- Division of Pediatric Cardiothoracic Surgery, University Hospitals Rainbow Babies and Children's, Cleveland, OH, USA
| | - James M Meza
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Travis J Wilder
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Edward J Hickey
- Department of Cardiothoracic Surgery, Texas Children's Hospital, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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13
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Konstantinov IE, Cooper DKC, Adachi I, Bacha E, Bleiweis MS, Chinnock R, Cleveland D, Cowan PJ, Fynn-Thompson F, Morales DLS, Mohiuddin MM, Reichart B, Rothblatt M, Roy N, Turek JW, Urschel S, West L, Wolf E. Consensus statement on heart xenotransplantation in children: Toward clinical translation. J Thorac Cardiovasc Surg 2023; 166:960-967. [PMID: 36184321 PMCID: PMC10124772 DOI: 10.1016/j.jtcvs.2022.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
Affiliation(s)
- Igor E Konstantinov
- Royal Children's Hospital, University of Melbourne, Murdoch Children's Research Institute, Melbourne Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Australia.
| | - David K C Cooper
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, Mass
| | - Iki Adachi
- Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Emile Bacha
- Columbia University Medical Center, Morgan Stanley Children's Hospital, New York, NY
| | | | | | - David Cleveland
- Department of Surgery, University of Alabama, Birmingham, Ala
| | - Peter J Cowan
- Immunology Research Centre, St. Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | | | - David L S Morales
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Muhammad M Mohiuddin
- Program in Cardiac Xenotransplantation, University of Maryland School of Medicine, Baltimore, Md
| | - Bruno Reichart
- Transregional Collaborative Research Center, Walter Brendel Centre of Experimental Medicine, Ludwig Maximilians University, Munich, Germany
| | | | - Nathalie Roy
- Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Joseph W Turek
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Simon Urschel
- Pediatric Cardiac Transplantation Program, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Lori West
- Pediatric Cardiac Transplantation Program, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada; Canadian Donation and Transplantation Research Program, Alberta Transplant Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Eckhard Wolf
- Gene Center and Department of Veterinary Sciences, Ludwig Maximilians University, Munich, Germany
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14
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Ramonfaur D, Zhang X, Garza AP, García-Pons JF, Britton-Robles SC. Hypoplastic Left Heart Syndrome: A Review. Cardiol Rev 2023; 31:149-154. [PMID: 35349498 DOI: 10.1097/crd.0000000000000435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Hypoplastic left heart syndrome is a rare and poorly understood congenital disorder featuring a univentricular myocardium, invariably resulting in early childhood death if left untreated. The process to palliate this congenital cardiomyopathy is of high complexity and may include invasive interventions in the first week of life. The preferred treatment strategy involves a staged correction with 3 surgical procedures at different points in time. The Norwood procedure is usually performed within the first weeks of life and aims to increase systemic circulation and relieve pulmonary vascular pressure. This procedure is followed by the bidirectional Glenn and the Fontan procedures in later life, which offer to decrease stress in the ventricular chamber. The prognosis of children with this disease has greatly improved in the past decades; however, it is still largely driven by multiple modifiable and nonmodifiable variables. Novel and clever alternatives have been proposed to improve the survival and neurodevelopment of these patients, although they are not used as standard of care in all centers. The neurodevelopmental outcomes among these patients have received particular attention in the last decade in light to improve this very limiting associated comorbidity that compromises quality of life.
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Affiliation(s)
- Diego Ramonfaur
- From the Division of Postgraduate Medical Education, Harvard Medical School, Boston, MA
| | - Xiaoya Zhang
- From the Division of Postgraduate Medical Education, Harvard Medical School, Boston, MA
| | - Abraham P Garza
- Departamento de Medicina, Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, México
| | - José Fernando García-Pons
- División de Ciencias de la Salud, Departamento de Medicina y Nutrición, Universidad de Guanajuato, Guanajuato, México
| | - Sylvia C Britton-Robles
- Departamento de Medicina, Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, México
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15
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Nandi D, Culp S, Yates AR, Hoffman TM, Juraszek AL, Snyder CS, Feltes TF, Cua CL. Initial Counseling Prior to Palliation for Hypoplastic Left Heart Syndrome: 2021 vs 2011. Pediatr Cardiol 2023; 44:1118-1124. [PMID: 37099209 DOI: 10.1007/s00246-023-03170-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 04/19/2023] [Indexed: 04/27/2023]
Abstract
We sought to examine current practices and changes in practice regarding initial counseling for families of patients with hypoplastic left heart syndrome (HLHS) given the evolution of options and outcomes over time. Counseling (Norwood with Blalock-Taussig-Thomas shunt (NW-BTT), NW with right ventricle to pulmonary artery conduit (NW-RVPA), hybrid palliation, heart transplantation, or non-intervention/hospice (NI)) for patients with HLHS were queried via questionnaire of pediatric care professionals in 2021 and compared to identical questionnaire from 2011. Of 322 respondents in 2021 (39% female), 299 respondents were cardiologists (92.9%), 17cardiothoracic surgeons (5.3%), and 6 were nurse practitioners (1.9%). Respondents were largely from North America (96.9%). In 2021, NW-RVPA procedure was the preferred palliation for standard risk HLHS patient (61%) and was preferred across all US regions (p < 0.001). NI was offered as an option by 71.4% of respondents for standard risk patients and was the predominant strategy for patients with end-organ dysfunction, chromosomal abnormality, and prematurity (52%, 44%, and 45%, respectively). The hybrid procedure was preferred for low birth-weight infants (51%). In comparison to the identical 2011 questionnaire (n = 200), the NW-RVPA was endorsed more in 2021 (61% vs 52%, p = 0.04). For low birth-weight infants, hybrid procedure was more recommended than in 2011 (51% vs 21%, p < 0.001). The NW-RVPA operation is the most recommended strategy throughout the US for infants with HLHS. The hybrid procedure for low birth-weight infants is increasingly recommended. NI continues to be offered even in standard risk patients with HLHS.
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Affiliation(s)
- Deipanjan Nandi
- Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA.
| | - Stacey Culp
- Department of Biomedical Informatics, Ohio State University, Columbus, OH, USA
| | - Andrew R Yates
- Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | | | | | | | - Timothy F Feltes
- Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Clifford L Cua
- Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
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16
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Backes ER, Afonso NS, Guffey D, Tweddell JS, Tabbutt S, Rudd NA, O'Harrow G, Molossi S, Hoffman GM, Hill G, Heinle JS, Bhat P, Anderson JB, Ghanayem NS. Cumulative comorbid conditions influence mortality risk after staged palliation for hypoplastic left heart syndrome and variants. J Thorac Cardiovasc Surg 2023; 165:287-298.e4. [PMID: 35599210 DOI: 10.1016/j.jtcvs.2022.01.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 12/29/2021] [Accepted: 01/27/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Prematurity, low birth weight, genetic syndromes, extracardiac conditions, and secondary cardiac lesions are considered high-risk conditions associated with mortality after stage 1 palliation. We report the impact of these conditions on outcomes from a prospective multicenter improvement collaborative. METHODS The National Pediatric Cardiology Quality Improvement Collaborative Phase II registry was queried. Comorbid conditions were categorized and quantified to determine the cumulative burden of high-risk diagnoses on survival to the first birthday. Logistic regression was applied to evaluate factors associated with mortality. RESULTS Of the 1421 participants, 40% (575) had at least 1 high-risk condition. The aggregate high-risk group had lower survival to the first birthday compared with standard risk (76.2% vs 88.1%, P < .001). Presence of a single high-risk diagnosis was not associated with reduced survival to the first birthday (odds ratio, 0.71; confidence interval, 0.49-1.02, P = .066). Incremental increases in high-risk diagnoses were associated with reduced survival to first birthday (odds ratio, 0.23; confidence interval, 0.15-0.36, P < .001) for 2 and 0.17 (confidence interval, 0.10-0.30, P < .001) for 3 to 5 high-risk diagnoses. Additional analysis that included prestage 1 palliation characteristics and stage 1 palliation perioperative variables identified multiple high-risk diagnoses, poststage 1 palliation extracorporeal membrane oxygenation support (odds ratio, 0.14; confidence interval, 0.10-0.22, P < .001), and cardiac reoperation (odds ratio, 0.66; confidence interval, 0.45-0.98, P = .037) to be associated with reduced survival odds to the first birthday. CONCLUSIONS The presence of 1 high-risk diagnostic category was not associated with decreased survival at 1 year. Cumulative diagnoses across multiple high-risk diagnostic categories were associated with decreased odds of survival. Further patient accrual is needed to evaluate the impact of specific comorbid conditions within the broader high-risk categories.
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Affiliation(s)
- Emily R Backes
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex.
| | - Natasha S Afonso
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - Danielle Guffey
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - James S Tweddell
- Division of Cardiology, Department of Surgery, Department of Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sarah Tabbutt
- Divisions of Critical Care and Cardiology, Department of Pediatrics, University of California San Francisco and Benioff Children's Hospital, San Francisco, Calif
| | - Nancy A Rudd
- Division of Cardiology, Department of Pediatrics, Department of Anesthesia, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Ginny O'Harrow
- Division of Critical Care, Department of Pediatrics, University of Chicago Medicine and Comer Children's Hospital, Chicago, Ill
| | - Silvana Molossi
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - George M Hoffman
- Division of Cardiology, Department of Pediatrics, Department of Anesthesia, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Garick Hill
- Division of Cardiology, Department of Surgery, Department of Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey S Heinle
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - Priya Bhat
- Divisions of Cardiology and Critical Care, Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Tex, Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Tex
| | - Jeffrey B Anderson
- Division of Cardiology, Department of Surgery, Department of Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nancy S Ghanayem
- Division of Critical Care, Department of Pediatrics, University of Chicago Medicine and Comer Children's Hospital, Chicago, Ill; Advocate Children's Hospital, Oak Lawn, Ill
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17
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Increased interstage morbidity and mortality following stage 1 palliation in patients with genetic abnormalities. Cardiol Young 2022; 32:1999-2004. [PMID: 35137681 DOI: 10.1017/s1047951122000166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Hypoplastic left heart syndrome and single ventricle variants with aortic hypoplasia are commonly classified as severe forms of CHD. We hypothesised patients with these severe defects and reported genetic abnormalities have increased morbidity and mortality during the interstage period. METHODS AND RESULTS This was a retrospective review of the National Pediatric Cardiology Quality Improvement Collaborative Phase I registry. Three patient groups were identified: major syndromes, other genetic abnormalities, and no reported genetic abnormality. Tukey post hoc test was applied for pairwise group comparisons of length of stay, death, and combined outcome of death, not a candidate for stage 2 palliation, and heart transplant. Participating centres received a survey to establish genetic testing and reporting practices. Of the 2182 patients, 110 (5%) had major genetic syndromes, 126 (6%) had other genetic abnormalities, and 1946 (89%) had no genetic abnormality. Those with major genetic syndromes weighed less at birth and stage 1 palliation. Patients with no reported genetic abnormalities reached full oral feeds sooner and discharged earlier. The combined outcome of death, not a candidate for stage 2 palliation, and heart transplant was more common in those with major syndromes. Survey response was low (n = 23, 38%) with only 14 (61%) routinely performing and reporting genetic testing. CONCLUSIONS Patients with genetic abnormalities experienced greater morbidity and mortality during the interstage period than those with no reported genetic abnormalities. Genetic testing and reporting practices vary significantly between participating centres.
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18
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Akintürk H, Yörüker U, Schranz D. Hypoplastic Left Heart Syndrome Palliation: Technical Aspects and Common Pitfalls of the Hybrid Approach. World J Pediatr Congenit Heart Surg 2022; 13:588-592. [PMID: 36053094 DOI: 10.1177/21501351221099935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The Giessen hybrid strategy is used for initial palliation of HLHS and variants when the intent is to pursue further staged palliative reconstruction toward Fontan circulation. It is also used for initial palliation of HLHC and other anomalies with potential for eventual biventricular repair. From June 1998 - October 2021, 197 patients with HLHS and related variants underwent hybrid stage 1. Follow-up is complete (median 8.3 [range 0-23.3] years). Operative mortality for hybrid stage I was 3.6% (7/197); reduced to 2.8% since 2010 (4/141). Interstage mortality was 4.1% (8/197). Operative mortality for comprehensive stage II was 5.8% (10/172), and since 2010 was 1.8% (2/113 patients). Fontan completion has been accomplished in 117 patients, and 33 are still awaiting stage III. Twelve patients underwent heart transplantation. Over 23 years, overall survival is 77.7% and transplant-free survival is 73.6%.
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Affiliation(s)
- Hakan Akintürk
- Department of Pediatric Cardiac Surgery and Congenital Heart Disease, Pediatric Heart Center, Justus Liebig University, Giessen, Germany
| | - Uygar Yörüker
- Department of Pediatric Cardiac Surgery and Congenital Heart Disease, Pediatric Heart Center, Justus Liebig University, Giessen, Germany
| | - Dietmar Schranz
- Department of Pediatric Cardiology, Goethe University, Frankfurt, Germany
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O'Byrne ML, McHugh KE, Huang J, Song L, Griffis H, Anderson BR, Bucholz EM, Chanani NK, Elhoff JJ, Handler SS, Jacobs JP, Li JS, Lewis AB, McCrindle BW, Pinto NM, Sassalos P, Spar DS, Pasquali SK, Glatz AC. Cumulative In-Hospital Costs Associated With Single-Ventricle Palliation. JACC. ADVANCES 2022; 1:100029. [PMID: 38939312 PMCID: PMC11198056 DOI: 10.1016/j.jacadv.2022.100029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/20/2022] [Accepted: 04/22/2022] [Indexed: 06/29/2024]
Abstract
Background In the SVR (Single Ventricle Reconstruction) Trial, 1-year survival in recipients of right ventricle to pulmonary artery shunts (RVPAS) was superior to that in those receiving modified Blalock-Taussig-Thomas shunts (MBTTS), but not in subsequent follow-up. Cost analysis is an expedient means of evaluating value and morbidity. Objectives The purpose of this study was to evaluate differences in cumulative hospital costs between RVPAS and MBTTS. Methods Clinical data from SVR and costs from Pediatric Health Information Systems database were combined. Cumulative hospital costs and cost-per-day-alive were compared serially at 1, 3, and 5 years between RVPAS and MBTTS. Potential associations between patient-level factors and cost were explored with multivariable models. Results In total, 303 participants (55% of the SVR cohort) from 9 of 15 sites were studied (48% MBTTS). Observed total costs at 1 year were lower for MBTTS ($701,260 ± 442,081) than those for RVPAS ($804,062 ± 615,068), a difference that was not statistically significant (P = 0.10). Total costs were also not significantly different at 3 and 5 years (P = 0.21 and 0.32). Similarly, cost-per-day-alive did not differ significantly for either group at 1, 3, and 5 years (all P > 0.05). In analyses of transplant-free survivors, total costs and cost-per-day-alive were higher for RVPAS at 1 year (P = 0.05 for both) but not at 3 and 5 years (P > 0.05 for all). In multivariable models, aortic atresia and prematurity were associated with increased cost-per-day-alive across follow-up (P < 0.05). Conclusions Total costs do not differ significantly between MBTTS and RVPAS. The magnitude of longitudinal costs underscores the importance of efforts to improve outcomes in this vulnerable population.
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Affiliation(s)
- Michael L. O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics and Cardiovascular Outcomes, Quality, and Evaluative Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kimberly E. McHugh
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jing Huang
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lihai Song
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Heather Griffis
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Brett R. Anderson
- Division of Cardiology, New York-Presbyterian Morgan-Stanley Children’s Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Emily M. Bucholz
- Department of Cardiology, Children’s Hospital Boston and Harvard University Medical School, Boston, Massachusetts, USA
| | - Nikhil K. Chanani
- Children’s Healthcare of Atlanta, Sibley Heart Center and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Justin J. Elhoff
- Sections of Critical Care and Cardiology, Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas, USA
| | | | - Jeffery P. Jacobs
- Division of Cardiothoracic Surgery, Departments of Surgery and Pediatrics, Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Jennifer S. Li
- Division of Pediatric Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Alan B. Lewis
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Brian W. McCrindle
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nelangi M. Pinto
- Division of Cardiology, Primary Children’s Hospital and University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Peter Sassalos
- Division of Pediatric Cardiothoracic Surgery, C.S. Mott Children’s Hospital and University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - David S. Spar
- The Heart Institute, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Sara K. Pasquali
- Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Andrew C. Glatz
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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D'Angelo J, Suguna Narasimhulu S, Pourmoghadam K, Hsia TY, Fleishman C, Kube A, Lucchesi N, DeCampli W. Outcomes Following Norwood Procedures: Analysis of a "Small Volume" Program. World J Pediatr Congenit Heart Surg 2022; 13:655-663. [PMID: 35593094 DOI: 10.1177/21501351221098599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Institutional survival following Norwood procedures is traditionally correlated with a center's surgical volume. Multiple single and multi-institutional studies conducted at large-volume centers have recently demonstrated improved survival following Norwood procedures. We report both short- and long-term outcomes at a single, small-volume institution and comment on factors potentially influencing outcomes at this institution. METHODS All patients undergoing Norwood procedures from January 1, 2005, to January 1, 2020, at our institution were included in this study. Kaplan-Meier survival and Cox regression risk factor analyses were performed in addition to first interstage risk factor scoring to compare observed versus expected survival. RESULTS The cohort included 113 patients. Kaplan-Meier freedom from death or transplant was 88%, 80%, and 76% at 1, 5, and 10 years, respectively. Freedom from death following hospital discharge after Norwood procedures was 94%, 87%, and 83% at 1, 5, and 10 years, respectively. The presence of genetic syndromes was a significant risk factor for mortality. First interstage observed-to-expected mortality following discharge was 0.57 (P = .04). Postoperative length of stay was comparable to that reported for the period 2015 to 2018 in the Society of Thoracic Surgeons Database. CONCLUSIONS Survival outcomes at this single, small-volume institution were similar to those reported by large-volume centers and multi-institutional collaborative studies. These results may be related to structural and functional features that have been demonstrated to influence outcomes in other studies. These factors are achievable by small-volume programs with sufficient resource allocation.
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Affiliation(s)
- John D'Angelo
- 124506University of Central Florida College of Medicine, Orlando, FL, USA
| | - Sukumar Suguna Narasimhulu
- 124506University of Central Florida College of Medicine, Orlando, FL, USA.,25102Orlando Health Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Kamal Pourmoghadam
- 124506University of Central Florida College of Medicine, Orlando, FL, USA.,25102Orlando Health Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Tain-Yen Hsia
- 124506University of Central Florida College of Medicine, Orlando, FL, USA.,25102Orlando Health Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Craig Fleishman
- 124506University of Central Florida College of Medicine, Orlando, FL, USA.,25102Orlando Health Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Alicia Kube
- 25102Orlando Health Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Nicole Lucchesi
- 25102Orlando Health Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - William DeCampli
- 124506University of Central Florida College of Medicine, Orlando, FL, USA.,25102Orlando Health Arnold Palmer Hospital for Children, Orlando, FL, USA
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Surgical Strategies in Single Ventricle Management of Neonates and Infants. Can J Cardiol 2022; 38:909-920. [PMID: 35513174 DOI: 10.1016/j.cjca.2022.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 12/17/2022] Open
Abstract
No area of congenital heart disease has undergone greater change and innovation than Single Ventricle management over the past 20 years. Surgical and catheter lab interventions have transformed outcomes such that in some subgroups more than 80% of these patients can survive into adulthood. Driven by parallel development in diagnostic imaging and cardiac intensive care, surgical management is focused on the neonatal period as the key time to creating a balanced circulation and limiting pulmonary blood-flow. Different configurations of the circulation including new types of surgical shunts and the role of 'hybrid' circulations provide greater options and better physiology. This overview will focus on these changes in surgical management and timing but also look at the exciting areas of regenerative therapies to improve ventricular function, and the concept of ventricular rehabilitation to achieve biventricular circulations in certain groups of patients. The importance of early (neonatal) intervention and multidisciplinary approach to management is emphasised, as well as looking beyond simply survival but also improving neurodevelopmental outcomes.
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22
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Ceneri NM, Desai MH, Tongut A, Ozturk M, Ramakrishnan K, Staffa SJ, Zurakowski D, Donofrio MT, Downing T, d’Udekem Y, Jonas RA, Yerebakan C, Clauss S, Kalinger K, Kanter J, Munoz R, Peer SM, Sinha P, Wernovsky G. Hybrid Strategy in Neonates with Ductal-Dependent Systemic Circulation and Multiple Risk Factors. J Thorac Cardiovasc Surg 2022; 164:1291-1303.e6. [DOI: 10.1016/j.jtcvs.2021.11.103] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 10/07/2021] [Accepted: 11/23/2021] [Indexed: 11/17/2022]
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Wirth SH, Heydarian HC, Marcuccio E, Tepe BE, Stein LH, Hill GD. Increasing Use of the Right Ventricle to Pulmonary Artery Shunt for Stage 1 Palliation. Ann Thorac Surg 2022; 115:1229-1236. [PMID: 35033509 DOI: 10.1016/j.athoracsur.2021.12.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 11/14/2021] [Accepted: 12/10/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Stage 1 palliation of hypoplastic left heart syndrome entails use of the Norwood operation with either a modified Blalock-Taussig shunt or a right ventricle-to-pulmonary artery shunt, or the Hybrid procedure. Utilization trends and factors influencing palliation selection remain unclear. We aimed to evaluate these questions and to compare outcomes between types of stage 1 palliation. METHODS The National Pediatric Cardiology Quality Improvement Collaborative phase 1 (6/2008-8/2016) and phase 2 (8/2016-9/2019) databases were used. Procedure type was assessed by operation year. Baseline characteristics and annual hospital volume were evaluated. Post-surgical admission duration and outcomes were compared. RESULTS 3,497 patients were included, 30.8% with modified Blalock-Taussig shunt, 59.7% with right-ventricle-to-pulmonary-artery shunt, and 9.5% with Hybrid. Use of the right-ventricle-to-pulmonary-artery shunt increased over time (p=0.02). This increase was similar among all hospital volumes. Higher hospital volume (OR 1.2 [95% CI 1.1-1.4], p=0.003), male sex (OR 1.3 [95% CI 1.1-1.6], p=0.01), and isolated cardiac disease (OR 1.33 [95% CI 1.01-1.55], p=0.05) were associated with relatively higher likelihoods of a modified Blalock-Taussig shunt. Mortality/transplant rates before stage 2 palliation were higher with the modified Blalock-Taussig shunt than the right-ventricle-to-pulmonary-artery shunt (12.3% vs 9.6%, p=0.03). CONCLUSIONS In stage one palliation, use of right-ventricle-to-pulmonary-artery shunts has increased over time, use of modified Blalock-Taussig shunts has decreased, and use of Hybrids was unchanged. The modified Blalock-Taussig shunt has a higher likelihood of use in higher volume centers, males, and less complex patients, but is associated with longer hospitalizations and lower transplant-free survival to stage 2 palliation.
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Affiliation(s)
- Scott H Wirth
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229.
| | - Haleh C Heydarian
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229
| | - Elisa Marcuccio
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229
| | - Brooke E Tepe
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229
| | - Laurel H Stein
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229
| | - Garick D Hill
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229
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24
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Commentary: Palliation Pitstop. J Thorac Cardiovasc Surg 2022; 164:1304-1305. [DOI: 10.1016/j.jtcvs.2022.01.009] [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: 01/04/2022] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 11/17/2022]
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Caring for a Child with Hypoplastic Left Heart Syndrome: Parent and Medical Perspective. Cardiol Ther 2021; 11:9-12. [PMID: 34826115 PMCID: PMC8617359 DOI: 10.1007/s40119-021-00246-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Indexed: 11/30/2022] Open
Abstract
This article, co-authored by parents of a child with hypoplastic left heart syndrome (HLHS) and his pediatric cardiology care team, discusses the parents’ experience of having a child with HLHS from diagnosis through living day-to-day with the heart condition as well as future directions.
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Farias M, Fleishman CE, Nykanen D, DeCampli WM. Clinical update on the hybrid comprehensive stage II operation. JTCVS OPEN 2021; 7:327-335. [PMID: 36003736 PMCID: PMC9390143 DOI: 10.1016/j.xjon.2021.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 11/19/2022]
Abstract
Objective We previously described the hybrid comprehensive stage II operation as an alternate surgical procedure for a subset of patients with single ventricle congenital heart disease with adequate native ascending aortic outflow. Here we provide a clinical update on the 4 patients who have undergone this procedure. Methods After undergoing a hybrid approach to the stage I Norwood palliation, the hybrid comprehensive stage II procedure was performed with an incision to the main pulmonary artery (PA), dilation of the ductal stent, creation of a stented baffle between the branch PAs, and a bidirectional Glenn connection. With this approach, dissection of the distal arch and creation of a Damus-Kaye-Stansel anastomosis was avoided. A standard Fontan procedure was planned after the usual period of growth. Results The first patient, who had trisomy 21 and elevated PA pressures, died postoperatively due to left PA thrombosis. The subsequent 3 patients survived the procedure and remain clinically well. All have required catheterizations for reintervention on their stented intrapulmonary baffles and ductal arches, and all have undergone successful completion of their Fontan procedures. Conclusions The hybrid comprehensive stage II is a feasible, less complex alternative to the conventional comprehensive stage II operation in a subset of patients with single ventricle physiology. Early postoperative anticoagulation therapy to avoid PA thrombosis is recommended, and restenting of the ductal arch is anticipated. Although the long-term consequences of separate outflow tracts supplying the upper and lower body is unknown, the 3 surviving patients with this circulation are doing well with their Fontan circulation at midterm follow-up.
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Affiliation(s)
| | | | | | - William M. DeCampli
- Address for reprints: William M. DeCampli, MD, PhD, The Heart Center, Arnold Palmer Hospital for Children, 92 W Miller St, MP 307, Orlando, FL 32806.
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Gasparini M, Cox N. Role of cardiac magnetic resonance strain analysis in patients with hypoplastic left heart syndrome in evaluating right ventricular (dys)function: a systematic review. Eur J Cardiothorac Surg 2021; 60:497-505. [PMID: 34331061 DOI: 10.1093/ejcts/ezab105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 12/08/2020] [Accepted: 01/07/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Right ventricular dysfunction predicts death in patients with hypoplastic left heart syndrome (HLHS), but differences in morphology and loading conditions make calculation of the ejection fraction (EF), a challenging measure of its function. Our goal was to evaluate how strain measurements with cardiac magnetic resonance feature tracking could be used to evaluate right ventricular function in patients with HLHS. METHODS A systematic search of the literature was performed by 2 independent researchers using the terms 'population', 'intervention', 'comparison', 'outcome' and 'time criteria'. PubMed and the Ovid database were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS Our review included 8 studies with 608 participants with ventricular strain values obtained using cardiac magnetic resonance feature tracking. After stage I palliation, global strain was reduced in patients after a hybrid procedure and a right ventricle-to-pulmonary artery conduit compared with a modified Blalock-Taussig shunt despite similar EFs. Global longitudinal strain did not differ between stage II and stage III (Fontan) palliation. Fontan patients had significantly impaired global longitudinal and circumferential strain compared to the left ventricular strain of the controls. Studies of Fontan patients that included patients with HLHS who were part of a cohort with a single right ventricle showed impaired global circumferential strain compared with the cohort with a single left ventricle, with controls, and over time. In this group, impaired global circumferential strain was associated with major adverse cardiac events. CONCLUSIONS Cardiac magnetic resonance feature tracking can be used in patients with HLHS to evaluate RV strain and demonstrate differences between surgical strategies, over time and compared with controls. It could be used alongside clinical symptoms and EF values to detect ventricular dysfunction.
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Affiliation(s)
- Marisa Gasparini
- Department of Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Natasha Cox
- Department of Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Wilder TJ, Caldarone CA. Apples to oranges: Making sense of hybrid palliation for hypoplastic left heart syndrome. JTCVS OPEN 2020; 4:47-54. [PMID: 36004289 PMCID: PMC9390685 DOI: 10.1016/j.xjon.2020.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 10/06/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Travis J. Wilder
- Address for reprints: Travis J. Wilder, MD, Legacy Tower, Floor 19, 6651 Main St, Mail Code 19345H, Houston, TX 77030.
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Zajonz T, Cupka P, Koerner C, Mann V, Menges T, Akintuerk H, Valeske K, Thul J, Schranz D, Mueller M. Anesthesia for bilateral pulmonary banding as part of hybrid stage I approach palliating neonates with hypoplastic left heart syndrome. Paediatr Anaesth 2020; 30:691-697. [PMID: 32291873 DOI: 10.1111/pan.13876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 03/11/2020] [Accepted: 04/05/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Neonatal management of patients with hypoplastic left heart syndrome and complex remains a challenging task, whereby the "hybrid" palliation is often reserved for high-risk patients as a "rescue" procedure. AIM This study documents the anesthetic challenges and potential complications associated with the Giessen hybrid stage I approach. METHODS The Giessen hybrid stage I approach is focused on surgical bilateral pulmonary artery banding. Retrospective perioperative data were analyzed. Contrary to a stable group A, inotropic treatment before surgery for treatment of postnatal shock classified patients as unstable (Group B). Clinical outcomes considered were inhospital mortality, duration of postoperative mechanical ventilation, postoperative time at the intensive care unit, perioperative vasoactive medication requirements, and red blood cell transfusion. RESULTS From June 1998 to December 2015, 185 patients were allocated to Group A (n = 165) and Group B (n = 20). The inhospital mortality was 2.2% with no difference between the groups. There was also no difference in the postoperative time on mechanical ventilation and the time in the intensive care unit. Vasoactive medication was more often required in Group B (100%) compared to Group A (19%). In Group B, more red blood cells were transfused 6.0 ± 8.3 vs 2.0 ± 5.8 mL/kg in Group A (P < .05, 95% CI 0.0 - 2.6). CONCLUSION Considering a learning curve, anesthesia for surgical bilateral pulmonary artery banding palliating patients with hypoplastic left heart syndrome and complex can safely be performed, independent from the preoperative clinical status.
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Affiliation(s)
- Thomas Zajonz
- Paediatric Cardiac Anesthesiology Service, Pediatric Heart Centre, Department of Anaesthesiology Intensive Care Medicine, Pain Therapy, University Hospital Giessen and Marburg GmbH, Giessen, Germany
| | - Pavol Cupka
- Paediatric Cardiac Anesthesiology Service, Pediatric Heart Centre, Department of Anaesthesiology Intensive Care Medicine, Pain Therapy, University Hospital Giessen and Marburg GmbH, Giessen, Germany
| | - Christian Koerner
- Paediatric Cardiac Anesthesiology Service, Pediatric Heart Centre, Department of Anaesthesiology Intensive Care Medicine, Pain Therapy, University Hospital Giessen and Marburg GmbH, Giessen, Germany
| | - Valesco Mann
- Paediatric Cardiac Anesthesiology Service, Pediatric Heart Centre, Department of Anaesthesiology Intensive Care Medicine, Pain Therapy, University Hospital Giessen and Marburg GmbH, Giessen, Germany
| | - Thilo Menges
- Paediatric Cardiac Anesthesiology Service, Pediatric Heart Centre, Department of Anaesthesiology Intensive Care Medicine, Pain Therapy, University Hospital Giessen and Marburg GmbH, Giessen, Germany
| | - Hakan Akintuerk
- Department of Pediatric and Congenital Heart Surgery, Pediatric Heart Centre, University Hospital Giessen and Marburg GmbH, Giessen, Germany
| | - Klaus Valeske
- Department of Pediatric and Congenital Heart Surgery, Pediatric Heart Centre, University Hospital Giessen and Marburg GmbH, Giessen, Germany
| | - Josef Thul
- Department of Pediatric Cardiology, Pediatric Heart Centre, University Hospital Giessen and Marburg GmbH, Giessen, Germany
| | - Dietmar Schranz
- Department of Pediatric Cardiology, Pediatric Heart Centre, University Hospital Giessen and Marburg GmbH, Giessen, Germany
| | - Matthias Mueller
- Paediatric Cardiac Anesthesiology Service, Pediatric Heart Centre, Department of Anaesthesiology Intensive Care Medicine, Pain Therapy, University Hospital Giessen and Marburg GmbH, Giessen, Germany
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Outcomes of hybrid and Norwood Stage I procedures for the treatment of hypoplastic left heart syndrome and its variants. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 28:282-293. [PMID: 32551158 DOI: 10.5606/tgkdc.dergisi.2020.18605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 01/05/2020] [Indexed: 02/06/2023]
Abstract
Background In this study, we present the outcomes of hybrid and Norwood Stage I procedures for the treatment of hypoplastic left heart syndrome and its variants. Methods In this study, a total of 97 pediatric patients who were operated due to hypoplastic left heart syndrome and its variants between March 2011 and October 2018 were retrospectively analyzed. Thirty-two of the patients (28 males, 4 females; median age 5 days; range, 1 to 25 days) underwent Norwood Stage I operation (Group N), while the remaining 65 patients (44 males, 21 females; median age 6 days; range, 1 to 55 days) underwent a hybrid procedure (Group H). Both treatment strategies were compared. Results The median body weight in Group H was significantly lower and the number of patients with a low birth weight (<2,500 g) was significantly higher than Group N (p=0.002 and 0.004, respectively). The postoperative early mortality rate was similar between the groups. Univariate and multivariate analyses revealed that the need for preoperative mechanical ventilation was a significant factor for mortality (p=0.004 and 0.003, respectively). Syndromic appearance was also a significant factor the multivariate analysis (p=0.03). There was a statistically significant difference between the groups in terms of the inter-stage mortality rates (p=0.0045). Second-stage procedure was performed in 32 patients. The early mortality rate after the Glenn operation was 7.6%. Six patients died after comprehensive Stage II operation. Five patients underwent biventricular repair and 8 patients had third-stage fenestrated extracardiac Fontan operation (Group N, n=7 and Group H, n=1). The Kaplan-Meier survival curve demonstrated that Group N had a higher survival rate at both one and five years than Group H, although the difference was not statistically significant (p=0.15). Subgroup analysis showed that the Norwood procedure with Sano modification had the highest survival rate with 40% at five years. Conclusion Our study results show that patients undergoing the Norwood procedure have a more uneventful course of inter-stage period and Stage II and III, despite drawbacks early after Stage I procedure. Based on our experiences, we recommend performing the hybrid intervention in patients with a poor clinical condition and a body weight of <2,500 g.
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Iacobelli R, Ricci Z, Marinari E, Haiberger R, Di Molfetta A, Toscano A, Di Chiara L. Effects of levosimendan on ventriculo-arterial coupling and cardiac efficiency in paediatric patients with single-ventricle physiology after surgical palliation: retrospective study. Interact Cardiovasc Thorac Surg 2020; 30:623-629. [PMID: 31986196 DOI: 10.1093/icvts/ivz319] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/12/2019] [Accepted: 12/19/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
The use of levosimendan for paediatric patients with low cardiac output after congenital heart surgery has been recently described. We sought to evaluate ventriculo-arterial coupling (VAC) and other ventricular energetic parameters before and after 72 h from levosimendan start in infants with single-ventricle physiology and cardiac failure after palliation with Norwood or hybrid procedures.
METHODS
In this single-centre retrospective study, 9 consecutive patients affected by hypoplastic left heart syndrome-like anatomy were retrospectively analysed. Systolic elastance, diastolic elastance, arterial elastance, VAC and cardiac mechanical efficiency were calculated by measuring, through 2-dimensional echocardiography, end-systolic volume and end-diastolic volume and by recording mean arterial pressure and central venous pressure.
RESULTS
The median (range) weight and age were 2.8 (2.3–6) kg and 16.5 (6–116) days, respectively. After 72 h from levosimendan start, end-systolic volume significantly decreased (−1 ml, −3.2 to −0.1, P = 0.007), whereas mean arterial pressure and end-diastolic volume remained stable. Heart rate showed a significant decrease (−28 beats/min, −41 to 22, P = 0.008). Systolic elastance (2.9 mmHg/ml, 0.4–5.4, P = 0.008), arterial elastance (−5.9, −24 to −0.5, P = 0.038), VAC (−0.86, −1.5 to −0.16, P = 0.009) and cardiac mechanical efficiency (0.18, 0.03–0.22, P = 0.008) differences also showed significant modifications.
CONCLUSIONS
In a small case series of patients with single-ventricle physiology, levosimendan showed to improve contractility and optimize VAC, with a reduction of heart rate. Monitoring of VAC and ventricular energetics can be an interesting aspect to improve the management of heart failure in infants with univentricular anatomy.
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Affiliation(s)
- Roberta Iacobelli
- Pediatric Cardiology Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Zaccaria Ricci
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Eleonora Marinari
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Roberta Haiberger
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Arianna Di Molfetta
- Department of Cardiac Surgery, Policlinico Universitario A. Gemelli, Rome, Italy
| | - Alessandra Toscano
- Pediatric Cardiology Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Luca Di Chiara
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy
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Valdeomillos E, Jalal Z, Boudjemline Y, Thambo JB. Transcatheter ductus arteriosus stenting in paediatric cardiology: Indications, results and perspectives. Arch Cardiovasc Dis 2019; 113:129-141. [PMID: 31753586 DOI: 10.1016/j.acvd.2019.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/27/2019] [Accepted: 10/02/2019] [Indexed: 12/17/2022]
Abstract
Stenting the arterial duct emerged in the early 1990s as an alternative to a variety of surgical interventions in neonates with a duct-dependent pulmonary or systemic circulation complex defect. Furthermore, palliative ductal stenting has been applied in older children with severe suprasystemic pulmonary arterial hypertension, as an alternative to surgical shunts, such as Potts anastomosis. Early results of this technique were discouraging, but by learning from the failures of the past, ductal stenting has become a reliable palliative therapy. In this review, we aim to describe the historical evolution of ductal stenting, its different clinical applications and outcomes, and future perspectives for this strategy in congenital cardiac catheterization.
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Affiliation(s)
- Estibaliz Valdeomillos
- Department of Paediatric and Adult Congenital Cardiology, Bordeaux University Hospital (CHU), avenue Magellan, 33600 Pessac, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, fondation Bordeaux université, 33600 Pessac, France; U1045, Inserm, centre de recherche cardio-thoracique de Bordeaux, 33000 Bordeaux, France.
| | - Zakaria Jalal
- Department of Paediatric and Adult Congenital Cardiology, Bordeaux University Hospital (CHU), avenue Magellan, 33600 Pessac, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, fondation Bordeaux université, 33600 Pessac, France; U1045, Inserm, centre de recherche cardio-thoracique de Bordeaux, 33000 Bordeaux, France
| | | | - Jean-Benoit Thambo
- Department of Paediatric and Adult Congenital Cardiology, Bordeaux University Hospital (CHU), avenue Magellan, 33600 Pessac, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, fondation Bordeaux université, 33600 Pessac, France; U1045, Inserm, centre de recherche cardio-thoracique de Bordeaux, 33000 Bordeaux, France
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- Department of Paediatric and Adult Congenital Cardiology, Bordeaux University Hospital (CHU), avenue Magellan, 33600 Pessac, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, fondation Bordeaux université, 33600 Pessac, France; U1045, Inserm, centre de recherche cardio-thoracique de Bordeaux, 33000 Bordeaux, France; Heart Center, Sidra Medicine, Doha, Qatar
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Bautista-Hernandez V, Avila-Alvarez A, Marx GR, Del Nido PJ. [Current surgical options and outcomes for newborns with hypoplastic left heart syndrome]. An Pediatr (Barc) 2019; 91:352.e1-352.e9. [PMID: 31694800 DOI: 10.1016/j.anpedi.2019.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 09/09/2019] [Indexed: 02/02/2023] Open
Abstract
Since the first successful palliation was performed by Norwood et al. in 1983, there have been substantial changes in diagnosis, management, and outcomes of hypoplastic left heart syndrome, Survival for stage 1 palliation has increased to 90% in many centres, with patients potentially surviving into adulthood. However, the associated morbidity and mortality remain substantial. Although the principles of staged surgical palliation of hypoplastic left heart syndrome are well established, there is significant variability in surgical procedure and management between centres, and several controversial aspects remain unresolved. In this review, we summarize the current surgical and management options for newborns with hypoplastic left heart syndrome and their outcomes.
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Affiliation(s)
- Victor Bautista-Hernandez
- Servicio de Cirugía Cardiovascular, Complexo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, España; Cardiopatía Estructural y Congénita, Instituto de Investigación Biomédica A Coruña (INIBIC), A Coruña, España.
| | - Alejandro Avila-Alvarez
- Cardiopatía Estructural y Congénita, Instituto de Investigación Biomédica A Coruña (INIBIC), A Coruña, España; Unidad de Neonatología, Servicio de Pediatría, Complexo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, España
| | - Gerald R Marx
- Servicio de Cardiología, Boston Children'S Hospital/Harvard Medical School, Boston, Estados Unidos
| | - Pedro J Del Nido
- Servicio de Cirugía Cardíaca, Boston Children's Hospital/Harvard Medical School, Boston, Estados Unidos
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Current surgical options and outcomes for newborns with hypoplastic left heart syndrome. An Pediatr (Barc) 2019. [DOI: 10.1016/j.anpede.2019.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Kavarana MN. Commentary: Difficulty Weaning From Bypass Following a Norwood Procedure: Revise or Support? Semin Thorac Cardiovasc Surg 2019; 32:126-127. [PMID: 31628996 DOI: 10.1053/j.semtcvs.2019.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 10/09/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Minoo N Kavarana
- Section of Pediatric Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina.
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Early and Midterm Outcomes in High-risk Single-ventricle Patients: Hybrid Vs Norwood Palliation. Ann Thorac Surg 2019; 108:1849-1855. [PMID: 31404546 DOI: 10.1016/j.athoracsur.2019.06.061] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/05/2019] [Accepted: 06/17/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Although overall outcomes have improved for single-ventricle patients, substantial morbidity and mortality remain for certain high-risk groups. The hybrid stage I procedure is an alternative to the Norwood operation for stage I palliation, but it remains unclear whether it is associated with improved outcomes in high-risk patients. METHODS This single-center, nested, case-control study included high-risk patients with a systemic right ventricle who underwent hybrid stage I or Norwood palliation from January 2000 to December 2016. High-risk features included prematurity < 34 weeks, birth weight < 2.5 kg, restrictive/intact atrial septum, at least moderate atrioventricular valve regurgitation or right ventricular dysfunction, genetic or extracardiac anomalies, or left ventricular sinusoids. Patients were matched by presence of genetic anomaly, restrictive/intact atrial septum, and prematurity/weight < 2 kg. Early and midterm outcomes were compared in the matched hybrid vs Norwood groups. RESULTS The study included 96 patients (35 hybrid, 61 Norwood). Despite improved 30-day survival in hybrid patients (91% vs 66%, P < .01), 1-year survival was similar between the hybrid and Norwood groups (46% vs 48%, P = .9). No hybrid patients required dialysis or extracorporeal membrane oxygenation after stage I palliation as compared with 19% and 22% of Norwood patients, respectively (both P < .01). Hybrid patients, however, required more unplanned reinterventions (43% vs 21%, P = .02). CONCLUSIONS There remains significant morbidity and mortality among high-risk single-ventricle infants. Despite an early survival benefit, hybrid stage I palliation has not been associated with improved midterm outcomes at our center.
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John MM, Razzouk AJ, Chinnock RE, Bock MJ, Kuhn MA, Martens TP, Bailey LL. Primary Transplantation for Congenital Heart Disease in the Neonatal Period: Long-term Outcomes. Ann Thorac Surg 2019; 108:1857-1864. [PMID: 31362016 DOI: 10.1016/j.athoracsur.2019.06.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 05/29/2019] [Accepted: 06/03/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Primary transplantation was developed in the 1980s as an alternative therapy to palliative reconstruction of uncorrectable congenital heart disease. Although transplantation achieved more favorable results, its utilization has been limited by the availability of donor organs. This review examines the long-term outcomes of heart transplantation in neonates at our institution. METHODS The institutional pediatric heart transplant database was queried for all neonatal heart transplants performed between 1985 and 2017. Follow-up was obtained from medical records and an annually administered questionnaire. Overall survival and time to development of complications were estimated using the Kaplan Meier method. Univariate and multivariate analyses were performed to identify independent predictors of survival. RESULTS Heart transplantation was performed in 104 neonates. Median age was 17 days. Hypoplastic left heart syndrome (classic or variant) was the primary diagnosis in 77.8% of patients. Survival at 10 years and 25 years was 73.9% and 55.8%, respectively. At 20 years, freedom from allograft vasculopathy and lymphoproliferative disease was 72.0% and 81.9%, respectively. Freedom from re-transplantation was 81.4% at 20 years. Eight patients (7.6%) developed end-stage renal disease. By multivariate analysis, lower glomerular filtration rate and allograft vasculopathy were the only significant predictors of death. CONCLUSIONS Neonatal heart transplantation remains a durable therapy with very acceptable long-term survival. Children transplanted in the newborn period have the potential to reach adulthood with minimal need for reintervention.
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Affiliation(s)
- Mohan M John
- Department of Cardiothoracic Surgery, Loma Linda University, Loma Linda, California
| | - Anees J Razzouk
- Department of Cardiothoracic Surgery, Loma Linda University, Loma Linda, California.
| | | | - Matthew J Bock
- Department of Pediatrics, Loma Linda University, Loma Linda, California
| | - Michael A Kuhn
- Department of Pediatrics, Loma Linda University, Loma Linda, California
| | - Timothy P Martens
- Department of Cardiothoracic Surgery, Loma Linda University, Loma Linda, California
| | - Leonard L Bailey
- Department of Cardiothoracic Surgery, Loma Linda University, Loma Linda, California
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Sweeney DM, Arcadi J. Stage 1 Palliation of Hypoplastic Left Heart Syndrome: What the Pediatric Anesthesiologist Needs to Know. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00329-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Daaboul DG, DiNardo JA, Nasr VG. Anesthesia for high-risk procedures in the catheterization laboratory. Paediatr Anaesth 2019; 29:491-498. [PMID: 30592354 DOI: 10.1111/pan.13571] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 12/18/2018] [Accepted: 12/24/2018] [Indexed: 12/17/2022]
Abstract
Recent advances in catheterization and imaging technology allow for more complex procedures to be performed in the catheterization laboratory. A number of lesions are now amenable to a percutaneous procedure, eliminating or at least postponing the need for a surgical intervention. Due to the increase in the complexity of the procedures performed, the involvement of anesthesiologists and their close collaboration with the interventional cardiologists have increased. It is important to understand the physiology and pathophysiology of the patients and to anticipate the plans and the potential complications in order to manage them. We are witnessing a rise in the number of complex interventions in newborns and infants, such as balloon valvotomy (critical aortic stenosis, pulmonary stenosis), radio frequency perforation (of pulmonary atresia and intact ventricular septum), right ventricular outflow tract stenting (in Tetralogy of Fallot), ductal stenting (in some ductus-dependent pulmonary circulation), and combined with a surgical procedure (hybrid procedure for hypoplastic left heart syndrome). Multiple registries have been created in order to understand and improve outcomes of patients with congenital heart disease undergoing catheterization procedures and to develop performance and quality metrics, from which data regarding anesthetic-related risks can be extrapolated. Experienced personnel and a multidisciplinary team approach with direct communication among the team members is a must to ensure anticipation and management of critical events when they occur.
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Affiliation(s)
- Dima G Daaboul
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - James A DiNardo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Mascio CE, Irons ML, Ittenbach RF, Gaynor JW, Fuller SM, Kaplinski M, Kennedy AT, Steven JM, Nicolson SC, Spray TL. Thirty years and 1663 consecutive Norwood procedures: Has survival plateaued? J Thorac Cardiovasc Surg 2019; 158:220-229. [PMID: 31248509 DOI: 10.1016/j.jtcvs.2018.12.117] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 11/26/2018] [Accepted: 12/27/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Hypoplastic left heart syndrome is one of the most common and challenging lesions requiring surgical intervention in the neonatal period. The Norwood procedure for hypoplastic left heart syndrome was first reported in 1983. The objective of this study was to describe early outcomes after the Norwood procedure at a single institution over 30 years. METHODS This retrospective cohort study included all patients with hypoplastic left heart syndrome (and variants) who underwent the Norwood procedure between January 1984 and May 2014 at a single institution. The study period was divided into 6 eras: era 1, 1984 to 1988; era 2, 1989 to 1993; era 3, 1994 to 1998; era 4, 1999 to 2003; era 5, 2004 to 2008; and era 6, 2009 to 2014. The primary outcome was in-hospital mortality after the Norwood procedure. Binomial point estimates complete with 95% confidence intervals (CL0.95) were computed for the entire cohort and by era. RESULTS During the study period, 1663 infants underwent the Norwood procedure. Overall in-hospital mortality was 25.9% (CL0.95, 23.8-28.0). Mortality by chronologic era was 40.4% (CL0.95, 34.9-45.9), 33.6% (CL0.95, 29.2-37.9), 28.7% (CL0.95, 22.8-34.6), 14.9% (CL0.95, 10.4-19.3), 11.2% (CL0.95, 7.4-15.0), and 15.7% (CL0.95, 10.3-21.1). Survival was improved in eras 4 to 6 compared with eras 1 to 3 (P all < .03). Anomalous pulmonary drainage, moderate to severe atrioventricular valve regurgitation, lower birth weight, earlier era, younger gestational age, genetic anomaly, preterm birth, race other than white or African-American, and lower weight at the Norwood procedure were associated with increased mortality. Mortality was greatest in patients with 3 or more risk factors. In the best-fitting multiple covariate model, anomalous pulmonary venous drainage, gestational age in weeks, genetic anomaly, and race other than white and African American were statistically significant contributors, after adjusting for era. CONCLUSIONS Survival after the Norwood procedure has plateaued despite improvements in diagnosis, perioperative care, and surgical techniques. Nonmodifiable patient characteristics are important determinants of the risk of mortality.
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Affiliation(s)
- Christopher E Mascio
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa.
| | - Mallory L Irons
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Richard F Ittenbach
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Stephanie M Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Michelle Kaplinski
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Andrea T Kennedy
- Clinical Data Analytics, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - James M Steven
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
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Cleveland D, Adam Banks C, Hara H, Carlo WF, Mauchley DC, Cooper DKC. The Case for Cardiac Xenotransplantation in Neonates: Is Now the Time to Reconsider Xenotransplantation for Hypoplastic Left Heart Syndrome? Pediatr Cardiol 2019; 40:437-444. [PMID: 30302505 DOI: 10.1007/s00246-018-1998-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 09/28/2018] [Indexed: 01/06/2023]
Abstract
Neonatal cardiac transplantation for hypoplastic left heart syndrome (HLHS) is associated with excellent long-term survival compared to older recipients. However, heart transplantation for neonates is greatly limited by the critical shortage of donor hearts, and by the associated mortality of the long pre-transplant waiting period. This led to the development of staged surgical palliation as the first-line surgical therapy for HLHS. Recent advances in genetic engineering and xenotransplantation have provided the potential to replicate the excellent results of neonatal cardiac allotransplantation while eliminating wait-list-associated mortality through genetically modified pig-to-human neonatal cardiac xenotransplantation. The elimination of the major pig antigens in addition to the immature B-cell response in neonates allows for the potential to induce B-cell tolerance. Additionally, the relatively mature neonatal T-cell response could be reduced by thymectomy at the time of operation combined with donor-specific pig thymus transplantation to "reprogram" the host's T-cells to recognize the xenograft as host tissue. In light of the recent significantly increased graft survival of genetically-engineered pig-to-baboon cardiac xenotransplantation, we propose that now is the time to consider devoting research to advance the potential clinical application of cardiac xenotransplantation as a treatment option for patients with HLHS. Employing cardiac xenotransplantation could revolutionize therapy for complex congenital heart defects and open a new chapter in the field of pediatric cardiac transplantation.
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Affiliation(s)
- David Cleveland
- Division of Pediatric Cardiovascular Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - C Adam Banks
- Division of Pediatric Cardiovascular Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hidetaka Hara
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Waldemar F Carlo
- Section of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David C Mauchley
- Division of Pediatric Cardiovascular Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David K C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Mavroudis C, Kirklin JK, DeCampli WM. Incremental History of the Congenital Heart Surgeons’ Society (2014-2018). World J Pediatr Congenit Heart Surg 2018; 9:668-676. [DOI: 10.1177/2150135118800305] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The history of the first 41 years of the Congenital Heart Surgeons Society (CHSS) was recorded in 2015 which chronicled the metamorphosis of a small informal meeting into a mature organization with bylaws, officers, committees, funded research, the Kirklin-Ashburn Fellowship, and a vision to become the premier organization of congenital heart surgery in North America. Chief among these transformations was the implementation and development of the CHSS Data Center. Member participation, fellowship education, and significant outcomes research have been the hallmark of the CHSS. This incremental historical review highlights continued CHSS sentinel advances. Fifty-three CHSS Data Center manuscripts have been published. Citation scores (number of literature citations that each manuscript has accrued) have been collated and analyzed by cohort study. The average citation score for all manuscripts was 75.4 ± 76.3 (range: 1-333). The Kirklin/Ashburn Fellowship continues to thrive with academic achievements and generous contributions to the endowment. The World Journal of Pediatric and Congenital Heart Surgery has been adopted as the official organ of the CHSS. A Past President’s Dinner has been inaugurated serving as a senior advisory committee to the Executive Council. Toronto Work Weekends continue. Congenital Heart Surgeons Society growth has accrued to 159 active members and 82 institutional members. Future considerations include the size, content, and duration of the annual meeting; the potential for increased membership; and political penetrance into national cardiothoracic governing organizations regarding committee appointments, executive council representation, and education initiatives. Congenital Heart Surgeons Society has achieved numerous advances during this incremental period.
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Affiliation(s)
- Constantine Mavroudis
- Johns Hopkins University School of Medicine, Florida Hospital for Children, Orlando, FL, USA
| | - James K. Kirklin
- Department of Surgery, University of Alabama, Birmingham, AL, USA
| | - William M. DeCampli
- Congenital Heart Surgery, Arnold Palmer Children’s Hospital, Orlando, FL, USA
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Yörüker U, Akintürk H. Giessen Procedure as Comprehensive Stage II Palliation With Aortic Arch Reconstruction After Hybrid Bilateral Pulmonary Artery Banding and Ductal Stenting for Hypoplastic Left Heart Syndrome. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2018; 21:19-27. [PMID: 29425520 DOI: 10.1053/j.pcsu.2017.11.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 11/08/2017] [Indexed: 11/11/2022]
Abstract
This article reviews our experience using hybrid stage I palliation in the neonatal period and subsequently with comprehensive stage II palliation for hypoplastic left heart syndrome. Between June 1998 and April 2017, 154 patients with the diagnosis of hypoplastic left heart syndrome and variants underwent a hybrid stage I palliation (bilateral pulmonary artery banding and ductal stenting). One hundred thirty-nine patients could be further univentricularly palliated. One hundred twenty-one patients underwent a comprehensive stage II operation with an operative mortality of 6.6%. The hybrid procedure provides reproducible results with reduced in-hospital, interstage, and long-term mortality and lower rates of aortic arch reinterventions.
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Affiliation(s)
- Uygar Yörüker
- Department of Pediatric Cardiac Surgery, Pediatric Heart Center, Justus Liebig University, Giessen, Germany
| | - Hakan Akintürk
- Department of Pediatric Cardiac Surgery, Pediatric Heart Center, Justus Liebig University, Giessen, Germany..
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45
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Cao JY, Lee SY, Phan K, Ayer J, Celermajer DS, Winlaw DS. Early Outcomes of Hypoplastic Left Heart Syndrome Infants: Meta-Analysis of Studies Comparing the Hybrid and Norwood Procedures. World J Pediatr Congenit Heart Surg 2018; 9:224-233. [PMID: 29544421 DOI: 10.1177/2150135117752896] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The hybrid strategy is an alternative to the traditional Norwood procedure for initial palliation of infants with hypoplastic left heart syndrome (HLHS) who are deemed to be at high surgical risk. Numerous single-center studies have compared the two procedures, showing similar early outcomes, although the cohort sizes are likely insufficiently powered to detect significant differences. The current meta-analysis aims to explore the early morbidity and mortality associated with the hybrid compared to the Norwood procedure. MEDLINE, Cochrane Libraries, and Embase were systematically searched, and 14 studies were included for statistical synthesis, comprising 263 hybrid and 426 Norwood patients. Early mortality was significantly higher in the hybrid patients (relative risk [RR] = 1.54, P < .05, 95% confidence interval [CI]: 1.02-2.34), whereas interstage mortality was comparable between the two groups (RR = 0.88, P > .05, 95% CI: 0.46-1.70). Six-month (RR = 0.89, P < .05, 95% CI: 0.80-1.00) and one-year (RR = 0.88, P < .05, 95% CI: 0.78-1.00) transplant-free survival was also inferior among the hybrid patients. Furthermore, the hybrid patients required more reinterventions following initial surgical palliation (RR = 1.48, P < .05, 95% CI: 1.09-2.01), although the two groups had comparable length of hospital and intensive care unit stay postoperatively. In conclusion, our results suggest that the hybrid procedure is associated with worse early survival compared to the traditional Norwood when used for initial palliation of infants with HLHS. However, due to the hybrid being used preferentially for high-risk patients, definitive conclusions regarding the efficacy of the procedure cannot be drawn.
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Affiliation(s)
- Jacob Y Cao
- 1 Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Seung Yeon Lee
- 1 Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Kevin Phan
- 1 Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,2 NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Julian Ayer
- 1 Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,3 Heart Centre for Children, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - David S Celermajer
- 1 Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,4 Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - David S Winlaw
- 1 Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,3 Heart Centre for Children, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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Haller C, Caldarone CA. The Evolution of Therapeutic Strategies: Niche Apportionment for Hybrid Palliation. Ann Thorac Surg 2018; 106:1873-1880. [PMID: 29913126 DOI: 10.1016/j.athoracsur.2018.05.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/14/2018] [Accepted: 05/16/2018] [Indexed: 01/21/2023]
Abstract
Hybrid palliation, the concept to stabilize univentricular circulation with bilateral pulmonary artery banding and maintenance of ductal patency, has significantly widened the therapeutic spectrum for patients with single-ventricle malformations or borderline hypoplasia. The concept has already been a part of early attempts to improve outcome in hypoplastic left heart syndrome but has not attracted much attention initially. Technical refinement and expertise have led to results that ultimately allowed the palliative strategy to gain traction and to be selectively adopted. By now, we have gained almost 2 decades of experience, and as much as hybrid palliation has changed our approach to single-ventricle management, new strategies and indications have been formed by this experience. We therefore review concepts and patterns of use of hybrid palliation as well as benefits and challenges of the respective pathways to highlight the current status of the hybrid procedure.
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Affiliation(s)
- Christoph Haller
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| | - Christopher A Caldarone
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Kido T, Hoashi T, Kitano M, Shimada M, Kurosaki K, Ishibashi-Ueda H, Ichikawa H. Impact of Hybrid Stage 1 Palliation for Hypoplastic Left Heart Syndrome: Histopathological Findings. Pediatr Cardiol 2018. [PMID: 29523921 DOI: 10.1007/s00246-018-1851-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The purpose of the study is to analyze the impact of hybrid stage 1 palliation on right ventricular myocardial pathology in hypoplastic left heart syndrome. Sufficient amount of right ventricular biopsies could be obtained from 16 of 32 patients who underwent Norwood operation between 2007 and 2013. Histopathological findings of right ventricle in patients who underwent primary Norwood operation (primary group, n = 5), patients with aortic atresia (HS1P AA group, n = 6) or aortic stenosis (HS1P AS group, n = 5) who underwent staged Norwood palliation following hybrid stage 1 palliation were compared. To eliminate the influence of right ventricular pressure afterload, right ventricular biopsies were obtained from patients with truncus arteriosus communis (TAC group, n = 6) at total correction. The percentage of myocardial fibrosis was significantly higher in both HS1P groups than in TAC group; moreover, it was significantly higher in HS1P AA group than in primary group. Capillary vascular density was significantly lower in all hypoplastic left heart syndrome groups than in TAC group. At the sub-endocardial layer, collagen type I/III ratios were higher in HS1P AA group than in other hypoplastic left heart syndrome groups. The proportions of N-cadherin immunolocalized to myocyte termini were lower in all hypoplastic left heart syndrome groups than in TAC group. Right ventricle in hypoplastic left heart syndrome showed more significant ischemic change and myocardial immaturity than that in truncus arteriosus communis. Hybrid stage 1 palliation for aortic atresia would be a risk factor for further right ventricular myocardial ischemia.
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Affiliation(s)
- Takashi Kido
- Department of Pediatric Cardiovascular Surgery, National Cardiovascular and Cerebral Center, 5-7-1, Fujishiro-dai, Suita, Osaka, 565-8565, Japan
| | - Takaya Hoashi
- Department of Pediatric Cardiovascular Surgery, National Cardiovascular and Cerebral Center, 5-7-1, Fujishiro-dai, Suita, Osaka, 565-8565, Japan.
| | - Masataka Kitano
- Department of Pediatric Cardiology, National Cardiovascular and Cerebral Center, 5-7-1, Fujishiro-dai, Suita, Osaka, 565-8565, Japan
| | - Masatoshi Shimada
- Department of Pediatric Cardiovascular Surgery, National Cardiovascular and Cerebral Center, 5-7-1, Fujishiro-dai, Suita, Osaka, 565-8565, Japan
| | - Kenichi Kurosaki
- Department of Pediatric Cardiology, National Cardiovascular and Cerebral Center, 5-7-1, Fujishiro-dai, Suita, Osaka, 565-8565, Japan
| | - Hatsue Ishibashi-Ueda
- Department of Pathology, National Cardiovascular and Cerebral Center, 5-7-1, Fujishiro-dai, Suita, Osaka, 565-8565, Japan
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cardiovascular and Cerebral Center, 5-7-1, Fujishiro-dai, Suita, Osaka, 565-8565, Japan
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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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Wilder TJ. Redefining Successful Outcomes in the Hybrid Era. World J Pediatr Congenit Heart Surg 2018; 9:234-235. [PMID: 29544425 DOI: 10.1177/2150135118761029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Travis J Wilder
- 1 Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT, USA
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Abstract
PURPOSE OF REVIEW The past couple of decades have brought tremendous advances to the field of pediatric and adult congenital cardiology. Recent collaborations between interventional cardiologists and cardiac surgeons have sparked novel innovative hybrid procedures that provide potentially safer, faster, and less invasive alternatives to the management of many diseases. This paper will review the most recent advances in hybrid interventions in the field of pediatric and adult congenital cardiology. RECENT FINDINGS The earliest experiences with hybrid interventions included intraoperative stenting of pulmonary arteries and perventricular device closure of ventricular septal defects. Newer hybrid interventions have focused on a hybrid approach to stage 1 palliation for infants with hypoplastic left heart syndrome and hybrid approaches to transcatheter pulmonary valve replacement in patients of all ages. Hybrid approaches to complex congenital heart disease are important in the management of congenital heart disease offering a less invasive approach, and novel hybrid procedures will likely be a focus of future research in this field.
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Affiliation(s)
- David W Bearl
- Division of Pediatric Cardiology, Duke University Hospital, 2301 Erwin Rd, Box 3090, Durham, NC, 27710, USA
| | - Gregory A Fleming
- Division of Pediatric Cardiology, Duke University Hospital, 2301 Erwin Rd, Box 3090, Durham, NC, 27710, USA.
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