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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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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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Jean-St-Michel E, Meza JM, Maguire J, Coles J, McCrindle BW. Survival to Stage II with Ventricular Dysfunction: Secondary Analysis of the Single Ventricle Reconstruction Trial. Pediatr Cardiol 2018. [PMID: 29520465 DOI: 10.1007/s00246-018-1845-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Ventricular dysfunction affects survival in patients with single right ventricle (RV), and remains one of the primary indications for heart transplantation. Since it is challenging to predict the capacity of patients with ventricular dysfunction to proceed to the stage II procedure, we sought to identify factors that would be associated with death or heart transplantation without achieving stage II for single RV patients with ventricular dysfunction after Norwood procedure. The Single Ventricle Reconstruction (SVR) trial public-use database was used. Patients with a RV ejection fraction less than 44% or a RV fractional area of change less than 35% on the post-Norwood echocardiogram were included. Parametric risk hazard analysis was used to identify risk factors for death or transplantation without achieving stage II. Of 365 patients with ventricular function measurements on the post-Norwood echocardiogram, 123 (34%) patients had RV dysfunction. The transplantation-free survival was significantly lower for those with ventricular dysfunction compared to those with normal function (log rank Chi-square = 4.23, p = 0.04). Furthermore, having a Blalock-Taussig (BT) shunt, a large RV, a post-Norwood infectious complication, and a surgeon who performs five or less Norwood per year were independent risk factors for death or transplantation without achieving stage II. The predicted 6-month transplantation-free survival for patients with all four identified risk factors was 1% (70% CI 0-13%). Early heart transplantation referral might be considered for post-Norwood patients with BT shunt and RV dysfunction, especially if other high-risk features are present.
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Affiliation(s)
- Emilie Jean-St-Michel
- Division of Cardiology, The Labatt Family Heart Centre, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - James M Meza
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, Department of Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Jonathon Maguire
- Li Ka Shing Knowledge Institute of St. Michael's hospital, Department of Pediatrics, St. Michael's Hospital, University of Toronto, 30 Bond St, Toronto, ON, M5B1W8, Canada
| | - John Coles
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, Department of Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Brian W McCrindle
- Division of Cardiology, The Labatt Family Heart Centre, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
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Wilder TJ, McCrindle BW, Hickey EJ, Ziemer G, Tchervenkov CI, Jacobs ML, Gruber PJ, Blackstone EH, Williams WG, DeCampli WM, Caldarone CA, Pizarro C. Is a hybrid strategy a lower-risk alternative to stage 1 Norwood operation? J Thorac Cardiovasc Surg 2016; 153:163-172.e6. [PMID: 27671550 DOI: 10.1016/j.jtcvs.2016.08.021] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 07/17/2016] [Accepted: 08/06/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND For neonates with critical left ventricular outflow tract obstruction (LVOTO), hybrid procedures are an alternative to the Norwood stage 1 procedure. Despite perceived advantages, however, outcomes are not well defined. Therefore, we compared outcomes after stage 1 hybrid and Norwood procedures. METHODS In a critical LVOTO inception cohort (2005-2014; 20 institutions), a total of 564 neonates underwent stage 1 palliation with the Norwood operation with a modified Blalock-Taussig shunt (NW-BT; n = 232; 41%), Norwood operation with a right ventricle-to-pulmonary artery conduit (NW-RVPA; n = 222; 39%), or a hybrid procedure (n = 110; 20%). Post-stage 1 outcomes were analyzed via competing-risks and parametric hazard analyses and compared among all 564 patients and between patients who underwent propensity-matched hybrid and those who underwent NW-BT/NW-RVPA. RESULTS By 6 years after the stage 1 operation, 50% ± 3%, 7% ± 2%, and 4% ± 1% of patients transitioned to Fontan, transplantation, and biventricular repair, respectively, whereas 7% ± 2% were alive without transition and 32% ± 2% died. Risk factors for death without transition included procedure type, smaller ascending aorta, aortic valve atresia, and lower birth weight. Risk-adjusted 4-year survival was better after NW-RVPA than after NW-BT or hybrid (76% vs 60% vs 61%; P < .001). Furthermore, for neonates with lower birth weight (<∼2 kg), an interaction between birth weight and hybrid resulted in a trend toward better survival after hybrid compared with NW-BT or NW-RVPA. For propensity-matched neonates between hybrid and NW-BT (88 pairs), 4-year survival was similar (62% vs 57%; P = .58). For propensity-matched neonates between hybrid and NW-RVPA (81 pairs), 4-year survival was better after NW-RVPA (59% vs 75%; P = .008). CONCLUSIONS For neonates with critical LVOTO undergoing single-ventricle palliation, NW-RVPA was associated with the best overall survival. Hybrid strategies are not a lower-risk alternative to Norwood operations overall; however, the impact of lower birth weight on survival may be mitigated after hybrid procedures compared with Norwood operations.
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Affiliation(s)
- Travis J Wilder
- Congenital Heart Surgeons' Society Data Center, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Brian W McCrindle
- Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Edward J Hickey
- Department of Cardiovascular Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gerhard Ziemer
- Division of Cardiac and Thoracic Surgery, Department of Surgery, University of Chicago Medicine, Chicago, Ill
| | - Christo I Tchervenkov
- Department of Cardiothoracic Surgery, Montreal Children's Hospital of the McGill University Health Center, Montreal, Quebec, Canada
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Md
| | - Peter J Gruber
- Division of Cardiothoracic Surgery, Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | - William G Williams
- Congenital Heart Surgeons' Society Data Center, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - William M DeCampli
- Department of Cardiothoracic Surgery, Arnold Palmer Hospital for Children, Orlando, Fla
| | - Christopher A Caldarone
- Department of Cardiovascular Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christian Pizarro
- Nemours Cardiac Center, Alfred I. DuPont Hospital for Children, Wilmington, Del
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DeCampli WM, Secasanu V, Argueta-Morales IR, Cox K, Ionan C, Kassab AJ. External counterpulsation of a systemic-to-pulmonary artery shunt increases coronary blood flow in neonatal piglets. World J Pediatr Congenit Heart Surg 2014; 6:75-82. [PMID: 25548347 DOI: 10.1177/2150135114558850] [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: 11/16/2022]
Abstract
BACKGROUND Systemic-to-pulmonary artery shunt (SPS) palliation reduces coronary blood flow (CBF), which may precipitate myocardial ischemia postoperatively. HYPOTHESIS Counterpulsation (CP) of SPS augments CBF. METHODS Seven neonatal piglets (4.3 ± 0.23 kg) underwent sternotomy and ductus ligation. With a 5-mm polytetrafluoroethylene graft, SPS was created from innominate to pulmonary artery. A rigid shell holding a 9.5-mm diameter balloon was placed around the graft for CP. Using electrocardiographic signal, CP was initiated to trigger balloon inflation/deflation during the diastolic/systolic intervals, respectively. Instantaneous proximal and distal pulmonary artery and mid-anterior descending coronary artery flow rates were measured using transit time flow probes. Blood pressure and flow rates were recorded during three states: shunt closed, shunt open, and shunt open with CP. STATISTICAL COMPARISON Friedman's test and repeated measures analysis of variance. RESULTS Diastolic pressure decreased significantly with the shunt open (39 ± 8.4 to 28 ± 4.5 mm Hg, P = .05), then increased with CP (33 ± 2.3 mm Hg, P = .03). Median ratio of pulmonary to systemic flow (Qp/Qs) was 1.19, 1.9, and 1.53 with shunt closed, open, and open with CP, respectively. With CP, both diastolic coronary flow per minute (P = .018) and average diastolic flow rate per diastolic interval (P = .03) increased as well as total coronary flow per minute (P = .066; 19.6% ± 11.7%, 25.2% ± 17.0%, and 15.4% ± 13.9% change from shunt open, respectively). The percentage increase in average diastolic flow rate per diastolic interval correlated strongly with Qp/Qs (R (2) = .838). CONCLUSIONS In this model of SPS, CP increased diastolic blood pressure and CBF while maintaining significant augmentation of pulmonary blood flow (Qp/Qs). Shunt CP may aid in early postoperative management of palliative congenital heart disease.
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Affiliation(s)
- William M DeCampli
- The Heart Center at Arnold Palmer Hospital for Children, Orlando, FL, USA College of Medicine at the University of Central Florida, Orlando, FL, USA College of Engineering and Computer Science, University of Central Florida, Mechanical and Aerospace Engineering, Orlando, FL, USA
| | - Virgil Secasanu
- College of Medicine at the University of Central Florida, Orlando, FL, USA
| | | | - Kelly Cox
- College of Engineering and Computer Science, University of Central Florida, Mechanical and Aerospace Engineering, Orlando, FL, USA
| | - Constantine Ionan
- The Heart Center at Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Alain J Kassab
- College of Engineering and Computer Science, University of Central Florida, Mechanical and Aerospace Engineering, Orlando, FL, USA
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