Introduction to a Norwood program in an emerging economy: learning curve of a single center

Outcomes of Norwood procedure with hypoplastic left heart syndrome: Our 12-year single-center experience

Background

In this study, we aimed to analyze the predictors and risk factors of mortality in patients who underwent Norwood I procedure with the diagnosis of hypoplastic left heart syndrome.

Methods

Between January 2009 and December 2020, a total of 139 patients (95 males, 44 females) who underwent Norwood I procedure with the diagnosis of hypoplastic left heart syndrome in our center were retrospectively analyzed.

Results

The median birth weight was 3,200 (range, 3,000 to 3,350) g and the median age at the time of operation was seven (range, 5 to 10) days. Pulmonary flow was achieved with a Sano shunt in the majority (72%) of patients. Survival rate was 41% after the first stage. Reoperation for bleeding (p=0.017), reoperation for residual lesion (p=0.011), and postoperative peak lactate level (p=0.029), were associated with in-hospital mortality. Nineteen (33%) of 57 patients died before the second stage. Thirty-three (58%) patients underwent second stage, and survival after the second stage was 94%. Thirteen patients underwent third stage, and survival after the third stage was 85%. Estimated probability of survival at six months, and one, two, three, and four years were 33%, 33%, 25%, 25%, and 22% respectively.

Conclusion

Hospital and inter-stage mortality rates are still high and this seems to be the most challenging period in term of survival efforts of the patients with hypoplastic left heart syndrome. Early recognition and reintervention of anatomical residual defects, close follow-up in the inter-stage period, and the accumulation of multidisciplinary experience may help to improve the results to acceptable limits.

A Simple Predictive Factor for Mortality in Fontan Surgery: Serum Hypo-Osmolality

OBJECTIVE

Close follow-up is important after the Fontan procedure, which is a palliative surgical method for a single ventricle. In this period, serum osmolality is an important parameter with the advantages of easy to obtain and poor outcome prediction.

METHODS

Patients who had undergone Fontan operation between May 2011 and February 2017 were retrospectively evaluated. Patients were divided into three groups based on their serum osmolality values: hypoosmolar (Group 1), isosmolar (Group 2), and hyperosmolar (Group 3). Demographics, clinical information and postoperative data of the groups were compared.

RESULTS

Forty-three patients had undergone extracardiac Fontan operation in the study period. There were 8, 19 and 16 patients in Groups 1, 2 and 3, respectively. Among the three groups, postoperative intubation and length of hospital stay, prolonged pleural effusion, need for inotropic support and mortality were statistically significantly higher in Group 1.

CONCLUSION

After the Fontan procedure, one of the determinants of cardiac output might be affected by serum osmolality. Decreased serum osmolality might be associated with poor prognosis after Fontan procedure. Serum osmolality monitoring may be beneficial to improve postoperative outcomes in these patients.

Paediatric and congenital cardiac surgery in emerging economies: surgical 'safari' versus educational programmes

To attract the interest of all people potentially involved in humanitarian activities in the emerging economies, in particular giving attention to the basic requirements of the organization of paediatric cardiac surgery activities, the requirements for a successful partnership with the local existing organizations and the basic elements of a patient-centred multidisciplinary integrated approach. Unfortunately, for many years, the interventions in the low and middle income countries were largely limited to short-term medical missions, not inappropriately nicknamed 'surgical safari', because of negative general and specific characteristics. The negative aspects and the limits of the short-term medical missions can be overcome only by long-term educational programmes. The most suitable and consistent models of long-term educational programmes have been combined and implemented with the personal experience to offer a proposal for a long-term educational project, with the following steps: (i) site selection; (ii) demographic research; (iii) site assessment; (iv) organization of surgical educational teams; (v) regular frequency of surgical educational missions; (vi) programme evolution and maturation; (vii) educational outreach and interactive support. Potential limits of a long-term educational surgical programme are: (i) financial affordability; (ii) basic legal needs; (iii) legal support; (iv) non-profit indemnification. The success should not be measured by the number of successful operations of any given mission, but by the successful operations that our colleagues perform after we leave. Considering that the children in need outnumber by far the people able to provide care, in this humanitarian medicine there should be plenty of room for cooperation rather than competition. The main goal should be to provide teaching to local staff and implement methods and techniques to support the improvement of the care of the patients in the long run. This review focuses on the organization of paediatric cardiac activities in the emerging economies, but 'the less privileged parts of the world' can be anywhere, not necessarily limited to economic constraints. Lack of diversity because of social, intellectual, educational and professional growth, the last consisting in cultural stagnation, is responsible for the lack of scientific progress and development.