Risk factors for prolonged length of stay after the stage 2 procedure in the single-ventricle reconstruction trial

Abstract

Objectives The Single Ventricle Reconstruction trial randomized patients with single right ventricle lesions to a modified Blalock-Taussig or right ventricle-to-pulmonary artery shunt at the Norwood. This analysis describes outcomes at the stage II procedure and factors associated with a longer hospital length of stay (LOS). Methods We examined the association of shunt type with stage II hospital outcomes. Cox regression and bootstrapping were used to evaluate risk factors for longer LOS. We also examined characteristics associated with in-hospital death. Results There were 393 subjects in the analytic cohort. Median stage II procedure hospital LOS (8 days, IQR (6,14)), hospital mortality (4.3%), transplantation (0.8%), median ventilator time (2 days, IQR (1,3)), median intensive care unit LOS (4 days (IQR (3,7)), number of additional cardiac procedures or complications and serious adverse events did not differ by shunt type. Longer LOS was associated (R2=0.26) with center, longer post-Norwood LOS (HR 1.93 per log day, P<0.001), non-elective timing of the stage II procedure (HR 1.78, P<0.001) and pulmonary artery (PA) stenosis (HR 1.56, P<0.001). By univariate analysis, non-elective stage II (65% vs. 32%, P=0.009), ≥ moderate atrioventricular valve (AVV) regurgitation (75% vs. 24%, P<0.001) and AVV repair (53% vs. 9%, P<0.001) were among the risk factors associated with in-hospital death. Conclusions Norwood LOS, PA stenoses and non-elective stage II procedure, but not shunt type, are independently associated with longer LOS. Non-elective stage II, >moderate AVV regurgitation and need for AVV repair are among the risk factors for death.

Risk Factors for Death or Heart Transplant for Patients with Right Ventricular Dysfunction After the Norwood Procedure: A Secondary Analysis of the Single Ventricle Reconstruction Trial

“…For example, surgeon volume was a predictor for post-Norwood morbidities, more precisely for renal failure, longer time to first extubation, and duration of ventilation (Tabutt et al 2012). Lower center Norwood volume was associated with sepsis, longer time to first extubation, as well as increased duration of ventilation and length of hospital stay after the stage II procedure (Schwartz et al, 2014). Similarly, lower surgeon volume, but not center volume was also associated with lower three-year transplant-free survival (OR 1.73, 95% CI 1.73 (1.05-2.85), p=0.001) (Newburger et al 2014).…”

“…However, the prevalence and influence of ventricular dysfunction seems to vary depending on the observation period assessed. For example, ventricular dysfunction was not a risk factor for death or heart transplant at discharge post-Norwood, at thirty-days post-Norwood (Tabbutt et al 2012), during the interstage period (Ghanayem et al 2012), during the stage II hospitalization (Schwartz et al 2014), or at the 12-month follow-up ).…”

“…Evaluating the composite outcome of death and heart transplant, 144 patients (26 % of the 555 enrolled infants) died or received a heart transplant between the randomization and the stage II surgery (Ohye et al 2012). Out of the survivors, there were 393 (71 %) infants who received a stage II procedure, which was associated with 17 (4 %) further deaths and three (1 %) heart transplants (Schwartz et al 2014). There was no influence of the type of shunt on mortality post stage II procedure.…”

“…The Pediatric Heart Network (PHN) investigators also evaluated the risk factors for Norwood hospitalization mortality and thirty-day post-operative mortality (Tabbutt et al 2012 There were 17 (4 %) subjects who died from the stage II procedure to hospital discharge and three subjects (1 %) underwent a heart transplant prior to their hospital discharge (Schwartz et al 2014). Univariate comparison between subjects that died or received a heart transplant to the rest of the cohort revealed that patients who died or received a heart transplant had lower weight for age z score (-2.5 +/-1.6 vs. Anderson & al evaluated the effect of surgeon and institutional volume on post-Norwood hospital mortality using the Pediatric Health Information System database (Anderson et al 2016).…”

The Optimal Timing of Stage 2 Palliation for Hypoplastic Left Heart Syndrome

“…12–16 Secondary analyses of the SVR and Infant Single Ventricle Trials showed no association of age at S2P with survival, hypoxemia, or ejection fraction. 17, 18 The timing of S2P remains at the discretion of institutional or individual surgeon/cardiologist preferences.…”