Superior cavopulmonary anastomosis timing and outcomes in infants with single ventricle

Cnota, James; Allen, Kerstin; Colan, Steven D.; Covitz, Wesley; Graham, Eric M.; Hehir, David A.; Levine, Jami C.; Margossian, Renée; McCrindle, Brian W.; Minich, L. LuAnn; Natarajan, Shobha; Richmond, Marc E.; Hsu, Daphne T.

doi:10.1016/j.jtcvs.2012.07.069

Cited by 29 publications

(32 citation statements)

References 22 publications

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“…Several studies have found that blacks undergo S2P at an older age than whites [11, 34], but our findings coincide with those of Ingaramo et al [26], who also found no significant racial difference in age at S2P and S3P in a large national database.…”

Section: Discussionsupporting

confidence: 90%

Effects of Race, Ethnicity, and Gender on Surgical Mortality in Hypoplastic Left Heart Syndrome

et al. 2013

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Information is limited regarding the effect of race, ethnicity, and gender on the outcomes of the three palliative procedures for hypoplastic left heart syndrome (HLHS). This study examined the effects of race, ethnicity, gender, type of admission, and surgical volume on in-hospital mortality associated with palliative procedures for HLHS between 1998 and 2007 using data from the University HealthSystem Consortium. According to the data, 1,949 patients underwent stage 1 palliation (S1P) with a mortality rate of 29 %, 1,279 patients underwent stage 2 palliations (S2P) with a mortality rate of 5.4 %, and 1,084 patients underwent stage 3 palliation (S3P) with a mortality rate of 4.1 %. The risk factors for increased mortality with S1P were black and “other” race, smaller surgical volume, and early surgical era. The only risk factors for increased mortality with S2P were black race (11 % mortality; odds ratio [OR], 3.19; 95 % confidence interval [CI] 1.69–6.02) and Hispanic ethnicity (11 % mortality; OR 3.30; 95 % CI 1.64–6.64). For S2P, no racial differences were seen in the top five surgical volume institutions, but racial differences were seen in the non-top-five surgical volume institutions. Mortality with S1P was significantly higher for patients discharged after birth (37 vs 24 %; p = 0.004), and blacks were more likely to be discharged after birth (12 vs 5 % for all other races; p < 0.001). No racial differences with S3P were observed. The risk factors for increased mortality at S1P were black and “other” race, smaller surgical volume, and early surgical era. The risk factors for increased in-hospital mortality with S2P were black race and His-panic ethnicity.

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Section: Discussionsupporting

confidence: 90%

Effects of Race, Ethnicity, and Gender on Surgical Mortality in Hypoplastic Left Heart Syndrome

et al. 2013

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“…There has been increasing evidence that earlier CPS can be performed safely, but with the concern that it can be associated with greater morbidity and longer hospital stay. 5,21 However, this study suggests that these findings may be more related to the unplanned nature of some of the earlier CPS procedures (and, in turn, their associated risk factors) and that, so long as the patient is thriving with good ventricular and AVV function, then earlier CPS can have excellent outcomes.…”

Section: Discussionmentioning

confidence: 82%

“…Ventricular function was based on echocardiographic assessment at the time of CPS, and moderate or greater impairment was defined as ''impaired function'' in the analysis in line with previous studies. 5,9 AVV regurgitation also was based on echocardiographic assessment and graded as trivial, mild, moderate, or severe. Any moderate or greater regurgitation was deemed significant and as an indication for valve repair.…”

Section: Methodsmentioning

confidence: 99%

“…[1][2][3] However, concerns over the relative fragility of the Norwood circulation and interstage mortality/morbidity have led to a general trend to earlier rather than later stage II surgery to achieve a more secure hemodynamic situation. 4,5 Conversion to stage II removes the volume load from the circulation and excludes the risks of a shunt-dependent circulation, such as shunt thrombosis, infection, stenosis, or sudden death. Although the use of the right ventricle to pulmonary artery (RV-PA) conduit may have reduced the latter risk, there remains significant attrition of patients during the interstage period in most published series, 1,3,6,7 sustaining the interest in converting to cavopulmonary circulation as soon as possible.…”

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confidence: 99%

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The importance of age and weight on cavopulmonary shunt (stage II) outcomes after the Norwood procedure: Planned versus unplanned surgery

Barron

Haq

Crucean

et al. 2017

The Journal of Thoracic and Cardiovascular Surgery

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The ventricular function, atrioventricular valve regurgitation, and need for tricuspid intervention were the primary risk factors for survival after the cavopulmonary shunt operation. Although unplanned surgery is associated with poor outcomes, this is related to the primary risk factors and not the timing or age of the patient. Somatic growth also has a significant influence on survival. Thus, an earlier cavopulmonary shunt operation is safe in infants who are thriving, but those with poor weight gain are at higher risk.

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“…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.…”

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confidence: 99%

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

et al. 2017

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Background In infants requiring three-stage single ventricle palliation for hypoplastic left heart syndrome, attrition after the Norwood procedure remains significant. The effect of the timing of stage-2-palliation (S2P), a physician-modifiable factor, on long term survival is not well understood. We hypothesized that an optimal interval between the Norwood and S2P that both minimizes pre-S2P attrition and maximizes post-S2P survival exists and is associated with individual patient characteristics. Methods The NIH/NHLBI Pediatric Heart Network Single Ventricle Reconstruction Trial public dataset was used. Transplant-free survival (TFS) was modeled from (1) Norwood to S2P and (2) S2P to three years, using parametric hazard analysis. Factors associated with death or heart transplantation were determined for each interval. To account for staged procedures, risk-adjusted, three-year, post-Norwood TFS (the probability of TFS at three years given survival to S2P) was calculated using parametric conditional survival analysis. TFS from the Norwood to S2P was first predicted. TFS after S2P to three years was then predicted and adjusted for attrition before S2P by multiplying by the estimate of TFS to S2P. The optimal timing of S2P was determined by generating nomograms of risk-adjusted, three-year, post-Norwood, TFS versus the interval from the Norwood to S2P. Results Of 547 included patients, 399 survived to S2P (73%). Of the survivors to S2P, 349 (87%) survived to three-year follow-up. The median interval from the Norwood to S2P was 5.1 (IQR 4.1–6.0) months. The risk-adjusted, three-year, TFS was 68±7%. A Norwood-S2P interval of three to six months was associated with greatest three-year TFS overall and in patients with few risk factors. In patients with multiple risk factors, TFS was severely compromised, regardless of the timing of S2P and most severely when S2P was performed early. No difference in the optimal timing of S2P existed when stratified by shunt type. Conclusions In infants with few risk factors, progressing to S2P at three to six months after the Norwood procedure was associated with maximal TFS. Early S2P did not rescue patients with greater risk factor burdens. Instead, referral for heart transplantation may offer their best chance at long term survival. ClinicalTrials.gov number: NCT00115934.

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Superior cavopulmonary anastomosis timing and outcomes in infants with single ventricle

Cited by 29 publications

References 22 publications

Effects of Race, Ethnicity, and Gender on Surgical Mortality in Hypoplastic Left Heart Syndrome

Effects of Race, Ethnicity, and Gender on Surgical Mortality in Hypoplastic Left Heart Syndrome

The importance of age and weight on cavopulmonary shunt (stage II) outcomes after the Norwood procedure: Planned versus unplanned surgery

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

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