Does the shunt type determine mid-term outcome after Norwood operation? (original) (raw)
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Journal of Thoracic and Cardiovascular Surgery, 2008
Objective-The initial palliative procedure for patients born with hypoplastic left heart syndrome and related single right ventricle anomalies, the Norwood procedure, remains among the highest risk procedures in congenital heart surgery. The classic Norwood procedure provides pulmonary blood flow with a modified Blalock-Taussig shunt. Improved outcomes have been reported in a few small, nonrandomized studies of a modification of the Norwood procedure that uses a right ventriclepulmonary artery shunt to provide pulmonary blood flow. Other nonrandomized studies have shown no differences between the two techniques.
Comparison of Shunt Types in the Norwood Procedure for Single-Ventricle Lesions
New England Journal of Medicine, 2010
BACKGROUND-The Norwood procedure with a modified Blalock-Taussig (MBT) shunt, the first palliative stage for single-ventricle lesions with systemic outflow obstruction, is associated with high mortality. The right ventricle-pulmonary artery (RVPA) shunt may improve coronary flow but requires a ventriculotomy. We compared the two shunts in infants with hypoplastic heart syndrome or related anomalies.
Determinants of Adverse Outcomes After Systemic-To-Pulmonary Shunts in Biventricular Circulation
The Annals of Thoracic Surgery
Background. Systemic-to-pulmonary shunts are useful palliative procedures, although many teams have been deterred by high mortality and morbidity. We aimed to identify predictors of adverse outcomes after shunts in biventricular lesions. Methods. From 2004 to 2014, 173 children had shunt procedures. Morphologies included: tetralogy of Fallot, pulmonary atresia with ventricular septal defect (VSD) with and without major aortopulmonary collaterals (MAPCAs), transposition of great arteries with pulmonary stenosis, and double outlet right ventricle. Median age was 22 days (range, 3 to 3,438 days) and median weight 3.2 kg (range, 1.7 to 20 kg). Shunt sizes ranged from 3 to 5 mm with median shunt size/weight ratio 1.03 mm/kg (range, 0.3 to 2.5 mm/kg). Results. In-hospital mortality was 5.2% for the initial shunt procedure. Inter-stage mortality was 3.6%. Overall, 86% of patients progressed to corrective surgery. Acute events were observed in 41 patients, leading to 6 deaths. Events included 30 emergency chest openings, 16 shunt
Pediatric Cardiology, 2007
The initial Norwood procedure remains the highest risk operation for the staged repair of univentricular congenital malformations with associated systemic outflow obstruction. The modified Blalock-Taussig shunt (MBTS) has been implicated as a major cause of not only the operative mortality, but also associated morbidity and interstage attrition. The etiology of these events has often been attributed to the diastolic runoff and ''coronary steal'' associated with the MBTS, in addition to the delicate balance between systemic and pulmonary blood flow that characterizes all systemic-to-pulmonary artery shunts.
Indications and results of systemic to pulmonary shunts: results from a national database†
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, 2016
The systemic-to-pulmonary shunt (SPS) remains an important palliative therapy in many congenital heart defects. Unlike other surgical treatments, the mortality after shunt operations has risen. We used an audit dataset to investigate potential reasons for this change and to report national results. A total of 1993 patients classified in 13 diagnoses underwent an SPS procedure between 2000 and 2013. Indication trends by era and also results before repair or next stage are reported. A dynamic hazard model with competing risks and modulated renewal was used to determine predictors of outcomes. The usage of SPS in Tetralogy of Fallot (ToF) has significantly decreased in the last decade, with cases of single ventricle (SV) and pulmonary atresia (PA) with septal communication increasing (P < 0.001 for trends). This is correlated with an increase of early mortality from 5.1% in the first half of the decade to 9.8% in the latter (P = 0.007 for trend). At 1.5 years, 13.9% of patients have...
Impact of right ventricle to pulmonary artery conduit on outcome of the modified norwood procedure
Annals of Thoracic Surgery, 2004
norwood procedure Impact of right ventricle to pulmonary artery conduit on outcome of the modified http://ats.ctsnetjournals.org/cgi/content/full/77/5/1727 located on the World Wide Web at: The online version of this article, along with updated information and services, is Print ISSN: 0003-4975; eISSN: 1552-6259. Southern Thoracic Surgical Association. Background. To determine and compare outcome of the modified Norwood procedure using either a systemic to pulmonary artery (SPA) shunt or right ventricle to pulmonary artery (RV-PA) conduit in a consecutive series of neonates at a single institution.
European Journal of Cardio-Thoracic Surgery, 2008
Objective: To identify factors associated with in-hospital and interim mortality in children with a systemic-to-pulmonary shunt (SPS). Methods: Between January 1988 and April 2005, 226 children with a median age of 17 days, and weight of 3.4 kg, underwent an isolated SPS for pulmonary atresia (PA)-VSD/ tetralogy (n = 124, 54.9%), functional single ventricle PA (n = 35, 5.5%), PA-intact septum (IS, n = 31, 13.7%), transposition of the great arteries VSD-PA (n = 30, 13.3%), and double outlet right ventricle-PA (n = 6, 2.6%). Surgery was performed through sternotomy (group S, n = 46) or thoracotomy (group T, n = 180). The origin of the SPS was either the innominate artery (n = 38) or ascending aorta (n = 8) in group S, and the subclavian artery (n = 180) in group T. Results: In-hospital mortality was 5.7%. Univariate and logistic regression analysis revealed younger age ( p = 0.01), lower body weight ( p < 0.04), a diagnosis of PA-IS with severe right ventricle hypoplasia ( p = 0.005), preoperative intubation ( p = 0.03), increased length of intubation ( p < 0.0001), longer ICU stay ( p < 0.0001), and group S ( p = 0.03) as risk factors for in-hospital death. Group S had a longer median ventilation time (112 vs 30 h, p < 0.0001) despite the similar median age, weight, mean indexed shunt size (1.19 vs 1.15 mm/kg, p = 0.2), and the number of patients with antegrade pulmonary flow. Interim mortality was 7% (n = 15), and younger age ( p = 0.03), and group T ( p = 0.03) were independent risk factors for death prior to second-stage surgery. Absence of antiplatelet agents or anticoagulants was not a risk factor for interim mortality. Conclusions: In-hospital mortality and longer ventilation time after SPS by sternotomy may be related to pulmonary over circulation due to shunt insertion origin and/or size, and pathologic features. Early and interim outcomes can be improved by using a smaller shunt or changing the SPS insertion origin when using a sternotomy approach. #
The Annals of Thoracic Surgery, 2009
Background. The purpose of this study was to describe the experience with staged surgical reconstruction of the hypoplastic left heart syndrome (HLHS) with a right ventricle to pulmonary artery conduit and to identify the risk factors that influence late outcome. Methods. Between February 1998 and June 2007, 62 patients with HLHS underwent a Norwood procedure by using right ventricle to pulmonary artery conduit (median age, 9 days [range, 1 to 57]; median body weight 2.7 kg [range, 1.6 to 3.9 kg]). The subsequent 47 patients underwent a bidirectional Glenn procedure (stage 2). Thirty-two patients underwent a modified Fontan procedure (stage 3). Follow-up was complete (median, 32 months; range, 1 to 101). Results. Hospital mortality after the Norwood procedure was 8% (5 of 62 patients). Between stages, 9 patients died, 3 before stage 2 and 6 before stage 3. There was 1 late death after stage 3. Overall survival was 76% (47 of 62). The estimated 1-year and and 5-year survival rates were 80% and 73%, respectively. Using the any-mortality as the endpoint, prematurity (gestational age <37 weeks), body weight less than 2.5 kg at stage 1 operation, and tricuspid regurgitation 2؉ or more were associated with mortality. Using Cox regression analysis, body weight less than 2.5 kg and tricuspid regurgitation 2؉ or more were two independent factors associated with midterm survival. Conclusions. From 9 years of experience, despite good early survival after Norwood stage 1 palliation, low body weight and tricuspid valve regurgitation were still associated with worse outcome. More efforts should be made to improve the late results for patients with hypoplastic left heart syndrome.