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Identified mortality risk factors associated with presentation, initial hospitalisation, and interstage period for the Norwood operation in a multi-centre registry: a report from the National Pediatric Cardiology-Quality Improvement Collaborative

Published online by Cambridge University Press:  07 February 2013

Russell R. Cross*
Affiliation:
Department of Pediatrics, Division of Cardiology, Children's National Medical Center and the George Washington University School of Medicine, Washington, DC, United States of America
Ashraf S. Harahsheh
Affiliation:
Department of Pediatrics, Division of Cardiology, Children's National Medical Center and the George Washington University School of Medicine, Washington, DC, United States of America
Robert McCarter
Affiliation:
Division of Biostatistics & Research Methodology, Children's National Medical Center and the George Washington University School of Medicine, Washington, DC, United States of America
Gerard R. Martin
Affiliation:
Department of Pediatrics, Division of Cardiology, Children's National Medical Center and the George Washington University School of Medicine, Washington, DC, United States of America
*
Correspondence to: Dr R. R. Cross, MD, FACC, Assistant Professor, Department of Pediatrics, Division of Cardiology, Center for Heart, Lung and Kidney Disease/Children's National Medical Center, George Washington University, 111 Michigan Ave, NW Washington, DC 20010, United States of America. Tel: +1 (202) 476-2020; Fax: 1 (202) 476-5700; E-mail: rcross@childrensnational.org

Abstract

Introduction

Despite improvements in care following Stage 1 palliation, interstage mortality remains substantial. The National Pediatric Cardiology-Quality Improvement Collaborative captures clinical process and outcome data on infants discharged into the interstage period after Stage 1. We sought to identify risk factors for interstage mortality using these data.

Materials and methods

Patients who reached Stage 2 palliation or died in the interstage were included. The analysis was considered exploratory and hypothesis generating. Kaplan–Meier survival analysis was used to screen for univariate predictors, and Cox multiple regression modelling was used to identify potential independent risk factors.

Results

Data on 247 patients who met the criteria between June, 2008 and June, 2011 were collected from 33 surgical centres. There were 23 interstage mortalities (9%). The identified independent risk factors of interstage mortality with associated relative risk were: hypoplastic left heart syndrome with aortic stenosis and mitral atresia (relative risk = 13), anti-seizure medications at discharge (relative risk = 12.5), earlier gestational age (relative risk = 11.1), nasogastric or nasojejunal feeding (relative risk = 5.5), unscheduled readmissions (relative risk = 5.3), hypoplastic left heart syndrome with aortic atresia and mitral stenosis (relative risk = 5.2), fewer clinic visits with primary cardiologist identified (relative risk = 3.1), and fewer post-operative vasoactive medications (relative risk = 2.2).

Conclusion

Interstage mortality remains substantial, and there are multiple potential risk factors. Future efforts should focus on further exploration of each risk factor, with potential integration of the factors into surveillance schemes and clinical practice strategies.

Type
Original Articles
Copyright
Copyright © Cambridge University Press 2013 

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References

1. Norwood, WI, Lang, P, Hansen, DD. Physiologic repair of aortic atresia-hypoplastic left heart syndrome. N Engl J Med 1983; 308: 2326.Google Scholar
2. Bourke, KD, Sondheimer, HM, Ivy, DD, et al. Improved pretransplant management of infants with hypoplastic left heart syndrome enables discharge to home while waiting for transplantation. Pediatr Cardiol 2003; 24: 538543.Google Scholar
3. Galantowicz, M, Cheatham, JP. Lessons learned from the development of a new hybrid strategy for the management of hypoplastic left heart syndrome. Pediatr Cardiol 2005; 26: 190199.Google Scholar
4. Hornik, CP, He, X, Jacobs, JP, et al. Relative impact of surgeon and center volume on early mortality after the Norwood operation. Ann Thorac Surg 2012; 93: 19921997.CrossRefGoogle ScholarPubMed
5. Jonas, RA, Jacobs, JP, Jacobs, ML, Mavroudis, C. Reporting of mortality associated with pediatric and congenital cardiac surgery. J Thorac Cardiovasc Surg 2010; 140: 726727; author reply 726.Google Scholar
6. Karamichalis, JM, del Nido, PJ, Thiagarajan, RR, et al. Early postoperative severity of illness predicts outcomes after the stage I Norwood procedure. Ann Thorac Surg 2011; 92: 660665.Google Scholar
7. Jacobs, JP, O'Brien, SM, Pasquali, SK, et al. Variation in outcomes for risk-stratified pediatric cardiac surgical operations: an analysis of the STS Congenital Heart Surgery Database. Ann Thorac Surg 2012; 94: 564571; discussion 571–572.Google Scholar
8. Pasquali, SK, Ohye, RG, Lu, M, et al. Variation in perioperative care across centers for infants undergoing the Norwood procedure. J Thorac Cardiovasc Surg 2012; 144: 915921.CrossRefGoogle ScholarPubMed
9. Glenn, WW. Superior vena cava-pulmonary artery shunt. Ann Thorac Surg 1989; 47: 6264.Google Scholar
10. Hehir, DA, Dominguez, TE, Ballweg, JA, et al. Risk factors for interstage death after stage 1 reconstruction of hypoplastic left heart syndrome and variants. J Thorac Cardiovasc Surg 2008; 136: 9499; 99 e1–e3.Google Scholar
11. Ohye, RG, Sleeper, LA, Mahony, L, et al. Comparison of shunt types in the Norwood procedure for single-ventricle lesions. N Engl J Med 2010; 362: 19801992.Google Scholar
12. Sathanandam, SK, Polimenakos, AC, Roberson, DA, et al. Mitral stenosis and aortic atresia in hypoplastic left heart syndrome: survival analysis after stage I palliation. Ann Thorac Surg 2010; 90: 15981599.CrossRefGoogle ScholarPubMed
13. Tweddell, JS, Hoffman, GM, Fedderly, RT, et al. Patients at risk for low systemic oxygen delivery after the Norwood procedure. Ann Thorac Surg 2000; 69: 18931899.Google Scholar
14. Jonas, RA, Hansen, DD, Cook, N, Wessel, D. Anatomic subtype and survival after reconstructive operation for hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 1994; 107: 11211128.Google Scholar
15. Bartram, U, Grunenfelder, J, Van Praagh, R. Causes of death after the modified Norwood procedure: a study of 122 postmortem cases. Ann Thorac Surg 1997; 64: 17951802.Google Scholar
16. Ashburn, DA, McCrindle, BW, Tchervenkov, CI, et al. Outcomes after the Norwood operation in neonates with critical aortic stenosis or aortic valve atresia. J Thorac Cardiovasc Surg 2003; 125: 10701082.Google Scholar
17. Schidlow, DN, Anderson, JB, Klitzner, TS, et al. Variation in interstage outpatient care after the Norwood procedure: a report from the Joint Council on Congenital Heart Disease National Quality Improvement Collaborative. Congenit Heart Dis 2011; 6: 98107.Google Scholar
18. Kugler, JD, Beekman, RH III, Rosenthal, GL, et al. Development of a pediatric cardiology quality improvement collaborative: from inception to implementation. From the Joint Council on Congenital Heart Disease Quality Improvement Task Force. Congeni Heart Dis 2009; 4: 318328.Google Scholar
19. Anderson, JB, Iyer, SB, Beekman, RH, et al. National pediatric cardiology quality improvement collaborative: lessons from development and early years. Prog in Pediatr Cardiol 2011; 32: 103109.Google Scholar
20. Gaynor, JW, Jarvik, GP, Bernbaum, J, et al. The relationship of postoperative electrographic seizures to neurodevelopmental outcome at 1 year of age after neonatal and infant cardiac surgery. J Thorac Cardiovasc Surg 2006; 131: 181189.Google Scholar
21. Newburger, JW, Jonas, RA, Wernovsky, G, et al. A comparison of the perioperative neurologic effects of hypothermic circulatory arrest versus low-flow cardiopulmonary bypass in infant heart surgery. N Engl J Med 1993; 329: 10571064.Google Scholar
22. Bellinger, DC, Jonas, RA, Rappaport, LA, et al. Developmental and neurologic status of children after heart surgery with hypothermic circulatory arrest or low-flow cardiopulmonary bypass. N Engl J Med 1995; 332: 549555.CrossRefGoogle ScholarPubMed
23. Bellinger, DC, Wypij, D, Kuban, KC, et al. Developmental and neurological status of children at 4 years of age after heart surgery with hypothermic circulatory arrest or low-flow cardiopulmonary bypass. Circulation 1999; 100: 526532.Google Scholar
24. Rappaport, LA, Wypij, D, Bellinger, DC, et al. Relation of seizures after cardiac surgery in early infancy to neurodevelopmental outcome. Boston Circulatory Arrest Study Group. Circulation. 1998; 97: 773779.Google Scholar
25. Mahle, WT, Spray, TL, Gaynor, JW, Clark, BJ III. Unexpected death after reconstructive surgery for hypoplastic left heart syndrome. Ann Thorac Surg 2001; 71: 6165.Google Scholar
26. Furck, AK, Uebing, A, Hansen, JH, et al. Outcome of the Norwood operation in patients with hypoplastic left heart syndrome: a 12-year single-center survey. J Thorac Cardiovasc Surg 2010; 139: 359365.Google Scholar
27. Vida, VL, Bacha, EA, Larrazabal, A, et al. Surgical outcome for patients with the mitral stenosis-aortic atresia variant of hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2008; 135: 339346.Google Scholar
28. Vida, VL, Bacha, EA, Larrazabal, A, et al. Hypoplastic left heart syndrome with intact or highly restrictive atrial septum: surgical experience from a single center. Ann Thorac Surg 2007; 84: 581585; discussion 586.Google Scholar
29. Hirsch, JC, Copeland, G, Donohue, JE, Kirby, RS, Grigorescu, V, Gurney, JG. Population-based analysis of survival for hypoplastic left heart syndrome. J Pediatr 2011; 159: 5763.Google Scholar
30. Williams, RV Ravishankar, C, Zak, V, et al. Birth weight and prematurity in infants with single ventricle physiology: pediatric heart network infant single ventricle trial screened population. Congenit Heart Dis 2010; 5: 96103.Google Scholar
31. Ghanayem, NS, Allen, KR, Tabbutt, S, et al. Interstage mortality after the Norwood procedure: results of the multicenter Single Ventricle Reconstruction trial. J Thorac Cardiovasc Surg 2012; 144: 896906.Google Scholar
32. Anderson, JB, Beekman, RH III, Border, WL, et al. Lower weight-for-age z score adversely affects hospital length of stay after the bidirectional Glenn procedure in 100 infants with a single ventricle. J Thorac Cardiovasc Surg 2009; 138: 397404; e1.Google Scholar
33. Kelleher, DK, Laussen, P, Teixeira-Pinto, A, Duggan, C. Growth and correlates of nutritional status among infants with hypoplastic left heart syndrome (HLHS) after stage 1 Norwood procedure. Nutrition 2006; 22: 237244.Google Scholar
34. Kogon, BE, Ramaswamy, V, Todd, K, et al. Feeding difficulty in newborns following congenital heart surgery. Congenit Heart Dis 2007; 2: 332337.Google Scholar
35. Garcia, X, Jaquiss, RD, Imamura, M, Swearingen, CJ, Dassinger, MS III, Sachdeva, R. Preemptive gastrostomy tube placement after Norwood operation. J Pediatr 2011; 159: 602607; e1.CrossRefGoogle ScholarPubMed
36. Hebson, CL, Oster, ME, Kirshbom, PM, Clabby, ML, Wulkan, ML, Simsic, JM. Association of feeding modality with interstage mortality after single-ventricle palliation. J Thorac Cardiovasc Surg 2012; 144: 173177.Google Scholar
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