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Norwood Operation Versus Comprehensive Stage II After Bilateral Pulmonary Artery Banding Palliation for Infants with Critical Left Heart Obstruction

Published:January 23, 2023DOI:https://doi.org/10.1016/j.jtcvs.2023.01.013
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      Abstract

      Objective

      Determine patient characteristics and outcomes after Norwood versus comprehensive stage II (COMPSII) for infants with critical left heart obstruction who had prior hybrid palliation (bilateral pulmonary artery banding [PAB] ± ductal stent).

      Methods

      From 23 Congenital Heart Surgeons’ Society institutions (2005-2020), 138 infants underwent hybrid palliation followed by either Norwood (n=73, 53%) or COMPSII (n=65). Baseline characteristics were compared between Norwood and COMPSII groups. Parametric hazard model with competing risk methodology was used to determine risk and factors associated with outcomes of Fontan, transplantation, or death.

      Results

      Infants who underwent Norwood versus COMPSII had a higher prevalence of prematurity (26% vs 14%, p=0.08), lower birth weight (median 2.8 vs 3.2 kilograms, p<0.01) and less frequent ductal stenting (37% vs 99%; p<0.01). Norwood was performed at a median age of 44 days and median weight of 3.5 kilograms, versus COMPSII at 162 days and 6.0 kilograms (both p<0.01). Median follow-up was 6.5 years. At 5 years after Norwood and COMPSII, respectively; 50% vs 68% had Fontan (p=0.16), 3% vs 5% had transplantation (p=0.70); 40% vs 15% died (p=0.10); 7% vs 11% are alive without transition. For factors associated with either mortality or Fontan, only preoperative mechanical ventilation occurred more frequently in the Norwood group.

      Conclusions

      Higher prevalence of prematurity, lower birth weight, and other patient-related characteristics in the Norwood versus COMPSII groups may influence differences in outcomes that were not statistically significant for this limited risk-adjusted cohort. The clinical decision regarding Norwood versus COMPSII after initial hybrid palliation remains challenging.

      Graphical abstract

      Key Words

      Glossary of Abbreviations:

      CHSS (Congenital Heart Surgeons’ Society), COMPSII (Comprehensive stage II), CLHO (Critical left heart obstruction), SCPC (Superior cavopulmonary connection), ECMO (Extracorporeal membrane oxygenation), PAB (Bilateral pulmonary artery banding), STS-CHSD (Society of Thoracic Surgeons – Congenital Heart Surgery Database), p25-p75 (25th percentile-75th percentile)
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