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

      Figure thumbnail fx1
      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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      Article info

      Publication history

      Accepted: January 17, 2023
      Received in revised form: December 15, 2022
      Received: November 2, 2022

      Publication stage

      In Press Journal Pre-Proof

      Footnotes

      Disclosure Statement: Authors report no conflicts of interest.

      Funding Statement: This research is funded by The Congenital Heart Surgeons’ Society participating institutions and members. Madison B. Argo is funded by The Hospital for Sick Children Division of Cardiovascular Surgery and The University of Wisconsin Department of Surgery.

      Institutional Review Board/Research Ethics Board: #1000072922; January 4, 2022

      Informed Consent: Voluntary parental/guardian consent was obtained for each participant.

      Central Picture: Survival after Norwood vs comprehensive stage II (COMPSII) following hybrid palliation.

      Central Message: After bilateral pulmonary artery banding ± ductal stent, infants who undergo Norwood versus comprehensive stage II have different underlying characteristics, which may influence subsequent outcomes

      Perspective Statement: For infants with critical left heart obstruction who undergo hybrid palliation and subsequent univentricular palliation, differences in outcomes after Norwood versus COMPSII were observed but were not statistically significant. Heterogeneity regarding intention and clinical characteristics introduced analytical complexity limiting definitive conclusions.

      Identification

      DOI: https://doi.org/10.1016/j.jtcvs.2023.01.013

      Copyright

      © 2023 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery

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