Intervention for arch obstruction after the Norwood procedure: Prevalence, associated factors, and practice variability

Paul J. Devlin, Brian W. McCrindle, James K. Kirklin, Eugene H. Blackstone, William M. DeCampli, Christopher A. Caldarone, Ali Dodge-Khatami, Pirooz Eghtesady, James M. Meza, Peter J. Gruber, Kristine J Guleserian, Bahaaladin Alsoufi, Linda M. Lambert, James E. O'Brien, Erle H. Austin, Jeffrey P. Jacobs, Tara Karamlou

Research output: Contribution to journalArticle

4 Scopus citations

Abstract

Objective: Arch obstruction after the Norwood procedure is common and contributes to mortality. We determined the prevalence, associated factors, and practice variability of arch reintervention and assessed whether arch reintervention is associated with mortality. Methods: From 2005 to 2017, 593 neonates in the Congenital Heart Surgeons' Society Critical Left Heart Obstruction cohort underwent a Norwood procedure. Median follow-up was 3.7 years. Multivariable parametric models, including a modulated renewal analysis, were performed. Results: Of the 593 neonates, 146 (25%) underwent 218 reinterventions for arch obstruction after the Norwood procedure: catheter-based (n = 168) or surgical (n = 50) at a median age of 4.3 months (quartile 1-quartile 3, 2.6-5.7). Interdigitation of the distal aortic anastomosis was protective against arch reintervention. Development of ≥ moderate tricuspid valve regurgitation and right ventricular dysfunction at any point was associated with arch reintervention. Nonsignificant variables for arch reintervention included shunt type and preoperative aortic measurements. Surgical arch reintervention was protective against arch reintervention, but transcatheter reintervention was associated with increased reintervention. Arch reintervention was not associated with increased mortality. There was wide institutional variation in incidence of arch reintervention (range, 0-40 reinterventions per 100 years patient follow-up) and in preintervention gradient (range, 0-64 mm Hg). Conclusions: Interdigitation of the distal aortic anastomosis during the Norwood procedure decreased the risk of arch reintervention. Surgical arch reintervention is more definitive than transcatheter. Arch reintervention after the Norwood procedure is not associated with increased mortality. Serial surveillance for arch obstruction, integrated with changes in right ventricular function and tricuspid valve regurgitation, is recommended after the Norwood procedure to improve outcomes.

Original languageEnglish (US)
Pages (from-to)684-695.e8
JournalJournal of Thoracic and Cardiovascular Surgery
Volume157
Issue number2
DOIs
StatePublished - Feb 1 2019
Externally publishedYes

Keywords

  • arch obstruction
  • coarctation
  • critical left heart obstruction
  • hypoplastic left heart syndrome
  • interdigitation
  • neoaorta
  • Norwood

ASJC Scopus subject areas

  • Surgery
  • Pulmonary and Respiratory Medicine
  • Cardiology and Cardiovascular Medicine

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    Devlin, P. J., McCrindle, B. W., Kirklin, J. K., Blackstone, E. H., DeCampli, W. M., Caldarone, C. A., Dodge-Khatami, A., Eghtesady, P., Meza, J. M., Gruber, P. J., Guleserian, K. J., Alsoufi, B., Lambert, L. M., O'Brien, J. E., Austin, E. H., Jacobs, J. P., & Karamlou, T. (2019). Intervention for arch obstruction after the Norwood procedure: Prevalence, associated factors, and practice variability. Journal of Thoracic and Cardiovascular Surgery, 157(2), 684-695.e8. https://doi.org/10.1016/j.jtcvs.2018.09.130