The Optimal Timing of Stage-2-Palliation After the Norwood Operation

James M. Meza, Edward Hickey, Brian McCrindle, Eugene Blackstone, Brett Anderson, David Overman, James K. Kirklin, Tara Karamlou, Christopher Caldarone, Richard Kim, William DeCampli, Marshall Jacobs, Kristine Guleserian, Jeffrey Jacobs, Robert Jaquiss

Research output: Contribution to journalArticle

10 Citations (Scopus)

Abstract

Background: The effect of the timing of stage-2-palliation (S2P) on survival through single ventricle palliation remains unknown. This study investigated the optimal timing of S2P that minimizes pre-S2P attrition and maximizes post-S2P survival. Methods: The Congenital Heart Surgeons' Society's critical left ventricular outflow tract obstruction cohort was used. Survival analysis was performed using multiphase parametric hazard analysis. Separate risk factors for death after the Norwood and after S2P were identified. Based on the multivariable models, infants were stratified as low, intermediate, or high risk. Cumulative 2-year, post-Norwood survival was predicted. Optimal timing was determined using conditional survival analysis and plotted as 2-year, post-Norwood survival versus age at S2P. Results: A Norwood operation was performed in 534 neonates from 21 institutions. The S2P was performed in 71%, at a median age of 5.1 months (IQR: 4.3 to 6.0), and 22% died after Norwood. By 5 years after S2P, 10% of infants had died. For low- and intermediate-risk infants, performing S2P after age 3 months was associated with 89% ± 3% and 82% ± 3% 2-year survival, respectively. Undergoing an interval cardiac reoperation or moderate-severe right ventricular dysfunction before S2P were high-risk features. Among high-risk infants, 2-year survival was 63% ± 5%, and even lower when S2P was performed before age 6 months. Conclusions: Performing S2P after age 3 months may optimize survival of low- and intermediate-risk infants. High-risk infants are unlikely to complete three-stage palliation, and early S2P may increase their risk of mortality. We infer that early referral for cardiac transplantation may increase their chance of survival.

Original languageEnglish (US)
JournalAnnals of Thoracic Surgery
DOIs
StateAccepted/In press - 2017

Fingerprint

Norwood Procedures
Survival Analysis
Right Ventricular Dysfunction
Ventricular Outflow Obstruction
Heart Transplantation
Reoperation
Referral and Consultation
Newborn Infant
Mortality

ASJC Scopus subject areas

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

Cite this

Meza, J. M., Hickey, E., McCrindle, B., Blackstone, E., Anderson, B., Overman, D., ... Jaquiss, R. (Accepted/In press). The Optimal Timing of Stage-2-Palliation After the Norwood Operation. Annals of Thoracic Surgery. https://doi.org/10.1016/j.athoracsur.2017.05.041

The Optimal Timing of Stage-2-Palliation After the Norwood Operation. / Meza, James M.; Hickey, Edward; McCrindle, Brian; Blackstone, Eugene; Anderson, Brett; Overman, David; Kirklin, James K.; Karamlou, Tara; Caldarone, Christopher; Kim, Richard; DeCampli, William; Jacobs, Marshall; Guleserian, Kristine; Jacobs, Jeffrey; Jaquiss, Robert.

In: Annals of Thoracic Surgery, 2017.

Research output: Contribution to journalArticle

Meza, JM, Hickey, E, McCrindle, B, Blackstone, E, Anderson, B, Overman, D, Kirklin, JK, Karamlou, T, Caldarone, C, Kim, R, DeCampli, W, Jacobs, M, Guleserian, K, Jacobs, J & Jaquiss, R 2017, 'The Optimal Timing of Stage-2-Palliation After the Norwood Operation', Annals of Thoracic Surgery. https://doi.org/10.1016/j.athoracsur.2017.05.041
Meza, James M. ; Hickey, Edward ; McCrindle, Brian ; Blackstone, Eugene ; Anderson, Brett ; Overman, David ; Kirklin, James K. ; Karamlou, Tara ; Caldarone, Christopher ; Kim, Richard ; DeCampli, William ; Jacobs, Marshall ; Guleserian, Kristine ; Jacobs, Jeffrey ; Jaquiss, Robert. / The Optimal Timing of Stage-2-Palliation After the Norwood Operation. In: Annals of Thoracic Surgery. 2017.
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abstract = "Background: The effect of the timing of stage-2-palliation (S2P) on survival through single ventricle palliation remains unknown. This study investigated the optimal timing of S2P that minimizes pre-S2P attrition and maximizes post-S2P survival. Methods: The Congenital Heart Surgeons' Society's critical left ventricular outflow tract obstruction cohort was used. Survival analysis was performed using multiphase parametric hazard analysis. Separate risk factors for death after the Norwood and after S2P were identified. Based on the multivariable models, infants were stratified as low, intermediate, or high risk. Cumulative 2-year, post-Norwood survival was predicted. Optimal timing was determined using conditional survival analysis and plotted as 2-year, post-Norwood survival versus age at S2P. Results: A Norwood operation was performed in 534 neonates from 21 institutions. The S2P was performed in 71{\%}, at a median age of 5.1 months (IQR: 4.3 to 6.0), and 22{\%} died after Norwood. By 5 years after S2P, 10{\%} of infants had died. For low- and intermediate-risk infants, performing S2P after age 3 months was associated with 89{\%} ± 3{\%} and 82{\%} ± 3{\%} 2-year survival, respectively. Undergoing an interval cardiac reoperation or moderate-severe right ventricular dysfunction before S2P were high-risk features. Among high-risk infants, 2-year survival was 63{\%} ± 5{\%}, and even lower when S2P was performed before age 6 months. Conclusions: Performing S2P after age 3 months may optimize survival of low- and intermediate-risk infants. High-risk infants are unlikely to complete three-stage palliation, and early S2P may increase their risk of mortality. We infer that early referral for cardiac transplantation may increase their chance of survival.",
author = "Meza, {James M.} and Edward Hickey and Brian McCrindle and Eugene Blackstone and Brett Anderson and David Overman and Kirklin, {James K.} and Tara Karamlou and Christopher Caldarone and Richard Kim and William DeCampli and Marshall Jacobs and Kristine Guleserian and Jeffrey Jacobs and Robert Jaquiss",
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T1 - The Optimal Timing of Stage-2-Palliation After the Norwood Operation

AU - Meza, James M.

AU - Hickey, Edward

AU - McCrindle, Brian

AU - Blackstone, Eugene

AU - Anderson, Brett

AU - Overman, David

AU - Kirklin, James K.

AU - Karamlou, Tara

AU - Caldarone, Christopher

AU - Kim, Richard

AU - DeCampli, William

AU - Jacobs, Marshall

AU - Guleserian, Kristine

AU - Jacobs, Jeffrey

AU - Jaquiss, Robert

PY - 2017

Y1 - 2017

N2 - Background: The effect of the timing of stage-2-palliation (S2P) on survival through single ventricle palliation remains unknown. This study investigated the optimal timing of S2P that minimizes pre-S2P attrition and maximizes post-S2P survival. Methods: The Congenital Heart Surgeons' Society's critical left ventricular outflow tract obstruction cohort was used. Survival analysis was performed using multiphase parametric hazard analysis. Separate risk factors for death after the Norwood and after S2P were identified. Based on the multivariable models, infants were stratified as low, intermediate, or high risk. Cumulative 2-year, post-Norwood survival was predicted. Optimal timing was determined using conditional survival analysis and plotted as 2-year, post-Norwood survival versus age at S2P. Results: A Norwood operation was performed in 534 neonates from 21 institutions. The S2P was performed in 71%, at a median age of 5.1 months (IQR: 4.3 to 6.0), and 22% died after Norwood. By 5 years after S2P, 10% of infants had died. For low- and intermediate-risk infants, performing S2P after age 3 months was associated with 89% ± 3% and 82% ± 3% 2-year survival, respectively. Undergoing an interval cardiac reoperation or moderate-severe right ventricular dysfunction before S2P were high-risk features. Among high-risk infants, 2-year survival was 63% ± 5%, and even lower when S2P was performed before age 6 months. Conclusions: Performing S2P after age 3 months may optimize survival of low- and intermediate-risk infants. High-risk infants are unlikely to complete three-stage palliation, and early S2P may increase their risk of mortality. We infer that early referral for cardiac transplantation may increase their chance of survival.

AB - Background: The effect of the timing of stage-2-palliation (S2P) on survival through single ventricle palliation remains unknown. This study investigated the optimal timing of S2P that minimizes pre-S2P attrition and maximizes post-S2P survival. Methods: The Congenital Heart Surgeons' Society's critical left ventricular outflow tract obstruction cohort was used. Survival analysis was performed using multiphase parametric hazard analysis. Separate risk factors for death after the Norwood and after S2P were identified. Based on the multivariable models, infants were stratified as low, intermediate, or high risk. Cumulative 2-year, post-Norwood survival was predicted. Optimal timing was determined using conditional survival analysis and plotted as 2-year, post-Norwood survival versus age at S2P. Results: A Norwood operation was performed in 534 neonates from 21 institutions. The S2P was performed in 71%, at a median age of 5.1 months (IQR: 4.3 to 6.0), and 22% died after Norwood. By 5 years after S2P, 10% of infants had died. For low- and intermediate-risk infants, performing S2P after age 3 months was associated with 89% ± 3% and 82% ± 3% 2-year survival, respectively. Undergoing an interval cardiac reoperation or moderate-severe right ventricular dysfunction before S2P were high-risk features. Among high-risk infants, 2-year survival was 63% ± 5%, and even lower when S2P was performed before age 6 months. Conclusions: Performing S2P after age 3 months may optimize survival of low- and intermediate-risk infants. High-risk infants are unlikely to complete three-stage palliation, and early S2P may increase their risk of mortality. We infer that early referral for cardiac transplantation may increase their chance of survival.

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