Hard Choices for High-Risk Patients With Critical Left Ventricular Outflow Obstruction

Abstract

Surgical management of high-risk newborns with critical left ventricular outflow tract obstruction (LVOTO) involves difficult decision making and complex procedures associated with significant morbidity and mortality. We sought to compare the outcomes of the hybrid and surgical strategies for the management of neonates with critical LVOTO considered at high risk in a contemporary nonrandomized cohort. This is a retrospective review of all patients undergoing management of critical LVOTO between January 2001 and December 2008. High-risk conditions included prematurity, low birth weight, and genetic or associated cardiac and noncardiac pathology. Analysis was performed based on intention to treat. Primary and secondary outcomes were operative and 6-month mortality. The cohort included 55 patients (21 hybrid and 34 surgical [31 Norwood, 3 biventricular repair]). The cohort had a median age of 4 (range, 1-62) days, mean weight of 2.7 ± 0.5 kg, and Aristotle comprehensive score of 18.6 ± 2.9. Low birth weight (P = .0007), prematurity (P = .004), and organ dysfunction (P = .04) were risk factors for operative death. Six-month mortality was associated with need for reintervention (P = .017) in the surgical group and history of organ dysfunction (P = .02) or aortic atresia (P = .03) in the hybrid group. Logistic regression identified low birth weight (P = .05; odds ratio [OR], 5.6 [0.9-34.6]), organ dysfunction (P = .05; OR, 4.7 [0.9-22.5]), and non–hypoplastic left heart syndrome (HLHS) diagnosis (P = .03; OR, 0.06 [0.005-0.93]) as predictors of mortality for the entire cohort. No differences in operative and 6-month mortality were detected between management strategies. Although initial surgical insult is lessened by the hybrid palliation, important interstage mortality and ongoing morbidity result in similar 6-month survival with either strategy. Patient-related factors have a larger influence on outcome than the management strategy chosen.

Keywords

CHD hypoplastic left heart syndrome CHD Norwood CHD univentricular heart surgery

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References

Ashburn

McCrindle

Tchervenkov

. Outcomes after the Norwood operation in neonates with critical aortic stenosis or aortic valve atresia. J Thorac Cardiovasc Surg. 2003;125:1070–1082.

Gaynor

Mahle

Cohen

. Risk factors for mortality after the Norwood procedure. Eur J Cardiothorac Surg. 2002;22:82–89.

Pizarro

Malec

Maher

. Right ventricle to pulmonary artery conduit improves outcome after stage I Norwood for hypoplastic left heart syndrome. Circulation. 2003;108 Suppl:II155–II160.

Artrip

Campbell

Ivy

. Birth weight and complexity are significant factors for the management of hypoplastic left heart syndrome. Ann Thorac Surg. 2006;82:1252–1257.

Lacour-Gayet

Clarke

. Aristotle Committee. The Aristotle method: a new concept to evaluate quality of care based on complexity. Curr Opin Pediatr. 2005;3:412–417.

Pizarro

Derby

Radtke

. Hybrid palliation for HLHS: the Nemours approach. J. Optechstvcs. 2009;14:86–98.

Hickey

Caldarone

Blackstone

. Congenital Heart Surgeons’ Society. Critical left ventricular outflow tract obstruction: the disproportionate cost of biventricular repair in borderline cases. J Thorac Cardiovasc Surg. 2007;134:1429–1436.

Hickey

Yeh

Jr Jacobs

. Ross and Yasui operations for “complex” biventricular repair in infants with critical left ventricular outflow tract obstruction. Eur J Cardiothorac Surg. 2010;37:279–288.

Akintuerk

Michel-Behnke

Valeske

. Stenting of the arterial duct and banding of the pulmonary arteries: basis of a combined Norwood stage I and II repair in hypoplastic left heart. Circulation. 2002;105:1099–1103.

10.

Galantowicz

Cheatham

. Lessons learned from the development of a new hybrid strategy for the management of hypoplastic left heart syndrome. Pediatr Cardiol. 2005;26:190–199.

11.

Pizarro

Murdison

. Off-pump palliation for hypoplastic left heart syndrome: surgical approach. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2005;7:66–71.

12.

Bacha

Daves

Hardin

. Single-ventricle palliation for high-risk neonates: the emergence of an alternative hybrid stage I strategy. J Thorac Cardiovasc Surg. 2006;131:163–171.

13.

Stoica

Philips

Egan

. The retrograde aortic arch in the hybrid approach to hypoplastic left heart syndrome. Ann Thorac Surg. 2009;88:1939–1947.